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Stimulus-response time to alarms of the intra-aortic balloon pump: safe care practices
Revista Brasileira de Enfermagem. 2017;70(6):1206-1211
Abstract
Stimulus-response time to alarms of the intra-aortic balloon pump: safe care practices
Revista Brasileira de Enfermagem. 2017;70(6):1206-1211
DOI 10.1590/0034-7167-2016-0432
Views0See moreABSTRACT
Objective:
To characterize the sound alarms of the Intra-Aortic Balloon Pump (IABP) during aortic counterpulsation therapy; to measure the stimulus-response time of the team to these; and to discuss the implications of increasing this time for patient safety from the alarm fatigue perspective.
Method:
This is an observational and descriptive study with quantitative and qualitative approach, case study type, carried out in a Cardiac Surgical Intensive Care Unit.
Results:
The most audible IABP alarm was the one of high priority increased-reduced diastolic blood pressure. The stimulus-response time was 33.9 seconds on average.
Conclusion:
Managing the alarms of these equipment is essential to minimize the occurrence of the alarm fatigue phenomenon and to offer a safer assistance to patients who rely on this technology.
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Possibilities of care for serodiscordant couples for HIV who got pregnant
Revista Brasileira de Enfermagem. 2017;70(6):1199-1205
Abstract
Possibilities of care for serodiscordant couples for HIV who got pregnant
Revista Brasileira de Enfermagem. 2017;70(6):1199-1205
DOI 10.1590/0034-7167-2016-0344
Views0See moreABSTRACT
Objective:
Understanding the meaning of pregnancy for heterosexual couples facing serodiscordant situation for HIV, aiming at construction of care possibilities based on subjectivity.
Method:
Phenomenological research, theoretical-philosophical-methodological framework by Martin Heidegger. Research was conducted in a University Hospital in the countryside of Southern Brazil, from September 2013 to May 2014 through a phenomenological interview, with participation of eleven couples.
Results:
For the couples, pregnancy is part of life when they wish to have a child, even when one or both of them already have children from previous relationships. In addition, it is part of life when they consider the risks and do not want to have children in such circumstances anymore, but it happened unexpectedly.
Conclusion:
Understanding reproductive needs and demands of these couples is an aid for qualification and improvement of care as a contribution to nursing care planning towards reproductive health of these couples.
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Interactive Theory of Breastfeeding: creation and application of a middle-range theory
Revista Brasileira de Enfermagem. 2017;70(6):1191-1198
Abstract
Interactive Theory of Breastfeeding: creation and application of a middle-range theory
Revista Brasileira de Enfermagem. 2017;70(6):1191-1198
DOI 10.1590/0034-7167-2016-0523
Views0See moreABSTRACT
Objective:
To describe a breastfeeding theory based on King’s Conceptual System.
Method:
Theoretical study that used analysis of concept, assertion synthesis, and derivation of theory for the creation of a new theory.
Results:
King’s system components were associated with elements of the breastfeeding process and a middle-range theory was created, which describes, explains, predicts, and prescribes breastfeeding by analyzing factors that precede and affect it, as well as their consequences on the breastfeeding process.
Conclusion:
The Breastfeeding Interactive Model is abstract enough to be applied in different social, cultural, political, and economic contexts, because it conceptualizes breastfeeding in systemic, dynamic, and procedural aspects. Based on a conceptual model of nursing, it contributes to the scientific construction of the subject; however it can also potentially be applied by other professionals involved in breastfeeding assistance.
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Efficiency of cleaning and disinfection of surfaces: correlation between assessment methods
Revista Brasileira de Enfermagem. 2017;70(6):1176-1183
Abstract
Efficiency of cleaning and disinfection of surfaces: correlation between assessment methods
Revista Brasileira de Enfermagem. 2017;70(6):1176-1183
DOI 10.1590/0034-7167-2016-0608
Views0ABSTRACT
Objective:
to assess the correlation among the ATP-bioluminescence assay, visual inspection and microbiological culture in monitoring the efficiency of cleaning and disinfection (C&D) of high-touch clinical surfaces (HTCS) in a walk-in emergency care unit.
Method:
a prospective and comparative study was carried out from March to June 2015, in which five HTCS were sampled before and after C&D by means of the three methods. The HTCS were considered dirty when dust, waste, humidity and stains were detected in visual inspection; when ≥2.5 colony forming units per cm2 were found in culture; when ≥5 relative light units per cm2 were found at the ATP-bioluminescence assay.
Results:
720 analyses were performed, 240 per method. The overall rates of clean surfaces per visual inspection, culture and ATP-bioluminescence assay were 8.3%, 20.8% and 44.2% before C&D, and 92.5%, 50% and 84.2% after C&D, respectively (p<0.001). There were only occasional statistically significant relationships between methods.
Conclusion:
the methods did not present a good correlation, neither quantitative nor qualitatively.
Keywords:Equipment ContaminationHealth Facility EnvironmentHousekeepingInfectious Disease TransmissionNursing AuditSee more -
Cultural adaptation of The End-Stage Renal Disease Adherence Questionnaire for hemodialysis patients
Revista Brasileira de Enfermagem. 2017;70(6):1169-1175
Abstract
Cultural adaptation of The End-Stage Renal Disease Adherence Questionnaire for hemodialysis patients
Revista Brasileira de Enfermagem. 2017;70(6):1169-1175
DOI 10.1590/0034-7167-2016-0519
Views0ABSTRACT
Objective:
To describe the stages in the cultural adaptation of “The End-Stage Renal Disease Adherence Questionnaire” for use in Brazil.
Method:
A descriptive, transversal study with a quantitative approach. The cultural adaptation followed the steps of translation, professional committee, back translation, panel of patients and pretest.
Results:
the translation stage created a version in Portuguese that was analyzed by specialists, who suggested alterations in the title, seven sentences in the questions and three sets of answers. In the panel of patients phase, two questions were altered. The back translation considered the original characteristics of the instrument were maintained, likewise there were no modifications in the pretest phase. The third version written in Portuguese was considered to be the final version of the questionnaire.
Conclusion:
this instrument should facilitate nursing care management in hemodialysis, enabling the monitoring of adherence among these patients and also contribute to improving the indicators of morbidity and mortality.
Keywords:Adherence to MedicationChronic Renal InsufficiencyHemodialysisNephrology NursingPatient CooperationSee more -
Revalidation of game for teaching blood pressure auscultatory measurement: a pilot study
Revista Brasileira de Enfermagem. 2017;70(6):1159-1168
Abstract
Revalidation of game for teaching blood pressure auscultatory measurement: a pilot study
Revista Brasileira de Enfermagem. 2017;70(6):1159-1168
DOI 10.1590/0034-7167-2016-0578
Views0ABSTRACT
Objective:
To adapt a pre-existing educational game, making it specific to the teaching of blood pressure auscultatory measurement, and to apply this game in a pilot study.
Method:
The original game cards were altered by the authors and submitted to content validation by six experts in the field. After redesigns, the game was applied to 30 subjects, who answered a questionnaire (pre-test and post-test) on auscultatory measurement. Data were analyzed descriptively and by the paired Student’s t-test and paired Wilcoxon test.
Results:
Throughout the content validation process, 17 of the 28 original cards were modified. Of these 17 cards, 13 obtained 80% agreement, and the rest were modified according to the judges’ suggestions. The obtained grades significantly increased between pre- and the post-test.
Conclusion:
It was concluded that the reformulated game presented satisfactory evidence of content validity. Its use as a teaching-learning method was effective for this sample.
Keywords:Determination of Blood PressureEducation in NursingEducational TechnologyExperimental GamesGames and ToysSee more -
Validation of Family Management Measure for the Brazilian culture
Revista Brasileira de Enfermagem. 2017;70(6):1151-1158
Abstract
Validation of Family Management Measure for the Brazilian culture
Revista Brasileira de Enfermagem. 2017;70(6):1151-1158
DOI 10.1590/0034-7167-2016-0326
Views0See moreABSTRACT
Etjective:
To validate the Family Management Measure (FaMM) for Brazilian culture.
Method:
Quantitative research excerpt, following the recommendations for validation studies. The data presented refer to the last stage of the process.
Results:
The internal consistency of the items was analyzed through Cronbach’s alpha of the six domains: Child’s Daily Life (0.78); Condition Management Effort (0.51); Condition Management Ability (0.55); Family Life Difficulty (0.86); View of Condition Impact (0.56); and Parental Mutuality (0.80). Exploratory factorial analysis of the instrument was carried out, obtaining an acceptable adjustment, according to validation standards.
Conclusion:
The FaMM presents evidence of validation and can be used in the Brazilian culture under the name of Instrumento de Medida de Manejo Familiar, which was adjusted in eight domains, providing varied aspects of family management and a good evaluation of the fundamental aspects of family life in the context of childhood chronic conditions.
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ORIGINAL ARTICLE01-10-2024
Childbirth dynamics in the riverside region of the Brazilian Amazon from the perspective of geospatialization
Revista Brasileira de Enfermagem. 2024;77:e20240038
Abstract
ORIGINAL ARTICLEChildbirth dynamics in the riverside region of the Brazilian Amazon from the perspective of geospatialization
Revista Brasileira de Enfermagem. 2024;77:e20240038
DOI 10.1590/0034-7167-2024-0038
Views0See moreABSTRACT
Objective:
to analyze the spatial-temporal pattern of childbirths and flow of postpartum women assisted at a regional reference maternity hospital.
Methods:
ecological study of 4,081 childbirths, between September 2018 and December 2021, at a public maternity hospital in the Baixo Tocantins region, Pará, Brazil. With data collected from five sources, a geographic database was constructed, and spatial analysis was used with Kernel density interpolator. Maps were generated using QGis/3.5 and TerraView/4.3, calculating chi-square (p<0.05).
Results:
the highest concentrations of normal and cesarean childbirths were observed in Barcarena (n=2,558/62.68%), Abaetetuba (n=750/18.38%), Moju (n=363/8.89%) and Igarapé-Miri (n=219/5.37%). Among the municipalities in the region, ten had obstetric beds, totaling 210 beds. In this scenario, postpartum women traveled up to 288 km to reach the maternity hospital.
Conclusions:
long distances between certain municipalities of residence and maternity hospital, and low supply of obstetric beds, were identified as risk factors for unfavorable obstetric outcomes.
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REVIEW01-10-2024
Nurses’ practical contributions to improving healthy and sustainable public spaces: an integrative review
Revista Brasileira de Enfermagem. 2024;77:e20240023
Abstract
REVIEWNurses’ practical contributions to improving healthy and sustainable public spaces: an integrative review
Revista Brasileira de Enfermagem. 2024;77:e20240023
DOI 10.1590/0034-7167-2024-0023
Views0ABSTRACT
Objective:
to identify knowledge production about nurses’ contributions to improving healthy and sustainable public spaces.
Methods:
an integrative review carried out in February 2023 in electronic databases. Studies that answered the research question and that were available in full, in Portuguese, English and Spanish, were included.
Results:
a total of five articles were selected. The findings highlighted the importance of educational projects in the training of local managers and community autonomy; citizen participation and health promotion as ways to implement Sustainable Development Goal 11; nurses as facilitators of collective care; new health practices and modes of producing subjectivity; and use of public transportation, bicycles and/or walking in these spaces.
Final considerations:
there is a clear need for greater incentives from local governments to develop effective sustainability strategies that are led by nurses and the community.
Keywords:AttitudesCommunity HealthHealth KnowledgeHealthy Lifestyle, NursesNursesPracticeSustainable DevelopmentSee more -
ORIGINAL ARTICLE01-10-2024
Pain management in hospitalized infants: recommendations for achieving the Sustainable Development Goals
Revista Brasileira de Enfermagem. 2024;77:e20230421
Abstract
ORIGINAL ARTICLEPain management in hospitalized infants: recommendations for achieving the Sustainable Development Goals
Revista Brasileira de Enfermagem. 2024;77:e20230421
DOI 10.1590/0034-7167-2023-0421
Views0See moreABSTRACT
Objective:
to assess pain management in infants in a Neonatal Intensive Care Unit (NICU) and discuss its articulation with the Sustainable Development Goals, with a focus on promoting neonatal well-being.
Method:
a documentary study, retrospective in nature and quantitative approach, conducted in a NICU of a public hospital in Paraná, Brazil, between January and July 2022, with 386 medical records of infants, hospitalized for more than 24 hours, between 2019 and 2021. Data were subjected to descriptive and inferential analysis, considering p-value<0.05 as a statistical difference. National ethical guidelines were respected.
Results:
all infants underwent at least one painful procedure, but only 13.7% had documented pain. Pharmacological interventions, such as fentanyl (25.9%), and non-pharmacological interventions, such as breastfeeding encouragement (86%) were used. Only 2.8% were reassessed.
Conclusion:
there was a devaluation of neonatal pain management that may perpetuate neonatal well-being and sustainable development.
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LETTER TO THE EDITOR01-10-2024
Adherence to COVID-19 vaccination during the pandemic and fake news: Correspondence
Revista Brasileira de Enfermagem. 2024;77:e202477Suppl101c
Abstract
LETTER TO THE EDITORAdherence to COVID-19 vaccination during the pandemic and fake news: Correspondence
Revista Brasileira de Enfermagem. 2024;77:e202477Suppl101c
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LETTER TO THE EDITOR01-10-2024
Adherence to COVID-19 vaccination during the pandemic and fake news: Correspondence
Revista Brasileira de Enfermagem. 2024;77:e202477Suppl101c
Abstract
LETTER TO THE EDITORAdherence to COVID-19 vaccination during the pandemic and fake news: Correspondence
Revista Brasileira de Enfermagem. 2024;77:e202477Suppl101c
DOI 10.1590/0034-7167.202477Suppl101c
Views0Dear Dr Dulce Aparecida BarbosaEditor in Chief of the Revista Brasileira de Enfermagem[…]See more -
ORIGINAL ARTICLE01-10-2024
Clinical and epidemiological characteristics and outcomes of patients affected by COVID-19 in the Intensive Care Unit
Revista Brasileira de Enfermagem. 2024;77:e20230527
Abstract
ORIGINAL ARTICLEClinical and epidemiological characteristics and outcomes of patients affected by COVID-19 in the Intensive Care Unit
Revista Brasileira de Enfermagem. 2024;77:e20230527
DOI 10.1590/0034-7167-2023-0527
Views0See moreABSTRACT
Objective:
To understand the clinical and epidemiological characteristics, outcomes, and nursing care of adult patients affected by COVID-19 in the Intensive Care Unit.
Methods:
This is a quantitative, retrospective, and descriptive study. The study participants were clinical and epidemiological statistical reports. Variables analyzed included age, gender, race, comorbidities, signs and symptoms, length of hospital stay, use of mechanical ventilation, medications, infections, monitoring, invasive devices, positioning, diet, comfort, and clinical outcomes.
Results:
The majority of individuals were men, of white race, with a mean age of 63 years, hypertensive, diabetic, and obese. The average length of hospital stay was 16 days. Most required invasive mechanical ventilation, vasopressor drugs, sedoanalgesia, and neuromuscular blockers.
Conclusion:
Nursing care is related to monitoring, ventilation, medication administration, installation of devices, prone positioning, diet administration, and providing comfort.
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ORIGINAL ARTICLE01-10-2024
Morbidity and factors associated with frailty in post-COVID-19 elderly patients attended at a reference center
Revista Brasileira de Enfermagem. 2024;77:e20230454
Abstract
ORIGINAL ARTICLEMorbidity and factors associated with frailty in post-COVID-19 elderly patients attended at a reference center
Revista Brasileira de Enfermagem. 2024;77:e20230454
DOI 10.1590/0034-7167-2023-0454
Views0See moreABSTRACT
Objective:
To assess the morbidity profile and identify factors associated with frailty syndrome in post-COVID-19 elderly patients treated at the only Reference Center for Elderly Health Care in northern Minas Gerais.
Methods:
This is a case series study, utilizing the Clinical-Functional Vulnerability Index-20 (CFVI-20) and Comprehensive Geriatric Assessment (CGA) to characterize and evaluate the health condition of the group. To define the variables associated with frailty, a multivariate analysis was conducted.
Results:
The study included 204 elderly individuals, with a predominance of females (63.7%). The variables associated with frailty were cognitive impairment (OR: 2.95; 95% CI: 1.12-7.80; p=0.029), the presence of five or more comorbidities (OR: 11.55; 95% CI: 2.22-60.01; p=0.004), and impairment in instrumental activities of daily living (OR: 41.97; 95% CI: 5.47-321.93; p<0.001).
Conclusions:
The results of this study highlight the need for a well-established and prepared coordination of integrated care to meet the demands of the post-COVID-19 elderly population.
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ORIGINAL ARTICLE01-10-2024
Nursing care management strategies to address the COVID-19 pandemic
Revista Brasileira de Enfermagem. 2024;77:e20230254
Abstract
ORIGINAL ARTICLENursing care management strategies to address the COVID-19 pandemic
Revista Brasileira de Enfermagem. 2024;77:e20230254
DOI 10.1590/0034-7167-20230254
Views0See moreABSTRACT
Objective:
To characterize nursing care management strategies for addressing the COVID-19 pandemic.
Method:
A descriptive, qualitative study conducted with 22 nurse professionals at a University Hospital in Southern Brazil. Data collection through interviews in June and August 2021, analyzed according to Bardin’s Content Analysis and the theoretical framework of complex thinking.
Results:
The identified strategies were organized into four categories: Reorganization of health services; People management and emergency admission; Multiprofessional articulation; and Bedside nursing care.
Final Considerations:
Professional performance revealed a complex interplay between leadership and care management practices, even in the face of working condition restrictions, and were understood as crucial in the pandemic scenario.
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The experience of grandmothers of children with cancer
Revista Brasileira de Enfermagem. 2016;69(3):559-565
Abstract
The experience of grandmothers of children with cancer
Revista Brasileira de Enfermagem. 2016;69(3):559-565
DOI 10.1590/0034-7167.2016690320i
Views0See moreABSTRACT
Objective:
to understand, from grandmothers’ perspectives, the experience of having a grandchild with cancer.
Method:
qualitative study, guided by philosophical hermeneutics. Eight grandmothers of children who had finished an oncology treatment participated in this study. Data were collected through interviews, which were recorded, transcribed, and analyzed according to the principles of hermeneutics.
Results:
the grandmothers underwent an experience of multiplied, silent, transformative, and permanent suffering. They believe it is their role to be present, but they recognize their adult children’s independence and self-determination. Grandmothers highlighted that their experience has been very little accessed and considered by health care professionals.
Conclusion:
we recommend including grandparents in the context of care and in additional research.
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Knowledge of healthcare professionals on the evaluation and treatment of neonatal pain
Revista Brasileira de Enfermagem. 2016;69(3):552-558
Abstract
Knowledge of healthcare professionals on the evaluation and treatment of neonatal pain
Revista Brasileira de Enfermagem. 2016;69(3):552-558
DOI 10.1590/0034-7167.2016690319i
Views0See moreABSTRACT
Objective:
to identify knowledge of healthcare professionals on the management, evaluation and treatment of pain in a neonatal unit in a municipality of Rio de Janeiro.
Method:
descriptive, exploratory study with quantitative analysis. Data were analyzed using the software R. Core Team
Results:
of the 96 healthcare professionals who participated in the study, 42 nursing aides/technicians responded, along with 22 nurses, 20 physicians and 2 physical therapists. The results showed that 40.5% of the nursing aides/technicians, 50% of the physicians and 50% of the physical therapists confirmed that they coordinate/perform/assist in the care of babies’ pain while performing procedures (lumbar puncture, chest tube insertion and central line). There was a significant difference of agreement in relation to the nursing aides/technicians and physicians. Most (69.8%) of the healthcare professionals knew of some non-pharmacological measure effective for relief of acute pain.
Conclusion:
there is a need for an educational intervention program, with participation of those involved, in the process to change professional practice.
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Moments for hand hygiene in Material and Sterilization Center
Revista Brasileira de Enfermagem. 2016;69(3):546-551
Abstract
Moments for hand hygiene in Material and Sterilization Center
Revista Brasileira de Enfermagem. 2016;69(3):546-551
DOI 10.1590/0034-7167.2016690318i
Views0See moreABSTRACT
Objective:
to characterize the moments when there is a need for hand hygiene (HH) by employees who work in Material and Sterilization Center (MSC).
Method:
we conducted a descriptive cross-sectional study in the MSC of a large hospital, from July to November 2012, in Goiânia, state of Goiás, Brazil. Data obtained through observation of workers, following a previously evaluated and tested checklist.
Results:
to the dirty area, standardized moments of HH were enough. In the clean area, “Extra moments with indication” for HH, resulting from the work process, such as: after disinfecting benches, after verification and inventory of consigned products, before assembling boxes/trays, before loading and unloading the autoclave, before handling and distributing health care products, among others, were necessary.
Conclusion:
the moments of HH in the dirty area coincide with indications of the clinical practice; and, in the clean area, characteristic moments of the work process were captured.
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The experience of family care in transitional support houses
Revista Brasileira de Enfermagem. 2016;69(3):538-545
Abstract
The experience of family care in transitional support houses
Revista Brasileira de Enfermagem. 2016;69(3):538-545
DOI 10.1590/0034-7167.2016690317i
Views0See moreABSTRACT
Objective:
to present the theoretical model that represents the experience of care in transitional homes of support to families of children in a period of post-transplantation of hematopoietic stem cells.
Method:
grounded theory, performed with 18 participants from three different samples. For analysis, we used the QSR Nvivo10 software.
Results:
we elaborated four categories: living in the transitional support home; experiencing care of children in post-transplantation of hematopoietic stem cells; taking care of the family caregiver; and returning to a new life at home, which interrelate according to the theoretical code of the interactive family.
Conclusion:
this research contributes to understanding the experience of care in transitional support homes of families with children in post-transplantation of hematopoietic stem cells and subsidizes nursing and health actions provided to this population; it also contributes to the development of a hospital discharge guidance and care directed to this clientele.
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Health care for children and adolescents with HIV: a comparison of services
Revista Brasileira de Enfermagem. 2016;69(3):522-531
Abstract
Health care for children and adolescents with HIV: a comparison of services
Revista Brasileira de Enfermagem. 2016;69(3):522-531
DOI 10.1590/0034-7167.2016690315i
Views0See moreABSTRACT
Objective:
compare the quality of different types of health care for children and adolescents with HIV, in the experience of family members and caregivers.
Method:
a cross-sectional study was conducted with 71 family members and caregivers, using the children’s version of the Primary Care Assessment Tool (PCATool-Brazil). The Mann-Whitney or Student’s t-test and Pearson’s chi-square or Fisher’s exact test were used for the analysis.
Results:
primary care services and, predominantly, specialized HIV services, were identified as the regular health care sources. There were no significant differences in quality, since their scores were close to the ideal level.
Conclusion:
the attributes of these services need to be improved, which would entail reformulating their structural and performance aspects. In addition, it is imperative to recognize primary health care as an integral place for promoting the health of children and adolescents with HIV.
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Nursing care in Specialized HIV/Aids Outpatient Services
Revista Brasileira de Enfermagem. 2016;69(3):515-521
Abstract
Nursing care in Specialized HIV/Aids Outpatient Services
Revista Brasileira de Enfermagem. 2016;69(3):515-521
DOI 10.1590/0034-7167.2016690314i
Views0See moreABSTRACT
Objective:
to analyze the discourses about the care provided by nurses operating in Specialized HIV/Aids Outpatient Services in four public institutions of the city of Fortaleza, Ceará, Brazil.
Method:
descriptive and exploratory study with a qualitative approach, which used as a method the discourse analysis.
Results:
when titling the “care as negative”, such title came from the analogy proposed by Freud (1912) with the photographic negative, represented by what that care can configure from the unconscious movement, since nurses did not perceive themselves in the care actions developed by supporting the work of other occupational categories, contributing to maintain the ideology of biomedicine.
Conclusion:
it is necessary to justify and theorize a nursing clinical practice from epistemological issues of the profession, in such a way that nurses can understand their relevance within the care provided.
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Notification of health problems among nursing workers in university hospitals
Revista Brasileira de Enfermagem. 2016;69(3):507-514
Abstract
Notification of health problems among nursing workers in university hospitals
Revista Brasileira de Enfermagem. 2016;69(3):507-514
DOI 10.1590/0034-7167.2016690313i
Views0See moreABSTRACT
Objective:
to identify the health problems of nursing workers and describe their consequences.
Method:
an epidemiological, descriptive study with a quantitative approach. The survey was conducted through the Health Monitoring System for Nursing Workers (SIMOSTE) in three university hospitals in São Paulo within a 12-month period.
Results:
a total of 970 records related to health problems were identified; most of these were related to sick leave, occupational accidents with leave, absences, and occupational accidents without leave, with a predominance of musculoskeletal and respiratory system diseases, infectious and parasitic diseases, and nervous system diseases, among others. A total of 4,161 days of work were lost because of the mentioned health problems.
Conclusion:
the results evidence the need to propose preventive strategies to mitigate and reduce health problems in nursing workers.
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