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01-01-2016
ERRATUM
Revista Brasileira de Enfermagem. 2016;69(1):206-206
Abstract
ERRATUM
Revista Brasileira de Enfermagem. 2016;69(1):206-206
DOI 10.1590/0034-7167.20166901e02
Views0In the article “Conceptions of mid-level nursing professionals facing those with a chemical dependency”, with the number of DOI: 10.1590/0034-7167.2015680610i, published in the journal Revista Brasileira de Enfermagem, v68(6):755-60, page 760 that read: “8. Vargas D, Soares J. Knowledge and attitudes of nurses towards alcohol and related problems: the impact of an educational intervention. Rev […]See more -
01-01-2016
ERRATUM
Revista Brasileira de Enfermagem. 2016;69(1):205-205
Abstract
ERRATUM
Revista Brasileira de Enfermagem. 2016;69(1):205-205
DOI 10.1590/0034-7167.20166901e01
Views0In the article “Using the theory of meaningful learning in nursing education”, with the number of DOI: 10.1590/0034-7167.2015680420i, published in the journal Revista Brasileira de Enfermagem, v68(4):626-35, page 627 that read:“Ausubel was descended from Jewish, born in New York in 1918 and died in 1994 at the age of 75. He thought and wrote until […]See more -
01-01-2016
Nursing process documentation: rationale and methods of analytical study
Revista Brasileira de Enfermagem. 2016;69(1):197-204
Abstract
Nursing process documentation: rationale and methods of analytical study
Revista Brasileira de Enfermagem. 2016;69(1):197-204
DOI 10.1590/0034-7167.2016690126i
Views0See moreABSTRACT
Objective:
to describe the methods used to analyze the associations between variables of service, nursing and the nursing process documentation in institutions of the Department of Health of the State of São Paulo.
Method:
multilevel analytical study with data obtained in the domains of institution, units of the institution and nursing professionals who work there, using standardized instruments. The analyses had as axis the degree of completeness of the nursing process documentation in units or institutions and their association with variables of nursing personnel, of units and of institutions.
Conclusion:
This study will provide important empirical evidence on the factors involved in the nursing process documentation.
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01-01-2016
Qualitative methodologies in health research: interpretive referential of Patricia Benner
Revista Brasileira de Enfermagem. 2016;69(1):192-196
Abstract
Qualitative methodologies in health research: interpretive referential of Patricia Benner
Revista Brasileira de Enfermagem. 2016;69(1):192-196
DOI 10.1590/0034-7167.2016690125i
Views0See moreABSTRACT
Objective:
this article reports on the experience of using the interpretive phenomenological framework of Patricia Benner in a Brazilian context. Benner’s interpretive phenomenology, based on existential and interpretative philosophy, aims to understand human experiences in the particular worlds of research participants. Data were collected through interviews with nine nurses in November and December 2014.
Results:
data analysis process according to Benner’s framework consisted of: transcription, coding, thematic analysis, and search for paradigmatic cases and examples. Therefore, the prior knowledge of the researcher is an important part of the study, consisting in manners of the research conduction.
Conclusion:
The use of this methodological framework entailed a great challenge for the researcher, however, it also enabled a unique opportunity to illuminate important existential phenomena related to the daily lives of research participants.
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01-01-2016
Nurses’ performance on primary care in the National Health Service in England
Revista Brasileira de Enfermagem. 2016;69(1):182-191
Abstract
Nurses’ performance on primary care in the National Health Service in England
Revista Brasileira de Enfermagem. 2016;69(1):182-191
DOI 10.1590/0034-7167.2016690124i
Views0See moreABSTRACT
Objective:
To analyze the expansion of nursing roles in primary care in the English National Health Service and the implications for professional practice.
Method:
qualitative research in case study format, held in London, England, in six primary care units. Data were obtained through interviews with nine nurses. After the thematic data analysis, two units emerged: the nurses’ performance characteristics and effects of the expansion of nursing roles.
Results:
expansion of nurses’ roles: consultation, diagnosis and drug therapy, case management and monitoring of chronic conditions. Repercussions: for the user, there was improved access, communication and comprehensive care, increased duration of consultations, resulting in greater adherence; for nurses, there was the expansion of professional skills, knowledge and professional recognition; to the health care system, it resulted in cost savings.
Conclusion:
benefits in expanding nursing roles, were visible, contributing to primary care quality.
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01-01-2016
Meleis’ Nursing Theories Evaluation: integrative review
Revista Brasileira de Enfermagem. 2016;69(1):174-181
Abstract
Meleis’ Nursing Theories Evaluation: integrative review
Revista Brasileira de Enfermagem. 2016;69(1):174-181
DOI 10.1590/0034-7167.2016690123i
Views0See moreABSTRACT
Objective:
to analyze the application of the theory evaluation model proposed by Meleis in Brazilian studies.
Method:
integrative review of online articles published from 2002 to 2012 in the databases LILACS and BDENF.
Results:
the 16 selected studies confirmed the use of only three of the five stages proposed for Meleis’ theories analysis: Description of the Theory, Criticism of the Theory and Analysis of the Theory, with a predominance of a single unit of analysis in each.
Conclusion:
the analysis of nursing theories provides support to nurses in the practice, research, education and administration of the different dimensions of care. Meleis’ model figures as very important by contributing to the development of knowledge of nursing discipline, considering that its use as a method allows several reflections on theories in order that they be revalidated to support a more theoretical and practical applicability.
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01-01-2016
Clinical indicators of sexual dysfunction in pregnant women: integrative literature review
Revista Brasileira de Enfermagem. 2016;69(1):165-173
Abstract
Clinical indicators of sexual dysfunction in pregnant women: integrative literature review
Revista Brasileira de Enfermagem. 2016;69(1):165-173
DOI 10.1590/0034-7167.2016690122i
Views0See moreABSTRACT
Objective:
to identify the nursing diagnosis clinical indicators of sexual dysfunction in pregnant women.
Method:
it is an integrative literature review, with research in databases using the keywords “sexual*”, “pregnan*” and “function*”. Studies included had an abstract available for analysis, referring to pregnant women over 18 years old, written in Portuguese, French, Spanish and English, with publication date between 2010 and 2014. Studies that reporting pregnant women with an associated pathology were excluded.
Results:
sexual dysfunction in pregnant women is consistent in the literature. Nine defining characteristics were identified and 16 related factors, some not classified in NANDA International.
Conclusion:
clinical indicators can be added to the nursing diagnosis to favor an accurate diagnosis and effective interventions in the surveillance of pregnancy as a period of healthy sexual experience.
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01-01-2016
Conditions of functional health literacy of an elderly diabetics group
Revista Brasileira de Enfermagem. 2016;69(1):156-164
Abstract
Conditions of functional health literacy of an elderly diabetics group
Revista Brasileira de Enfermagem. 2016;69(1):156-164
DOI 10.1590/0034-7167.2016690121i
Views0See moreABSTRACT
Objective:
to evaluate the conditions of functional health literacy of an elderly diabetics group.
Method:
cross-sectional and descriptive study, with diabetic’s elderly assisted in the SUS (N = 114). The social and health conditions were evaluated as well as functional health literacy by S-TOFHLA test (short version); the simple proportions, average, standard deviation and Pearson’s Chi-square were described by SPSS software (20.0) with α = 5% value.
Results:
the mean age was 67.4 years, 74.0% of the elderly were women, had up to four years of schooling; 29.8% had a long-standing illness, 64.0% reported having high blood pressure, 47.4% smoke or were smokers, 73.7% had low functional health literacy, which was associated with schooling p = 0.001.
Conclusions:
the low functional health literacy could be a self-care conditioning and can be influenced by low schooling because it implies to have skills to understand and make decisions aimed at self-management of health.
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ERRATUM04-22-2020
ERRATUM
Revista Brasileira de Enfermagem. 2020;73(3):202073n3e05
Abstract
ERRATUMERRATUM
Revista Brasileira de Enfermagem. 2020;73(3):202073n3e05
DOI 10.1590/0034-7167.202073n3e05
Views0Article “Concept formation of ambience for labor and normal institutionalized delivery”, with number of DOI: , published in the journal Revista Brasileira de Enfermagem, 72(Suppl 3):348-59, on page 357:Include after Final Considerations the information:[…]See more -
ORIGINAL ARTICLE04-09-2020
Health promotion in schools: speeches, representations, and approaches
Revista Brasileira de Enfermagem. 2020;73(3):e20180774
Abstract
ORIGINAL ARTICLEHealth promotion in schools: speeches, representations, and approaches
Revista Brasileira de Enfermagem. 2020;73(3):e20180774
DOI 10.1590/0034-7167-2018-0774
Views0See moreABSTRACT
Objectives:
to analyze speeches, representations, and approaches on health and health promotion in schools, materialized in the speech of teachers.
Methods:
a qualitative study, of the case study type, carried out with 17 teachers from the municipal and state educational network. The data were obtained from interviews and analyzed by the Content-Oriented Discourse Analysis.
Results:
medical-sanitary and clinical-biological discourses predominated. Health is represented as the absence of disease, reflecting approaches that prioritize healthy habits and changes in behavior. Problematization of social determinants occurs in projects, in an intersectorial partnership.
Final Considerations:
carrying out projects of health promotion in schools ignores the solidification of partnerships and the construction of new speeches that represent it as quality of life conditioned by social, economic, and cultural factors as well as strategies for the ideological repositioning of those actors who act in this setting.
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ORIGINAL ARTICLE04-09-2020
Nursing work and competence in hemotherapy services: an ergological approach
Revista Brasileira de Enfermagem. 2020;73(3):e20180775
Abstract
ORIGINAL ARTICLENursing work and competence in hemotherapy services: an ergological approach
Revista Brasileira de Enfermagem. 2020;73(3):e20180775
DOI 10.1590/0034-7167-2018-0775
Views0See moreABSTRACT
Objetives:
to analyze the ingredients of the competence that the nurses use in the performance of their work in hemotherapy.
Methods:
qualitative study with 22 nurses, accomplished through documentary study, observation and semi-structured interview, with resources of Atlas.ti software based on the foundations of Historical Materialism Dialectic and Ergology. Performed Content Analysis.
Results:
the domain of specific knowledge of hemotherapy and the time of experience in the area, allied to the motivation of the worker and the ability to work in a team favor the competent action in the work activities. On the other hand, the lack of adequate work conditions, especially in relation to adequate materials, equipment and structure, impairs the work of the nurse in hemotherapy.
Final Considerations:
experience gained is critical to successful decision making. In addition, adequate working conditions, updating of knowledge and ability in teamwork favor a scenario of safe practices.
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ORIGINAL ARTICLE04-22-2020
Happiness as a strength in the promotion of adolescent and adult young health
Revista Brasileira de Enfermagem. 2020;73(3):e20190064
Abstract
ORIGINAL ARTICLEHappiness as a strength in the promotion of adolescent and adult young health
Revista Brasileira de Enfermagem. 2020;73(3):e20190064
DOI 10.1590/0034-7167-2019-0064
Views0See moreABSTRACT
Objectives:
to assess the relation between sociodemographic characteristics of young people associated with the subjectivity of being happy; to evaluate the relationship between the subjectivity of being happy and the perception of health status; to evaluate the relationship between the subjectivity of being happy and the school and family environments and peer groups at school.
Methods:
this is an observational study, with an intentional sample of 1,069 young Portuguese people, with ages varying from 14 to 24, most of them women, attending secondary education. The self-filling questionnaire was used.
Results:
there are statistically significant associations between the subjectivity of being happy and schooling, perception of health status, family APGAR, school and family involvement, absence of problems or teasing by peers at school.
Conclusions:
a positive and holistic care coupled with the potential of obtaining and consolidating healthy lifestyles for young people will enable health professionals to perceive them as agents of individual and social change.
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ORIGINAL ARTICLE04-22-2020
Preventing vertical HIV virus transmission: hospital care assessment
Revista Brasileira de Enfermagem. 2020;73(3):e20190491
Abstract
ORIGINAL ARTICLEPreventing vertical HIV virus transmission: hospital care assessment
Revista Brasileira de Enfermagem. 2020;73(3):e20190491
DOI 10.1590/0034-7167-2019-0491
Views0See moreABSTRACT
Objectives:
assess the implementation of actions to prevent vertical transmission of HIV.
Methods:
a retrospective cohort study conducted in two maternity hospitals in the city of Montes Claros, State of Minas Gerais. All women admitted for childbirth diagnosed with HIV and their respective newborns were included from 2014 to 2017. Data were collected from medical records and analyzed descriptively.
Results:
population consisted of 46 pairs of mothers and newborns. Management was considered inadequate in 30 cases of parturient/postpartum women (65.2%) and 14 cases of newborns (30.4%). The main reasons for inadequate maternal management were lack of pharmacological inhibition of lactation (53.3%) and counseling/consent for HIV testing (43.3%). For newborns, late onsetoffirst dose ofZidovudine (50.0%) and no prescriptionofNevirapine (28.6%).
Conclusions:
important prevention opportunities were missed, pointing to the need for improved care.
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ORIGINAL ARTICLE06-08-2020
Maternal-child nursing care for adolescent mothers: health education
Revista Brasileira de Enfermagem. 2020;73(4):e20180769
Abstract
ORIGINAL ARTICLEMaternal-child nursing care for adolescent mothers: health education
Revista Brasileira de Enfermagem. 2020;73(4):e20180769
DOI 10.1590/0034-7167-2018-0769
Views0See moreABSTRACT
Objectives:
to develop an educational intervention through a game that addresses aspects related to adolescent motherhood and child care.
Methods:
this is an action research based on diagnosis, intervention and apprehension stages.
Results:
the situational diagnosis was based on a literature review on adolescent motherhood and child care. In the intervention stage, the educational game’s first version was elaborated. In the third stage constituted by apprehension, the game was submitted to assessment of interdisciplinary experts. Suggestions of experts were adopted and the game had its second version.
Final Considerations:
the educational intervention in the present study appears a care technology that adds knowledge and practices to the work of nurses in Primary Health Care, focusing on adolescent women and children health care.
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REVIEW06-01-2020
Access of the black population to health services: integrative review
Revista Brasileira de Enfermagem. 2020;73(4):e20180834
Abstract
REVIEWAccess of the black population to health services: integrative review
Revista Brasileira de Enfermagem. 2020;73(4):e20180834
DOI 10.1590/0034-7167-2018-0834
Views1See moreABSTRACT
Objectives:
demonstrate and discuss how the black population’s access to health services occurs
Methods:
integrative literature review with the following question: How does the black population’s access to health services occur? The search was carried out in the Scholar, LILACS and SciELO databases and used the descriptor “access to health services” and the term “population,” resulting in a sample with twelve articles.
Results:
studies show that the difficulty of access is a fundamental factor for the quality of life of people, directly compromising preventive services, especially for women’s health and, in addition, it has significant impact on the illness process of the black population within its particularities.
Final Considerations:
several limiting factors compromise the black population’s access to health services, including institutional and structural factors
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ORIGINAL ARTICLE05-18-2020
Militancy of nurses in the institutionality field: printed media versions
Revista Brasileira de Enfermagem. 2020;73(4):e20180835
Abstract
ORIGINAL ARTICLEMilitancy of nurses in the institutionality field: printed media versions
Revista Brasileira de Enfermagem. 2020;73(4):e20180835
DOI 10.1590/0034-7167-2018-0835
Views0See moreABSTRACT
Objectives:
to analyze nurses’ professional militancy in the institutionality field, presented by the printed media from Bahia State in the 1970s and 1980s.
Methods:
a historical and qualitative research under Social History’s perspective, whose data source was the newspaper A Tarde. The temporal cut-off encompasses milestones such as professional body restructuring and creation.
Results:
the Associação Brasileira de Enfermagem democratization movement was reported in a superficial way, highlighting the struggle for power spaces. With respect to Conselhos Federal e Regional de Enfermagem daBahia, the newspaper notified creation and function of bodies, however, there was no visibility to the newspaper’s performance. Concerning the union, there was political fragility of nurses against the creation and union participation in the fight for labor rights.
Final Considerations:
organization of political action occurred from isolated groups mobilization of professionals who were already traveling in political spaces, not the large mass of professionals.
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ORIGINAL ARTICLE08-19-2019
Social Determinants of Health and their influence on the choice of birth control methods
Revista Brasileira de Enfermagem. 2019;72(4):1044-1051
Abstract
ORIGINAL ARTICLESocial Determinants of Health and their influence on the choice of birth control methods
Revista Brasileira de Enfermagem. 2019;72(4):1044-1051
DOI 10.1590/0034-7167-2017-0574
Views0See moreABSTRACT
Objective:
To verify the association between Social Determinants of Health and birth control methods used by women of childbearing age.
Methods:
Documentary and retrospective study, performed at a Brazilian Natural Birth Center with evaluation of the medical records of patients seen between 2003 and 2011 (n=2410). Data were collected on identification and general history, gynecological, sexual and obstetric.
Results:
Hormone birth control methods were the most used among participants (25.0%); followed by barrier methods (21.5%) and surgical methods (19.3%). Statistical associations were observed regarding age, menarche, onset of sexual activity, pregnancy, miscarriage, smoking, hypertension, marital status, gynecological care and schooling with the choice of methods.
Conclusion:
The results confirm the importance of studies involving Social Determinants of Health, since they interfere in the way women choose birth control methods and the risks that this choice may pose to their health.
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ORIGINAL ARTICLE08-19-2019
Feelings of pleasure of nurses working in primary care
Revista Brasileira de Enfermagem. 2019;72(4):1036-1043
Abstract
ORIGINAL ARTICLEFeelings of pleasure of nurses working in primary care
Revista Brasileira de Enfermagem. 2019;72(4):1036-1043
DOI 10.1590/0034-7167-2018-0518
Views0See moreABSTRACT
Objective:
identify the sources that generate feelings of pleasure at work in the perception of primary care nurses.
Methods:
this is a descriptive study with a qualitative approach, developed with eleven nurses working in Primary Health Care Units. Data were collected using semi-structured interviews, systematized and analyzed using Bardin’s content analysis technique and based on the theoretical framework of Psychodynamics of Work.
Results:
pleasure at work was related to the resolubility of the nurse’s work, interpersonal relationship with the team, therapeutic relationship with the community, positive professional return, identification with work in nursing and public health.
Final considerations:
The factors that generate feelings of pleasure may contribute to guide actions that value the optimization of the nurses’ work and, consequently, the care provided to the primary care user.
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ORIGINAL ARTICLE08-19-2019
The daily routine of nurses in rural areas in the Family Health Strategy
Revista Brasileira de Enfermagem. 2019;72(4):918-925
Abstract
ORIGINAL ARTICLEThe daily routine of nurses in rural areas in the Family Health Strategy
Revista Brasileira de Enfermagem. 2019;72(4):918-925
DOI 10.1590/0034-7167-2018-0243
Views0See moreABSTRACT
Objective:
to analyze the daily work of rural Family Health Strategy (FHS) nurses.
Method:
a qualitative, descriptive and exploratory research. The data were collected with eleven rural nurses of the city of Campina Grande, Paraíba State, through semi-structured interviews, between January and March of 2017, using Content Analysis.
Results:
rural nurses have a strong relationship with the population. However, they reveal a daily work with various organizational barriers that range from the team displacement to the workplace to the operationalization of health actions, which are mediated by the characteristics of rurality. Some of these barriers can be remedied by a more proactive action from the management.
Final considerations:
conditioned by the characteristics of rurality, the differentiated dynamics work reveal weaknesses in the quality of nursing care and lower effectiveness of the FHS.
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REFLECTION09-07-2020
Public health nursing: regulation and public health policies
Revista Brasileira de Enfermagem. 2020;73(6):e20190550
Abstract
REFLECTIONPublic health nursing: regulation and public health policies
Revista Brasileira de Enfermagem. 2020;73(6):e20190550
DOI 10.1590/0034-7167-2019-0550
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Objective:
To analyze regulation and public policies related to nursing and the specialist nurse in community and public health nursing.
Methods:
Analysis of the legal and normative framework of community and public health nursing in Portugal, as well as current public health policies, regarding the competences and intervention of this nurse, articulated with the attributions of the Public Health Unit.
Results:
The intervention of this nurse deserves a broad reflection, in the sense of maximizing the activities of community and public health, essential for the implementation of public policies and obtaining health gains.
Final considerations:
This nurse has competences foreseen in the regulations and standards for public health interventions, in line with the attributions of the Public Health Unit, of the National Health Service, in which specialties are identified for their performance in the current structure.
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REFLECTION03-05-2021
Reflections on patient safety incident reporting systems
Revista Brasileira de Enfermagem. 2021;74:e20200307
Abstract
REFLECTIONReflections on patient safety incident reporting systems
Revista Brasileira de Enfermagem. 2021;74:e20200307
DOI 10.1590/0034-7167-2020-0307
Views0See moreABSTRACT
Objective:
To reflect on the main characteristics and recommendations of Incident Reporting Systems, discuss the population’s participation in reporting, and point out challenges in the Brazilian system.
Method:
Reflection study, based on Ordinance No. 529/13, which instituted the National Patient Safety Program, under Collegiate Board Resolution (CBR) No. 36/13; reflections by experts were added.
Results:
Reporting systems are a source for learning and monitoring, allow early detection of incidents, investigations and, mainly, the generation of recommendations prior to recurrences, in addition to raising information for patients and relatives. There is little participation of the population in the reporting, regardless of the type of system and characteristics such as confidentiality, anonymity, and mandatory nature.
Final Considerations:
In Brazil, although reporting is mandatory, there is an urgency to advance the involvement and participation of the population, professionals, and institutions. To simplify data entry by improving the interface and importing data from the reporting system is an objective to be achieved.
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ORIGINAL ARTICLE08-19-2019
Development of research on nursing diagnoses in Brazilian graduate programs
Revista Brasileira de Enfermagem. 2019;72(4):926-932
Abstract
ORIGINAL ARTICLEDevelopment of research on nursing diagnoses in Brazilian graduate programs
Revista Brasileira de Enfermagem. 2019;72(4):926-932
DOI 10.1590/0034-7167-2018-0259
Views0See moreABSTRACT
Objective:
to characterize the development of research on nursing diagnoses in nursing graduate programs and verify the application of the results of these studies according to the perception of academic advisors.
Methods:
documental research on dissertations and theses available from the databases of Brazilian universities with graduate programs in nursing, and exploratory survey on the practical application of their results.
Results:
216 dissertations and theses were analyzed. Most of them were descriptive studies, and the most widely used diagnostic taxonomy was NANDA International. Little practical use of the knowledge produced by the dissertations and theses was identified.
Conclusion:
Although there has been a considerable increase in research on nursing diagnoses, the survey stage revealed scarce practical application of their results, prompting the need for further studies in order to identify the barriers in the way of transposing theory to practice.
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06-11-2021
Resilience in elderly people: factors associated with sociodemographic and health conditions
Revista Brasileira de Enfermagem. 2021;74:e20200171
Abstract
Resilience in elderly people: factors associated with sociodemographic and health conditions
Revista Brasileira de Enfermagem. 2021;74:e20200171
DOI 10.1590/0034-7167-2020-0171
Views0See moreABSTRACT
Objective:
to describe the sociodemographic and health characteristics of elderly people, measure the score of total resilience and by sex and verify the association of sociodemographic and health variables with total resilience and by sex.
Methods:
this is a household survey with 808 elderly people, assessed by validated instruments. Student’s t test and multiple linear regression (p<0.05).
Results:
most were female, 60|-|79 years old. The total resilience score was 78.06, for men 81.53 and for women, 76.32. Total resilience was associated with males; positive self-perceived health; greater participation in Advanced Activities of Daily Living; fewer morbidities; absence of depressive symptoms. Among men and women, resilience was associated with greater participation in Advanced Activities of Daily Living and absence of depressive symptoms and, specifically, among women, positive self-perceived health.
Conclusion:
these results contribute to nursing care, aiming to encourage resilience.
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REVIEW07-13-2020
Augmentative and Alternative Communication in Ventilated Patients: A Scoping Review
Revista Brasileira de Enfermagem. 2020;73(5):e20190562
Abstract
REVIEWAugmentative and Alternative Communication in Ventilated Patients: A Scoping Review
Revista Brasileira de Enfermagem. 2020;73(5):e20190562
DOI 10.1590/0034-7167-2019-0562
Views0See moreABSTRACT
Objectives:
to map the benefits of Augmentative and Alternative Communication in ventilated adults in Intensive Care Unit and identify strategies used.
Methods:
a Scoping Review was carried out according to the Joanna Brigs Institute Protocol. The research question was: “In adult patients ventilated in Intensive Care Units, what are the benefits of Augmentative and Alternative Communication?”. An article research was carried out at PubMed, EBSCOhost and B-On databases. It was held between October and November 2018, from 2013 to 2018, in Portuguese and in English.
Results:
61 references were obtained. After selection according to the inclusion criteria, 7 articles were analyzed.
Conclusions:
studies enunciate Augmentative and Alternative Communication as a strategy to enhance communication, describing methods and tools. There is no agreement on the most effective tool.
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