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ORIGINAL ARTICLE07-31-2023
Primary Health Care assessment in the COVID-19 pandemic from physicians’ and nurses’ perspective
Revista Brasileira de Enfermagem. 2023;76:e20220475
Abstract
ORIGINAL ARTICLEPrimary Health Care assessment in the COVID-19 pandemic from physicians’ and nurses’ perspective
Revista Brasileira de Enfermagem. 2023;76:e20220475
DOI 10.1590/0034-7167-2022-0475
Views0ABSTRACT
Objectives:
to assess the operationalization of Primary Health Care in the COVID-19 pandemic, according to Primary Care Assessment Tool: PCATool-Brasil attributes, from physicians’ and nurses’ perspective.
Methods:
a cross-sectional study, carried out with 99 physicians and nurses from Basic Health Units in a state in northeastern Brazil, with the aid of the adapted instrument PCATool-Brasil.
Results:
Essential Score was classified as high performance (6.6) and General Score as low performance (6.5). First Contact Access, Care Integration, and Community Guidance scores were <6.6. The best performances were attributed to the Longitudinality, Comprehensiveness and Family Guidance services (scores>6.6).
Conclusions:
the attributes of Primary Health Care, in general, showed values above or close to the cut-off point in the assessment. These data can support strategies for local and national managers to strengthen Primary Health Care in the COVID-19 pandemic and future public health emergencies.
Keywords:COVID-19Health Care Evaluation MechanismsHealth PersonnelHealth Services ResearchPrimary Health CareSee more -
ORIGINAL ARTICLE07-10-2023
Correlation between symptoms of depression, attitude, and self-care in elderly with type 2 diabetes
Revista Brasileira de Enfermagem. 2023;76(3):e20220741
Abstract
ORIGINAL ARTICLECorrelation between symptoms of depression, attitude, and self-care in elderly with type 2 diabetes
Revista Brasileira de Enfermagem. 2023;76(3):e20220741
DOI 10.1590/0034-7167-2022-0741
Views0See moreABSTRACT
Objectives:
to correlate depressive symptoms, attitude, and self-care of elderly people with type 2 diabetes.
Methods:
study developed with 144 elderly people with diabetes; carried out in Family Health Units. A semi-structured instrument was used to obtain data on the sociodemographic profile; the Geriatric Depression Scale (15 items), the Questionário de Atitudes Psicológicas do Diabetes [Psychological Attitudes of Diabetes Questionnaire], and the Diabetes Self-Care Activities Questionnaire (DSCA) were also used.
Results:
it was identified that 24.3% of the participants presented depressive symptoms, and 93.8% presented negative attitudes of coping. A greater adherence to self-care activities related to the practice of medication was observed. In the correlation between the scales, a negative and inversely proportional correspondence was noted between depressive symptomatology and physical activity (p=0.010) and foot care (p=0.006), likewise between attitude and foot care (p=0.009).
Conclusions:
self-care in elderly people with diabetes mellitus is influenced by depressive symptoms and negative coping attitudes.
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ORIGINAL ARTICLE07-10-2023
Metodologia Lean Seis Sigma para melhoria do processo de alta em uma unidade de terapia intensiva
Revista Brasileira de Enfermagem. 2023;76(3):e20220538
Abstract
ORIGINAL ARTICLEMetodologia Lean Seis Sigma para melhoria do processo de alta em uma unidade de terapia intensiva
Revista Brasileira de Enfermagem. 2023;76(3):e20220538
DOI 10.1590/0034-7167-2022-0538
Views0RESUMEN
Objetivos:
describir el proceso de implementación de Lean Six Sigma para mejorar el proceso de alta en una unidad de cuidados intensivos brasileña.
Métodos:
estudio prospectivo siguiendo el método de desarrollo de proyectos denominado DMAIC (Define-Measure-Analyze-Improve-Control). Este método consta de cinco fases, a saber: definición del proyecto, medición del punto de partida y recolección de datos, análisis de resultados, mejora en los procesos y control estadístico.
Resultados:
la aplicación de la metodología Lean Six Sigma fue efectiva para mejorar el proceso de alta de la unidad de cuidados intensivos a la unidad de hospitalización. Esta mejora representó una reducción en el tiempo promedio de alta de 189 a 75 minutos, totalizando una mejora del 61%.
Conclusiones:
este artículo demuestra la efectividad de la aplicación de la metodología Lean Six Sigma para mejorar el flujo de descarga en una unidad crítica, lo que resulta en la reducción de tiempo y desperdicio.
Keywords:Administração em SaúdeFluxo de TrabalhoGestão da QualidadeMelhoria de QualidadeUnidades de Terapia IntensivaSee more -
REVIEW07-10-2023
Lean Six Sigma methodology to improve the discharge process in a Brazilian intensive care unit
Revista Brasileira de Enfermagem. 2023;76(3):e20220538
Abstract
REVIEWLean Six Sigma methodology to improve the discharge process in a Brazilian intensive care unit
Revista Brasileira de Enfermagem. 2023;76(3):e20220538
DOI 10.1590/0034-7167-2022-0538
Views0ABSTRACT
Objectives:
to describe the Lean Six Sigma implementation process to improve the discharge process in a Brazilian health institution’s ICU.
Methods:
prospective study following the Define-Measure-Analyse-Improve-Control project development method. This method consists of five phases, namely: project definition, measurement of the starting point and data collection, analysis of results, improvement in processes, and statistical control.
Results:
applying Lean Six Sigma methodology following the Define-Measure-Analyse-Improve-Control in the discharge process from the intensive care unit to the inpatient unit was effective in improving processes. This improvement represented a reduction in the mean patient transfer time to the inpatient unit from 189 minutes to 75 minutes, representing a 61% improvement in discharge time.
Conclusions:
this article demonstrates the effectiveness of applying Lean Six Sigma methodology to improve the discharge flow in a critical unit, resulting in time and waste reduction.
Keywords:Health Services AdministrationIntensive Care UnitsPatient DischargeTotal Quality ManagementWorkflowSee more -
ORIGINAL ARTICLE07-10-2023
Primary care in supplementary health: assessment of costs in the care of older adult patients with heart diseases
Revista Brasileira de Enfermagem. 2023;76(3):e20220486
Abstract
ORIGINAL ARTICLEPrimary care in supplementary health: assessment of costs in the care of older adult patients with heart diseases
Revista Brasileira de Enfermagem. 2023;76(3):e20220486
DOI 10.1590/0034-7167-2022-0486
Views0ABSTRACT
Objectives:
to identify whether implementing a supplementary Primary Health Care (PHC) system makes it possible to reduce care costs for older adults with heart diseases.
Methods:
a retrospective cohort of 223 patients with heart disease aged ≥ 60 years. Data were obtained from medical records and cost databases, assessed for a period of one year before and after PHC implementation. The results were expressed as mean absolute frequencies for number of hospitalizations and as average annual expenses expressed in dollars (US$) in relation to cost data.
Results:
there was a reduction in hospitalization expenses after implementing supplementary PHC (p=0.01) and a decrease in the frequency of hospitalizations for the entire sample (p=0.006). There was a reduction in the frequency of consultations at the Emergency Room among frail older adults (p=0.011).
Conclusions:
there was a reduction in hospitalization costs and frequency of visits to the Emergency Room after supplementary PHC.
Keywords:AgedCardiovascular DiseasesCosts and Cost AnalysisLearning Health SystemPrimary Health CareSee more -
ORIGINAL ARTICLE07-10-2023
Occurrence and preventability of adverse events in hospitals: a retrospective study
Revista Brasileira de Enfermagem. 2023;76(3):e20220025
Abstract
ORIGINAL ARTICLEOccurrence and preventability of adverse events in hospitals: a retrospective study
Revista Brasileira de Enfermagem. 2023;76(3):e20220025
DOI 10.1590/0034-7167-2022-0025
Views0See moreABSTRACT
Objectives:
to analyze the incidence of preventable adverse events related to health care in adult patients admitted to public hospitals in Brazil.
Methods:
observational, analytical, retrospective study based on medical records review.
Results:
medical records from 370 patients were evaluated, 58 of whom had at least one adverse event. The incidence of adverse events corresponded to 15.7%. Adverse events were predominantly related to healthcare-related infection (47.1%) and procedures (24.5%). Regarding the adverse event severity, 13.7% were considered mild, 51.0% moderate, and 35.3% severe. 99% of adverse events were classified as preventable. Patients admitted to the emergency room had a 3.73 times higher risk for adverse events.
Conclusions:
this study’s results indicate a high incidence of avoidable adverse events and highlight the need for interventions in care practice.
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EDITORIAL03-08-2024
A enfermagem como protagonista no enfrentamento da hesitação e recusa vacinal
Revista Brasileira de Enfermagem. 2024;77:e77suppl101
Abstract
EDITORIALA enfermagem como protagonista no enfrentamento da hesitação e recusa vacinal
Revista Brasileira de Enfermagem. 2024;77:e77suppl101
DOI 10.1590/0034-7167.202477suppl101pt
Views0Desde a década de 1970, o Ministério da Saúde do Brasil instituiu o Programa Nacional de Imunização (PNI), que precedeu o Sistema Único de Saúde e que lhe foi incorporado e fortalecido, devido ao modelo descentralizado aos municípios, mas de comando único ao nível central. Seu objetivo era e ainda é coordenar as ações de […]See more -
EDITORIAL03-08-2024
Nursing as a player in tackling vaccine hesitancy and refusal
Revista Brasileira de Enfermagem. 2024;77:e77suppl101
Abstract
EDITORIALNursing as a player in tackling vaccine hesitancy and refusal
Revista Brasileira de Enfermagem. 2024;77:e77suppl101
DOI 10.1590/0034-7167.202477suppl101
Views1Since the 1970s, the Brazilian Ministry of Health established the Brazilian National Immunization Program (PNI – Programa Nacional de Imunização), which preceded the Brazilian Health System and which was incorporated and strengthened due to the decentralized model to municipalities, but under single command at central level. Its objective was and still is to coordinate vaccination […]See more -
EDITORIAL02-26-2024
Enfermeiro Navegador de Pacientes com Câncer: contribuições para a discussão no cenário nacional
Revista Brasileira de Enfermagem. 2024;77(2):e770201
Abstract
EDITORIALEnfermeiro Navegador de Pacientes com Câncer: contribuições para a discussão no cenário nacional
Revista Brasileira de Enfermagem. 2024;77(2):e770201
DOI 10.1590/0034-7167.2024770201pt
Views0A prática profissional da navegação de pacientes é algo incipiente no Brasil e, sendo assim, é indispensável uma ampla discussão com vários setores da sociedade, sendo essa a principal propositura deste editorial. Comecemos pela história.A navegação de pacientes foi definida em 1989 como uma intervenção de prestação de serviços baseada na comunidade, com o objetivo […]See more -
EDITORIAL02-26-2024
Nurse Navigator of Cancer Patients: contributions to the discussion on the national stage
Revista Brasileira de Enfermagem. 2024;77(2):e770201
Abstract
EDITORIALNurse Navigator of Cancer Patients: contributions to the discussion on the national stage
Revista Brasileira de Enfermagem. 2024;77(2):e770201
DOI 10.1590/0034-7167.2024770201
Views0The professional practice of patient navigation is incipient in Brazil and, therefore, a broad discussion with various sectors of society is essential, which is the main purpose of this editorial. Shall we start with the story.Patient navigation was defined in 1989 as a community-based service delivery intervention aimed at appropriately promoting access to diagnosis and […]See more -
ERRATUM02-26-2024
ERRATUM
Revista Brasileira de Enfermagem. 2024;77(1):e2024n1e02
Abstract
ERRATUMERRATUM
Revista Brasileira de Enfermagem. 2024;77(1):e2024n1e02
DOI 10.1590/0034-7167.20247701e02
Views0In the article “Active teaching model to promote critical thinking”, with DOI number: , published in Revista Brasileira de Enfermagem, 2019;72(1):293-8, on page 297:Include before REFERENCES:[…]See more -
REVIEW02-26-2024
Practice of immersion in hot water to relieve pain in neonatology: an integrative review
Revista Brasileira de Enfermagem. 2024;77(1):e20230260
Abstract
REVIEWPractice of immersion in hot water to relieve pain in neonatology: an integrative review
Revista Brasileira de Enfermagem. 2024;77(1):e20230260
DOI 10.1590/0034-7167-2023-0260
Views0See moreABSTRACT
Objectives:
to identify immersion use in hot water to relieve pain in newborns.
Methods:
an integrative literature review, carried out in the PubMed, VHL, EMBASE, Scopus, CINAHL, Cochrane and SciELO databases, with investigations in English, Spanish, French or Portuguese, published between 2002 and 2022. The Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH) were used to answer the following question: what are the uses of hot water immersion in relieving pain in newborns?
Results:
nine studies were included, mainly Brazilian, experimental, with a predominance of strong and moderate levels of evidence. Hydrotherapy and bath use (immersion and bandaging) was observed, promising interventions in reducing pain scores, assessed using scales, physiological and endocrine parameters.
Conclusions:
hot water proved to be a promising non-pharmacological intervention in relieving pain in infants in different contexts.
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ORIGINAL ARTICLE02-26-2024
Artificial intelligence to predict bed bath time in Intensive Care Units
Revista Brasileira de Enfermagem. 2024;77(1):e20230201
Abstract
ORIGINAL ARTICLEArtificial intelligence to predict bed bath time in Intensive Care Units
Revista Brasileira de Enfermagem. 2024;77(1):e20230201
DOI 10.1590/0034-7167-2023-0201
Views0See moreABSTRACT
Objectives:
to assess the predictive performance of different artificial intelligence algorithms to estimate bed bath execution time in critically ill patients.
Methods:
a methodological study, which used artificial intelligence algorithms to predict bed bath time in critically ill patients. The results of multiple regression models, multilayer perceptron neural networks and radial basis function, decision tree and random forest were analyzed.
Results:
among the models assessed, the neural network model with a radial basis function, containing 13 neurons in the hidden layer, presented the best predictive performance to estimate the bed bath execution time. In data validation, the squared correlation between the predicted values and the original values was 62.3%.
Conclusions:
the neural network model with radial basis function showed better predictive performance to estimate bed bath execution time in critically ill patients.
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REVIEW02-26-2024
Evidence of intrauterine device insertion by nurses in Primary Health Care: an integrative review
Revista Brasileira de Enfermagem. 2024;77(1):e20230134
Abstract
REVIEWEvidence of intrauterine device insertion by nurses in Primary Health Care: an integrative review
Revista Brasileira de Enfermagem. 2024;77(1):e20230134
DOI 10.1590/0034-7167-2023-0134
Views0ABSTRACT
Objectives:
to synthesize and analyze evidence on intrauterine device insertion by nurses in Primary Health Care.
Methods:
an integrative review, carried out in the BDENF, CINAHL, LILACS, SciELO, Scopus, PubMed and Web of Science databases in June 2022, delimiting the period from 1960 to 2022.
Results:
141 articles were identified in the initial search, and 10 studies made up the final sample. Four (40%) were developed in the United States and one (10%) in Brazil, with publications from 1979 to 2021. The findings were grouped into three categories: Nurse training to insert an intrauterine device; Nurses’ competency to insert an intrauterine device; and Women’s access to intrauterine devices.
Conclusions:
nurse theoretical and practical training is a prominent element, consolidated in the favorable outcomes of insertions performed by nurses and satisfaction among women, a practice that has expanded access to the contraceptive method in Primary Health Care.
Keywords:Advanced Practice NursingIntrauterine DevicesLong-Acting Reversible ContraceptionNursesPrimary Health CareSee more
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ORIGINAL ARTICLE12-16-2024
Nursing team’s perceptions about care for pregnant women in a psychiatric unit
Revista Brasileira de Enfermagem. 2024;77(6):e20230186
Abstract
ORIGINAL ARTICLENursing team’s perceptions about care for pregnant women in a psychiatric unit
Revista Brasileira de Enfermagem. 2024;77(6):e20230186
DOI 10.1590/0034-7167-2023-0186
Views0See moreABSTRACT
Objectives:
to understand the nursing team’s perception in relation to the care provided to pregnant women with mental disorders admitted to a psychiatric hospital unit.
Methods:
Convergent Care Research carried out between August and December 2021, through semi-structured interviews with 25 nursing professionals from a Psychiatric Unit from a reference Hospital in Southern Brazil.
Results:
the organized and analyzed data resulted in two thematic categories: Technical, generic and impersonal care; and From impersonality to the singularity of nursing care. Ensuring unique care for pregnant women with mental disorders means giving them a meaning of existence and providing care from a multidimensional and continuous perspective.
Final Considerations:
nursing care for pregnant women in psychiatric hospitalization requires continuous professional qualification, interactive technologies and support for the nursing process, in addition to promoting singular and multidimensional care.
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ORIGINAL ARTICLE12-16-2024
Bladder ultrasound: evidence of content validity of a checklist for training nurses
Revista Brasileira de Enfermagem. 2024;77(6):e20230183
Abstract
ORIGINAL ARTICLEBladder ultrasound: evidence of content validity of a checklist for training nurses
Revista Brasileira de Enfermagem. 2024;77(6):e20230183
DOI 10.1590/0034-7167-2023-0183
Views0See moreABSTRACT
Objectives:
to develop and analyze evidence of content validity of a checklist for training nurses in measuring bladder volume through ultrasound.
Methods:
a methodological study, consisting of three stages: literature review; instrument item preparation; and analysis of evidence of content validity. The Content Validity Index (CVI) and Gwet’s AC2 were used for content validity analyses.
Results:
the checklist consisted of 23 items. The CVIs for clarity, relevance and dimensionality were 0.99, 0.99 and 0.98 respectively, and the CVIs for Gwet’s AC2 with coefficients for clarity, relevance and dimensionality were 0.89, 0.97 and 0.95, respectively, with p<0.001.
Conclusions:
the checklist developed for training nurses in measuring bladder volume through ultrasound achieved adequate evidence of content validity, and can be used to train nurses in clinical practice and future research.
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ORIGINAL ARTICLE12-16-2024
Childbirth care by health professionals: conflicting practices in obstetrics
Revista Brasileira de Enfermagem. 2024;77(6):e20230129
Abstract
ORIGINAL ARTICLEChildbirth care by health professionals: conflicting practices in obstetrics
Revista Brasileira de Enfermagem. 2024;77(6):e20230129
DOI 10.1590/0034-7167-2023-0129
Views0See moreABSTRACT
Objectives:
to understand the perceptions of women and health professionals regarding childbirth care at a teaching hospital in the western state of Paraná, Brazil.
Methods:
this qualitative study employed Grounded Theory, conducted in an obstetric care service with 38 participants (women and health professionals) through semi-structured interviews.
Results:
limitations in physical infrastructure and management of care, along with the women’s limited knowledge about the childbirth process and the decision-making and guidance of professionals, show conflicting obstetric practices-a discrepancy between good practices and obstetric violence. Training in obstetric nursing and active participation in care, alongside the presence of a companion, were identified as intervening conditions and strategies in the process.
Final Considerations:
childbirth care is characterized by dichotomous practices. While some professionals base their practices on scientific evidence, others rely on teachings and experiences from the time of their training.
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ORIGINAL ARTICLE12-16-2024
A relação entre gênero, formação educacional e ambiente de aprendizagem com a ansiedade do estudante de enfermagem
Revista Brasileira de Enfermagem. 2024;77(6):e20220615
Abstract
ORIGINAL ARTICLEA relação entre gênero, formação educacional e ambiente de aprendizagem com a ansiedade do estudante de enfermagem
Revista Brasileira de Enfermagem. 2024;77(6):e20220615
DOI 10.1590/0034-7167-2022-0615
Views0See moreRESUMEN
Objetivos:
identificar las variables asociadas a la práctica clínica relacionadas con la ansiedad de los estudiantes de enfermería.
Métodos:
se utilizó un diseño descriptivo, cuantitativo, correlacional con las recomendaciones STROBE, EQUATOR. La población fue de 233 estudiantes de enfermería con una muestra de 135 personas. Los datos se recopilaron de marzo a abril de 2022 utilizando instrumentos validados.
Resultados:
la prueba de chi-cuadrado y razón de verosimilitud significativa para género, formación académica y entorno de aprendizaje son superiores a 0.05, por lo que no existe una relación significativa entre las variables y la ansiedad de los estudiantes.
Conclusiones:
los estudiantes necesitan prepararse nuevamente antes de ingresar al campo de la práctica. Investigaciones cualitativas también son necesarias.
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ORIGINAL ARTICLE12-16-2024
The relationship between gender, educational background, and learning environment with nursing student’s anxiety
Revista Brasileira de Enfermagem. 2024;77(6):e20220615
Abstract
ORIGINAL ARTICLEThe relationship between gender, educational background, and learning environment with nursing student’s anxiety
Revista Brasileira de Enfermagem. 2024;77(6):e20220615
DOI 10.1590/0034-7167-2022-0615
Views0See moreABSTRACT
Objectives:
to identify variables associated with nursing students’ anxiety-related clinical practice.
Methods:
this study used a correlational quantitative descriptive design with the STROBE equator instrument. The population is 233 nursing students with a sample of 135. Data were collected from March to April 2022 using validated instruments.
Results:
the Chi-square test and the sig likelihood ratio on the gender, educational background, and learning environment is more than 0.05 so there is no significant relationship between the variables and student anxiety.
Conclusions:
students need to be prepared again before entering the practice field. Qualitative research is needed too.
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ORIGINAL ARTICLE12-13-2024
Educational booklet on labor and delivery: validity study
Revista Brasileira de Enfermagem. 2024;77(5):e20240138
Abstract
ORIGINAL ARTICLEEducational booklet on labor and delivery: validity study
Revista Brasileira de Enfermagem. 2024;77(5):e20240138
DOI 10.1590/0034-7167-2024-0138
Views0See moreABSTRACT
Objectives:
to develop and validate an educational booklet on labor and delivery for pregnant women.
Methods:
this methodological study involved constructing and validating a booklet based on Echer’s framework. We used the Content Validity Index and Cronbach’s alpha for content and face validation, selecting judges according to Fering’s criteria. We then conducted a clinical validation with the target population.
Results:
the booklet, developed based on evidence from an integrative review and validated by judges and the target audience, achieved global Content Validity Index of 0.919 and 0.913, respectively. After clinical validation with 22 pregnant women, it included 28 topics and 48 pages, with illustrations by a graphic designer.
Conclusions:
expert judges and the target audience considered this educational technology valid, deeming it a relevant tool for promoting the health of pregnant women.
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ORIGINAL ARTICLE12-13-2024
Knowledge and attitudes of nursing students regarding the sexuality of older adults: a quasi-experimental study
Revista Brasileira de Enfermagem. 2024;77(5):e20240011
Abstract
ORIGINAL ARTICLEKnowledge and attitudes of nursing students regarding the sexuality of older adults: a quasi-experimental study
Revista Brasileira de Enfermagem. 2024;77(5):e20240011
DOI 10.1590/0034-7167-2024-0011
Views0See moreABSTRACT
Objectives:
to compare the knowledge and attitudes of nursing students regarding sexual behavior and sexually transmitted infections (STIs) in older adults before and after an educational intervention.
Methods:
this quasi-experimental study involved a convenience sample of 45 nursing students from a public university, conducted in three stages: pre-intervention, intervention, and post-intervention. A questionnaire was used to assess sociodemographic characteristics, academic training, and knowledge and attitudes on the topic. The intervention was an educational web conference. Paired t-test and Wilcoxon test were used for data analysis.
Results:
there was a statistically significant difference in the knowledge and attitude scores of nursing students before and after the educational intervention (p < 0.001). A significant increase was observed in the knowledge score (from 9.3 to 12.2) and attitude score (from 108 to 117.2) in the post-intervention phase.
Conclusions:
the knowledge of nursing students regarding the sexuality of older adults increased after the educational intervention, and their attitudes on the subject became more positive.
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ORIGINAL ARTICLE12-13-2024
Stress in nursing workers caring for people with COVID-19
Revista Brasileira de Enfermagem. 2024;77(5):e20230542
Abstract
ORIGINAL ARTICLEStress in nursing workers caring for people with COVID-19
Revista Brasileira de Enfermagem. 2024;77(5):e20230542
DOI 10.1590/0034-7167-2023-0542
Views0See moreABSTRACT
Objectives:
to analyze stress from the perspective of nursing workers caring for people with COVID-19 in a public hospital in the Recôncavo region of Bahia.
Methods:
this is an exploratory qualitative study, conducted through semi-structured interviews. The data were analyzed using word clouds, similarity trees, and content analysis.
Results:
nursing workers were exposed to stress while attending to patients with COVID-19. The reported stressors in the workplace included: work overload, lack of planning, speed in performing tasks, fatigue, lack of participation in decision-making, lack of support from management, technological changes, excessive responsibility without preparation, interpersonal conflicts, and professional undervaluation.
Conclusions:
exposure to these stressors leads to emotional exhaustion and demotivation, which were intensified during the COVID-19 pandemic.
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