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ORIGINAL ARTICLE07-19-2024
Validation of an instrument for patient classification to support obstetric nursing care
Revista Brasileira de Enfermagem. 2024;77(2):e20230401
Abstract
ORIGINAL ARTICLEValidation of an instrument for patient classification to support obstetric nursing care
Revista Brasileira de Enfermagem. 2024;77(2):e20230401
DOI 10.1590/0034-7167-2023-0401
Views0See moreABSTRACT
Objectives:
to develop and validate an instrument for the classification of pregnant and postpartum women according to the demand for nursing care.
Methods:
a methodological study conducted in three stages: 1) construction of the instrument based on literature review; 2) content validation using the Delphi technique with 12 experts; and 3) Evaluation of the convergent construct validity through the correlation between the scores of the constructed instrument and the Fugulin instrument.
Results:
an instrument with ten indicators of specific care for pregnant and postpartum women was developed. A content validity index higher than 0.9 was obtained, requiring only one round of the Delphi technique. The Spearman coefficient was 0.64 between the instruments, indicating a strong correlation.
Conclusions:
the classification instrument specifically constructed for pregnant and postpartum women showed evidence of content validity and convergent construct validity with a widely used instrument in the national territory.
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ORIGINAL ARTICLE07-19-2024
Validation of an instrument for assessing leprosy care in children and adolescents
- Gutembergue Santos de Sousa
, - Isael Marcos Silva Mendonça ,
- Lia Hanna Martins Morita ,
- Denise da Costa Boamorte Cortela ,
- Pãmela Rodrigues de Souza Silva , [ … ],
- Silvana Margarida Benevides Ferreira
Abstract
ORIGINAL ARTICLEValidation of an instrument for assessing leprosy care in children and adolescents
Revista Brasileira de Enfermagem. 2024;77(2):e20230344
DOI 10.1590/0034-7167-2023-0344
- Gutembergue Santos de Sousa ,
- Isael Marcos Silva Mendonça ,
- Lia Hanna Martins Morita ,
- Denise da Costa Boamorte Cortela ,
- Pãmela Rodrigues de Souza Silva ,
- Silvana Margarida Benevides Ferreira
Views1See moreABSTRACT
Objectives:
to validate the content of an instrument for assessing leprosy care in individuals under 15 years old in the context of Primary Health Care.
Methods:
methodological study of content validation, based on the evaluation of essential and derived attributes in primary care, in the professional version. For data analysis, the Content Validation Index (CVI ≥ 0.8) and Cronbach’s Alpha were calculated.
Results:
a higher percentage of judges among nurses (61.5%) was observed; with a doctorate (46.2%), and engaged in teaching and research (77%). The overall Content Validation Index of the instrument was 0.98. In the analysis of Cronbach’s Alpha of the instrument, the assigned value was 0.717.
Conclusions:
the instrument represents an advancement in the measurement of health evaluation policies and can significantly contribute to improving the quality of care provided to children and adolescents with leprosy.
- Gutembergue Santos de Sousa
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ORIGINAL ARTICLE07-19-2024
Validation of the Brazilian Version of the Modified Scale for Delineating Advanced Practice Nursing Roles
Revista Brasileira de Enfermagem. 2024;77(2):e20230211
Abstract
ORIGINAL ARTICLEValidation of the Brazilian Version of the Modified Scale for Delineating Advanced Practice Nursing Roles
Revista Brasileira de Enfermagem. 2024;77(2):e20230211
DOI 10.1590/0034-7167-2023-0211
Views0See moreABSTRACT
Objectives:
to validate the Brazilian version of the Modified Scale for Delineating Advanced Practice Nursing Roles.
Methods:
this was a methodological study for the clinical validation of an instrument, conducted with 207 nurses working in primary care. Exploratory and confirmatory factor analysis, Cronbach’s alpha test, and z-test for proportion comparison were used.
Results:
the internal reliability of the scale was 0.944, with alpha greater than 0.80 in most domains, except for Education (0.786). In the exploratory factor analysis, considering the criterion of eigenvalue greater than one, eight factors were identified, explaining 79.38% of the variance. In the comparison of proportions, the adequate responses (≥ 2) in the domain of Comprehensive Direct Care, in both analyzed groups, were statistically equal. This domain had the highest score of adequate responses, followed by Education and Systems Support. Insufficient scoring was observed in the domains of Publication and Professional Leadership.
Conclusions:
the instrument demonstrated stability and reliability to be used in the evaluation of advanced nursing practice.
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REVIEW07-15-2024
Factors associated with Burnout Syndrome in police officers: a scoping review
- Beatriz Maria dos Santos Santiago Ribeiro ,
- Fabio Scorsolini-Comin ,
- Maria Lucia do Carmo Cruz Robazzi ,
- Sérgio Valverde Marques dos Santos ,
- Fábio de Souza Terra , [ … ],
- Rita de Cassia de Marchi Barcellos Dalri
Abstract
REVIEWFactors associated with Burnout Syndrome in police officers: a scoping review
Revista Brasileira de Enfermagem. 2024;77(2):e20230444
DOI 10.1590/0034-7167-2023-0444
- Beatriz Maria dos Santos Santiago Ribeiro ,
- Fabio Scorsolini-Comin ,
- Maria Lucia do Carmo Cruz Robazzi ,
- Sérgio Valverde Marques dos Santos ,
- Fábio de Souza Terra ,
- Rita de Cassia de Marchi Barcellos Dalri
Views0See moreABSTRACT
Objectives:
to synthesize research on factors associated with Burnout Syndrome (BS) in police officers.
Methods:
a scoping review was conducted without temporal or language restrictions. Data were exported to EndNote to remove duplicates and then imported into the Rayyan app for organization, article selection, and data extraction.
Results:
a total of 4559 publications were identified, with 50 studies included in the review. Research conducted in Brazil and the United States predominated. Certain occupational factors were found to be more closely linked to police officers compared to other professions, including law enforcement, frequency of interaction with suspects and criminals, rank, dissatisfaction with the organization, and civilian confrontations.
Conclusions:
certain aspects of the police profession contribute to BS, even in countries with better working conditions in public security. It is recommended to prioritize health promotion initiatives for these professionals.
- Beatriz Maria dos Santos Santiago Ribeiro
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07-15-2024
Invisibilidade do trabalho da enfermagem: tecnologia como via de combate
Revista Brasileira de Enfermagem. 2024;77:e77suppl0301
Abstract
Invisibilidade do trabalho da enfermagem: tecnologia como via de combate
Revista Brasileira de Enfermagem. 2024;77:e77suppl0301
DOI 10.1590/0034-7167.202477suppl0301pt
Views0Na concepção comum, o trabalho é comumente associado a uma atividade remunerada em uma sociedade mercantil e de direito, refletindo a visão moderna que o limita ao tempo trocado por salário. Essa perspectiva, influenciada pelos princípios da Revolução Industrial, estabelece uma dicotomia entre o trabalho e o tempo fora dele, segmentando a vida em esferas […]See more -
ORIGINAL ARTICLE07-15-2024
Root cause analysis of safety incidents in antineoplastic use in children
- Elizangela Domiciano Garcia Barreto ,
- Valcieny Souza Sandes ,
- Gustavo Cattelan Nobre ,
- Monica Martins ,
- Sima Esther Ferman , [ … ],
- Elisangela Costa Lima
Abstract
ORIGINAL ARTICLERoot cause analysis of safety incidents in antineoplastic use in children
Revista Brasileira de Enfermagem. 2024;77:e20230139
DOI 10.1590/0034-7167-2021-0139
- Elizangela Domiciano Garcia Barreto ,
- Valcieny Souza Sandes ,
- Gustavo Cattelan Nobre ,
- Monica Martins ,
- Sima Esther Ferman ,
- Elisangela Costa Lima
Views1See moreABSTRACT
Objectives:
to identify and analyze the factors that contribute to safety incident occurrence in the processes of prescribing, preparing and dispensing antineoplastic medications in pediatric oncology patients.
Methods:
a quality improvement study focused on oncopediatric pharmaceutical care processes that identified and analyzed incidents between 2019-2020. A multidisciplinary group performed root cause analysis (RCA), identifying main contributing factors.
Results:
in 2019, seven incidents were recorded, 57% of which were prescription-related. In 2020, through active search, 34 incidents were identified, 65% relating to prescription, 29% to preparation and 6% to dispensing. The main contributing factors were interruptions, lack of electronic alert, work overload, training and staff shortages.
Conclusions:
the results showed that adequate recording and application of RCA to identified incidents can provide improvements in the quality of pediatric oncology care, mapping contributing factors and enabling managers to develop an effective action plan to mitigate risks associated with the process.
- Elizangela Domiciano Garcia Barreto
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07-15-2024
Invisibility of nursing work: technology as a means of combat
Revista Brasileira de Enfermagem. 2024;77:e77suppl0301
Abstract
Invisibility of nursing work: technology as a means of combat
Revista Brasileira de Enfermagem. 2024;77:e77suppl0301
DOI 10.1590/0034-7167.202477suppl0301
Views0In the common conception, work is commonly associated with a paid activity in a commercial and legal society, reflecting the modern view that limits it to time exchanged for wage. This perspective, influenced by Industrial Revolution principles, establishes a dichotomy between work and time outside of work, segmenting life into professional and private spheres. However, […]See more -
REVIEW07-15-2024
Risk for imbalanced blood pressure pattern among incarcerated women: Middle-Range Theory
- Gabrielle Pessôa da Silva ,
- Camila Takáo Lopes ,
- Marcos Venícios de Oliveira Lopes ,
- Ryanne Carolynne Marques Gomes Mendes ,
- Jaqueline Galdino Albuquerque Perrelli , [ … ],
- Francisca Márcia Pereira Linhares
Abstract
REVIEWRisk for imbalanced blood pressure pattern among incarcerated women: Middle-Range Theory
Revista Brasileira de Enfermagem. 2024;77:e20230288
DOI 10.1590/0034-7167-2023-0288
- Gabrielle Pessôa da Silva ,
- Camila Takáo Lopes ,
- Marcos Venícios de Oliveira Lopes ,
- Ryanne Carolynne Marques Gomes Mendes ,
- Jaqueline Galdino Albuquerque Perrelli ,
- Lívia Maia Pascoal ,
- Suzana de Oliveira Mangueira ,
- Francisca Márcia Pereira Linhares
Views0See moreABSTRACT
Objectives:
to develop a Middle-Range Theory for the Risk for imbalanced blood pressure pattern among incarcerated women.
Methods:
theoretical development study to obtain the theoretical-causal validity of the Nursing Diagnosis Risk for unstable blood pressure. The Middle-Range Theory was developed according to six stages: establishment of the approach to developing the theory; definition of the conceptual models to be later analyzed; definition of the main conceptions; a pictorial diagram; propositions; causal relationships and evidence for practice.
Results:
two attributes and 20 antecedents related to imbalanced blood pressure were identified, a pictorial diagram was developed, and nine theoretical propositions were presented.
Conclusions:
the theory developed here favors the diagnostic reasoning of nurses and contributes to planning actions to promote the cardiovascular health of incarcerated women. A new proposition for the diagnosis of Risk for unstable blood pressure was also structured with a new title, definition, and etiological factors.
- Gabrielle Pessôa da Silva
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REVIEW06-11-2021
Mental health interventions implemented in the COVID-19 pandemic: what is the evidence?
- Wanderson Carneiro Moreira ,
- Kayo Henrique Jardel Feitosa Sousa ,
- Anderson Reis de Sousa ,
- Thiago da Silva Santana ,
- Regina Célia Gollner Zeitoune , [ … ],
- Maria do Perpétuo Socorro de Sousa Nóbrega
Abstract
REVIEWMental health interventions implemented in the COVID-19 pandemic: what is the evidence?
Revista Brasileira de Enfermagem. 2021;74:e20200635
DOI 10.1590/0034-7167-2020-0635
- Wanderson Carneiro Moreira ,
- Kayo Henrique Jardel Feitosa Sousa ,
- Anderson Reis de Sousa ,
- Thiago da Silva Santana ,
- Regina Célia Gollner Zeitoune ,
- Maria do Perpétuo Socorro de Sousa Nóbrega
Views0See moreABSTRACT
Objective:
to map the evidence on mental health interventions implemented during the COVID-19 pandemic.
Method:
this scoping review was carried out in the MEDLINE/PubMed, SCOPUS, Web of Science, PsycINFO, and Science Direct databases and in the medRxiv, bioRxiv, and PsyArXiv preprints servers using the descriptors “Covid-19”, “coronavirus infection”, “coronavirus”, “2019-nCoV”, “2019 novel coronavirus disease”, “SARS-CoV-2”, “health personnel”, “general public”, and “mental health”.
Results:
eight articles were selected and categorized into mental health interventions for the population, among which mental health interventions were for people diagnosed with suspicion/confirmed COVID-19 and mental health interventions for health professionals.
Conclusion:
telemonitoring, virtual games and strategies focused on social support and muscle relaxation techniques, characterized as non-pharmacological and low-cost, were shown as interventions, which, since they are effective, need to be encouraged and included in mental health care practices.
- Wanderson Carneiro Moreira
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06-07-2019
Nursing performance in robotic surgeries: integrative review
- Raísha Costa Martins ,
- Denilse Damasceno Trevilato ,
- Marielli Trevisan Jost ,
- Rita Catalina Aquino Caregnato
Abstract
Nursing performance in robotic surgeries: integrative review
Revista Brasileira de Enfermagem. 2019;72(3):795-800
DOI 10.1590/0034-7167-2018-0426
- Raísha Costa Martins ,
- Denilse Damasceno Trevilato ,
- Marielli Trevisan Jost ,
- Rita Catalina Aquino Caregnato
Views0See moreABSTRACT
Objective:
To know the scientific production on the performance of the nursing staff in robotic surgeries, identifying the role of the nurse in the three perioperative periods.
Methods:
Integrative review, search in the databases National Library of Medicine, National Institutes of Health, Scientific Electronic Library Online and Biblioteca Virtual em Saúde, performed from June to September, 2017; 17 selected articles met the inclusion criteria.
Results:
Most articles were published in foreign journals in English, nine in the United States, classified with evidence level of 4 and 5. The role of nursing in the perioperative period was identified, related mainly to patient safety. The most mentioned perioperative period in the articles was the intraoperative, with greater concern in the positioning of the patient.
Conclusion:
The nursing performance and patient safety in robotic surgeries are similar to the ones in major surgeries, requiring from the patient a specific knowledge on the setting and preparation of the robot.
- Raísha Costa Martins
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ORIGINAL ARTICLE10-21-2019
“Waiting for a miracle”: Spirituality/Religiosity in coping with sickle cell disease
- Maiara Vitor Gomes ,
- Aline da Silva Gomes Xavier ,
- Evanilda Souza de Santana Carvalho ,
- Rosa Cândida Cordeiro ,
- Sílvia Lúcia Ferreira , [ … ],
- Amarry Dantas Morbeck
Abstract
ORIGINAL ARTICLE“Waiting for a miracle”: Spirituality/Religiosity in coping with sickle cell disease
Revista Brasileira de Enfermagem. 2019;72(6):1554-1561
DOI 10.1590/0034-7167-2018-0635
- Maiara Vitor Gomes ,
- Aline da Silva Gomes Xavier ,
- Evanilda Souza de Santana Carvalho ,
- Rosa Cândida Cordeiro ,
- Sílvia Lúcia Ferreira ,
- Amarry Dantas Morbeck
Views0See moreABSTRACT
Objective:
To understand spirituality/religiosity as experienced by people with sickle cell disease, and its influence on coping with the disease.
Method:
A qualitative, descriptive, and exploratory study conducted in the State of Bahia. Twenty-nine respondents participated in semi-structured interviews. Content analysis was used to analyze the empirical material.
Results:
Individuals with sickle cell disease experience spirituality/religiosity motivated by their hope for a miracle, and fear of death; among their rites are: reading religious materials, individual and group prayer, and attendance at worship services. The effects on their health include: comfort by means of coping by comparing two evils, anxiety relief, social support, and lifestyle changes; however, spirituality/religiosity may be impaired.
Final considerations:
This study demonstrates the need to qualify health professionals to address spiritual issues of these individuals during illness, with the aims of diagnosing suffering and anguish, and providing care, comfort and strengthening of the spiritual bonds of these individuals.
- Maiara Vitor Gomes
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ORIGINAL ARTICLE12-21-2020
Construction and validation of a mobile application for development of nursing history and diagnosis
- Evandro Bernardino Mendes de Melo ,
- Cândida Caniçali Primo ,
- Walckiria Garcia Romero ,
- Hugo Cristo Sant’Anna ,
- Carlos Alberto da Cruz Sequeira , [ … ],
- Mirian Fioresi
Abstract
ORIGINAL ARTICLEConstruction and validation of a mobile application for development of nursing history and diagnosis
Revista Brasileira de Enfermagem. 2020;73:e20190674
DOI 10.1590/0034-7167-2019-0674
- Evandro Bernardino Mendes de Melo ,
- Cândida Caniçali Primo ,
- Walckiria Garcia Romero ,
- Hugo Cristo Sant’Anna ,
- Carlos Alberto da Cruz Sequeira ,
- Eliane de Fátima Almeida Lima ,
- Mirian Fioresi
Views0See moreABSTRACT
Objectives:
to describe the construction and validation process for a mobile application for development of the nursing history and diagnosis.
Methods:
methodological study conducted in 2018 in three stages: content creation, based on the Basic Human Needs categories and nursing diagnoses; content assessment by nine nursing judges, with calculation of the content validity index; and construction of the application, which included definition of the requirements, a conceptual map, implementation and prototyping options, tests and implementation.
Results:
the application was organized by sections: Grouped Basic Human Needs, Cranial pair tests, Clinical assessment scales and Additional tests. Two section were adjusted according to the judges’ suggestions.
Final Considerations:
it is the first application produced in Brazil based on the Basic Human Need categories, which enables quick access to information, concepts and typical nomenclatures of semiology, recording of clinical data and definition of nursing diagnoses.
- Evandro Bernardino Mendes de Melo
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ORIGINAL ARTICLE10-01-2022
Factors associated with vulnerability and fragility in the elderly: a cross-sectional study
- Caroline Ribeiro de Sousa ,
- Janaína Fonseca Victor Coutinho ,
- João Bastos Freire Neto ,
- Rachel Gabriel Bastos Barbosa ,
- Marília Braga Marques , [ … ],
- Jamylle Lucas Diniz
Abstract
ORIGINAL ARTICLEFactors associated with vulnerability and fragility in the elderly: a cross-sectional study
Revista Brasileira de Enfermagem. 2022;75(2):e20200399
DOI 10.1590/0034-7167-2020-0399
- Caroline Ribeiro de Sousa ,
- Janaína Fonseca Victor Coutinho ,
- João Bastos Freire Neto ,
- Rachel Gabriel Bastos Barbosa ,
- Marília Braga Marques ,
- Jamylle Lucas Diniz
Views0See moreABSTRACT
Objectives:
to assess factors associated with vulnerability and fragility in the elderly.
Methods:
crosssectional study with 384 elderly people in Fortaleza, Ceará. The Vulnerable Elders Survey and Clinical-Functional Vulnerability Index – 20 were used. Chi-square and Fisher’s exact tests were used for associations. In the analysis of the combined influence of risk factors, the stepwise logistic regression and multinomial regression methods were adopted.
Results:
251 (65.4%) non-vulnerable and 133 (34.6%) vulnerable elders. From the vulnerable elders analyzed, 42 (30.9%) are at high risk for frailty. Factors associated with vulnerability: age, gender, presence of comorbidities, hypertension, diabetes, osteoporosis and use of polypharmacy. There is a 30% increase in the chance of vulnerability for each additional drug. Physical activity reduces the chance of vulnerability by 60%. Factors associated with frailty: educational level; self-perception of health; comorbidities; polypharmacy.
Conclusions:
it is important to pay attention to the presence of arterial hypertension, osteoporosis, polypharmacy, and encourage the practice of physical activity.
- Caroline Ribeiro de Sousa
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ORIGINAL ARTICLE10-21-2019
Caring ability, burden, stress and coping of family caregivers of people in cancer treatment
- Larissa de Carli Coppetti ,
- Nara Marilene Oliveira Girardon-Perlini ,
- Rafaela Andolhe ,
- Laís Mara Caetano da Silva ,
- Steffani Nikoli Dapper , [ … ],
- Elissa Noro
Abstract
ORIGINAL ARTICLECaring ability, burden, stress and coping of family caregivers of people in cancer treatment
Revista Brasileira de Enfermagem. 2019;72(6):1541-1546
DOI 10.1590/0034-7167-2018-0605
- Larissa de Carli Coppetti ,
- Nara Marilene Oliveira Girardon-Perlini ,
- Rafaela Andolhe ,
- Laís Mara Caetano da Silva ,
- Steffani Nikoli Dapper ,
- Elissa Noro
Views0See moreABSTRACT
Objective:
To analyze the association between the caring ability and the burden, stress and coping of family caregivers of people in cancer treatment.
Method:
A cross-sectional study with 132 family caregivers. The following instruments were applied: a characterization instrument, the Caring Ability Inventory, the Zarit Burden Interview, the Perceived Stress Scale, and the Brief COPE. The Spearman Correlation was used with significance ≤5%.
Results:
There were significant and positive correlations between total caring ability and: burden – interpersonal relationship (p=0.03); stress (p=0.02) and maladaptive coping (p=0.00); and inversely proportional correlations with problem-focused coping (p=0.03). The courage had inversely proportional correlation with: self-efficacy (p=0.03), interpersonal relationship (p=0.00), stress (p=0.04) and maladaptive coping (p=0.00). The knowledge had significant and positive correlation with problem-focused coping (p=0.00), adaptive coping (p=0.01), and inverse correlation with stress (p=0.02).
Conclusion:
The level of caring ability correlates with levels of stress and burden, and with the type of coping strategy used by family caregivers.
- Larissa de Carli Coppetti
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ORIGINAL ARTICLE10-18-2022
Clinical simulation as a Nursing Fundamentals teaching method: a quasi-experimental study
- Fernanda Letícia da Silva Campanati ,
- Laiane Medeiros Ribeiro ,
- Izabel Cristina Rodrigues da Silva ,
- Paula Regina de Souza Hermann ,
- Guilherme da Costa Brasil , [ … ],
- Silvana Schwerz Funghetto
Abstract
ORIGINAL ARTICLEClinical simulation as a Nursing Fundamentals teaching method: a quasi-experimental study
Revista Brasileira de Enfermagem. 2022;75(2):e20201155
DOI 10.1590/0034-7167-2020-1155
- Fernanda Letícia da Silva Campanati ,
- Laiane Medeiros Ribeiro ,
- Izabel Cristina Rodrigues da Silva ,
- Paula Regina de Souza Hermann ,
- Guilherme da Costa Brasil ,
- Karen Karoline Gouveia Carneiro ,
- Silvana Schwerz Funghetto
Views0See moreABSTRACT
Objectives:
to evaluate students’ knowledge gain after the implementation of clinical simulation in Nursing Fundamentals disciplines.
Methods:
a quasi-experimental intervention was carried out with 60 students, distributed in comparison and intervention groups, who underwent traditional teaching and traditional teaching associated with simulated teaching, respectively. Pre-test and post-test instruments were applied to both groups.
Results:
after analyzing the students’ performance through the applied instruments, both groups had a cognitive evolution along with the taught content, however, when compared, the intervention group obtained a higher knowledge gain than the comparison group (p = 0.016), demonstrating progressive and increasing improvement with the use of the methodology.
Conclusions:
simulated teaching significantly helps students in gaining technical-cognitive knowledge. Therefore, it is recommended to adhere to the use of this methodology for teaching Nursing Fundamentals.
- Fernanda Letícia da Silva Campanati
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ORIGINAL ARTICLE08-10-2020
Eliot Freidson’s sociology of professions: an interpretation for Health and Nursing
Revista Brasileira de Enfermagem. 2020;73(6):e20180950
Abstract
ORIGINAL ARTICLEEliot Freidson’s sociology of professions: an interpretation for Health and Nursing
Revista Brasileira de Enfermagem. 2020;73(6):e20180950
DOI 10.1590/0034-7167-2018-0950
Views0See moreABSTRACT
Objectives:
to analyze theoretical conceptions of Eliot Freidson’s Sociology of Professions scoped on health and nursing professions.
Methods:
Eight nurses were interviewed, all involved in the development of the professional Council on the timeframe from 1975 to 1986. Documental resources were Laws, Ordinances, Resolutions, Reports, Meeting Minutes and Public Deeds. Information was organized as from literature and Eliot Freidson’s conceptions, and thematic content analysis was carried out.
Results:
the concepts authored by Eliot Freidson allowed for the development of a concept chart that portrays the nursing profession and that may be expanded for the other occupations in the health field, in consonance with professional organization in the country.
Final Considerations:
Eliot Freidson’s framework, in interpretation for nursing, consolidates the profession with relative autonomy, expertise by Nursing Care Systematization and credentialism by professional normalizations.
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