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01-01-2015
Critical incidents in nursing academics: discovering a new identity
Revista Brasileira de Enfermagem. 2015;68(2):219-227
Abstract
Critical incidents in nursing academics: discovering a new identity
Revista Brasileira de Enfermagem. 2015;68(2):219-227
DOI 10.1590/0034-7167.2015680206i
Views0See moreABSTRACT
Objective:
a qualitative study that followed the principles of the grounded theory in order to analyze the professional identity of nursing academics through the analysis of the most disturbing critical incidents.
Method:
semi-structured interviews were conducted with seven nurses who worked as professors and researchers in a private university in Barcelona.
Results:
the resulting empirical material was organized into two categories: characterization of critical incidents and responsiveness to the incident.
Conclusion:
the professional identity of nurses regarding the academic area is still under construction and inexperience is the major obstacle in the management of critical incidents in the teaching career.
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01-01-2015
Body mass index, waist circumference, and arterial hypertension in students
Revista Brasileira de Enfermagem. 2015;68(2):214-218
Abstract
Body mass index, waist circumference, and arterial hypertension in students
Revista Brasileira de Enfermagem. 2015;68(2):214-218
DOI 10.1590/0034-7167.2015680205i
Views0See moreABSTRACT
Objective:
to investigate what is the best anthropometric predictor of arterial hypertension among private school students.
Method:
this was a cross-sectional study with 286 students between the ages of 10 and 14 from two private schools in the city of Paranavaí, Paraná, Brazil. The following variables were analyzed: body mass index, waist circumference and blood pressure. Statistical analysis was conducted with Pearson’s partial correlation test and multivariate logistic regression, with p<0.05.
Results:
both anthropometric indicators displayed weak correlation with systolic and diastolic levels, with coeffi cients (r) ranging from 0.27 to 0.36 (p < 0.001). Multivariate analysis showed that the only anthropometric indicator associated with arterial hypertension was waist circumference (OR= 2.3; 95% CI: 1.1-4.5), regardless of age or gender.
Conclusion:
this age group, waist circumference appeared to be a better predictor for arterial hypertension than body mass index.
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01-01-2015
Perception of primary healthcare management nurses on the nursing process
Revista Brasileira de Enfermagem. 2015;68(2):206-213
Abstract
Perception of primary healthcare management nurses on the nursing process
Revista Brasileira de Enfermagem. 2015;68(2):206-213
DOI 10.1590/0034-7167.2015680204i
Views0See moreABSTRACT
Objective:
this qualitative study aimed to analyze the perceptions of primary health care management nurses on the nursing process.
Method:
data were collected through interviews and analyzed by the Content Analysis proposed by Bardin’s theoretical framework.
Results:
managers recognize the importance of the nursing process, although its implementation was not a priority at the time of the interviews. A conceptual diffi culty and a lack of understanding that the implementation of the care methodology should be a cross-departmental action in the local healthcare management were clearly observed.
Conclusion:
managers should have their perspectives broadened concerning the relevance of the nursing process and the professional training. The active participation of legislative nursing bodies, local healthcare management and the federal government may open the way for the effective implementation of the nursing process.
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01-01-2015
Cross-cultural cultural adaptation of the “Nursing Students’ Attitudes Toward Mental Health Nursing and Consumers” in Brazil
Revista Brasileira de Enfermagem. 2015;68(2):198-205
Abstract
Cross-cultural cultural adaptation of the “Nursing Students’ Attitudes Toward Mental Health Nursing and Consumers” in Brazil
Revista Brasileira de Enfermagem. 2015;68(2):198-205
DOI 10.1590/0034-7167.2015680203i
Views0See moreABSTRACT
Objective:
to make across-cultural adaptation of the “Nursing Students’ Attitudes Toward Mental Health Nursing and Consumers” scale in Brazil.
Method:
the scale was tested regarding conceptual, item, semantic, and operational equivalence.
Results:
content validation was conducted by an expert committee with a minimum consensus level of 80%. This process resulted in a 35-item scale divided into 6 factors. The experts reached 100% consensus on the scale’s clarity of language, practical pertinence and theoretical relevance, as well as on the need for excluding one factor. Data were collected in 2013 in the city of Londrina, Paraná, Brazil.
Conclusion:
the instrument was cross-culturally adapted to Brazilian Portuguese and presented satisfactory content validity. We propose further studies on the scale’s psychometric properties, such as construct validity, internal consistency and reliability.
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01-01-2015
Relational skills and preserving patient privacy in the caring process
Revista Brasileira de Enfermagem. 2015;68(2):191-197
Abstract
Relational skills and preserving patient privacy in the caring process
Revista Brasileira de Enfermagem. 2015;68(2):191-197
DOI 10.1590/0034-7167.2015680202i
Views0See moreABSTRACT
Objective:
to analyze the development and mobilization of relational skills central to the caring process among nursing students throughout their professional training.
Method:
this was a quantitative study, descriptive and cross-sectional in design. The sample consisted of nursing undergraduate students from the Higher School of Health Sciences, in the city of Évora, Portugal. Data were collected using the previously validated Helping Relational Skills Inventory.
Results:
the students gradually acquired “generic skills”, “communication skills” and “contact skills”, presenting the highest mean score in the last year of the program. However, the highest mean score for the “empathetic skills” subscale was presented by second-year students.
Conclusion:
age and year in program were found to be decisive variables regarding the acquisition of specifi c skills (empathetic and communication) by nursing students.
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01-01-2015
The Brazilian Association of Nursing in the uncompromising defense of the Brazilian Unified Health System
Revista Brasileira de Enfermagem. 2015;68(2):185-186
Abstract
The Brazilian Association of Nursing in the uncompromising defense of the Brazilian Unified Health System
Revista Brasileira de Enfermagem. 2015;68(2):185-186
DOI 10.1590/0034-7167.2015680201i
Views0The title of the 2015 Editor’s Comments could very well be from a journal published in decades past, a time when, in Brazil, all professional entities and civil society fought for the right to health, as was later established in the Brazilian Constitution of 1988. Twenty-five years later, despite its financial limitations and restricted operational […]See more -
01-01-2015
A ABEn na defesa intransigente do SUS
Revista Brasileira de Enfermagem. 2015;68(2):185-186
Abstract
A ABEn na defesa intransigente do SUS
Revista Brasileira de Enfermagem. 2015;68(2):185-186
DOI 10.1590/0034-7167.2015680201i
Views0Este título do Editorial de 2015 bem poderia ser de uma revista publicada em décadas passadas, período em que todas as entidades profissionais e a sociedade civil lutaram pela saúde como direito, como conquistado na Constituição de 1988. Vinte e cinco anos depois, com o Sistema Único de Saúde capilarizado por todo o país, mesmo […]See more -
EXPERIENCE REPORT01-01-2015
Nursing diagnoses and interventions for a child after cardiac surgery in an intensive care unit
Revista Brasileira de Enfermagem. 2015;68(1):155-160
Abstract
EXPERIENCE REPORTNursing diagnoses and interventions for a child after cardiac surgery in an intensive care unit
Revista Brasileira de Enfermagem. 2015;68(1):155-160
DOI 10.1590/0034-7167.2015680121i
Views0See moreObjetivo:
descrever o julgamento clínico de enfermagem para identificar diagnósticos NANDA e desenvolver um plano de tratamento NIC para uma criança em pós-operatório de cirurgia cardíaca em terapia intensiva.
Método:
estudo de caso com coleta de dados retrospectiva no prontuário.
Resultados:
três enfermeiras identificaram diagnósticos NANDA e intervenções NIC. Criança de 6 meses, submetida a cirurgia cardíaca, necessitou oxigenação extracorpórea por membrana no pós-operatório. Foram identificados quatro principais diagnósticos, aos quais foram direcionadas dez intervenções. A proposta de intervenções para responder às necessidades humanas prioritárias da criança foi otimizada pelo uso das terminologias padronizadas. Todos os diagnósticos foram sustentados por indicadores diagnósticos; todas as intervenções foram cientificamente sustentadas.
Conclusão:
espera-se que os enfermeiros abordem não somente as respostas fisiológicas, mas também aquelas dos domínios psicossociais.
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01-01-2016
Nasal colonization with Staphylococcus aureus in nursing students: ground for monitoring
Revista Brasileira de Enfermagem. 2016;69(6):1046-1051
Abstract
Nasal colonization with Staphylococcus aureus in nursing students: ground for monitoring
Revista Brasileira de Enfermagem. 2016;69(6):1046-1051
DOI 10.1590/0034-7167-2016-0210
Views0See moreABSTRACT
Objective:
to monitor bacterial strains of Staphylococcus aureus that are resistant or not to oxacillin in nursing undergraduate students, with an emphasis on the process of colonization.
Method:
cross-sectional prevalence study carried out with 138 nursing students. The biological samples of the nasal cavity were collected in June 2015, by means of sterile swabs, which were subsequently submitted to confirmatory tests of catalase and coagulase. Isolated Staphylococcus aureus had their sensitivity profile determined by means of the Kirby Bauer method. Descriptive, univariate and bivariate analyses were performed.
Results:
the prevalence of Staphylococcus aureus was 21.7. Regarding the resistance profile, 24.1% of strains were resistant to oxacillin, with ampicillin being the antimicrobial with the greatest resistance (82.8%).
Conclusion:
the nasal cavity is an important bacterial flora of S. aureus in nursing students. The profile of isolated strains highlights the increase of Staphylococcus aureus resistance to antimicrobials such as oxacillin.
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01-01-2016
Factors associated with the occurrence of adverse events in critical elderly patients
Revista Brasileira de Enfermagem. 2016;69(6):1039-1045
Abstract
Factors associated with the occurrence of adverse events in critical elderly patients
Revista Brasileira de Enfermagem. 2016;69(6):1039-1045
DOI 10.1590/0034-7167-2016-0199
Views0See moreABSTRACT
Objective:
to identify the factors associated with the occurrence of adverse events in critical elderly patients admitted to intensive care unit according to demographic and clinical characteristics.
Method:
a retrospective cohort study was conducted in nine units of a teaching hospital. Data were collected from medical records and from monitoring of nursing shift change. We used the t-test/Mann-Whitney, chi-square and logistic regression to test associations. Significance level of 5% was used.
Results:
out of the 315 elderly, 94 experienced events. Those who experienced events were men (60.6%) with mean age of 70.7 years, length of hospital stay of 10.6 days and survivors (61.7%). Most of the 183 events were clinical processes and procedures (37.1%). There was an association between adverse event and length of hospital stay in the unit (p=0.000; OR=1.10, 95% CI [1.06, 1.14]).
Conclusion:
the identification of associated events and factors in the elderly subsidize the prevention of these occurrences before the vulnerability of this age group.
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01-01-2016
Challenges to implementation of advance directives of will in hospital practice
Revista Brasileira de Enfermagem. 2016;69(6):1031-1038
Abstract
Challenges to implementation of advance directives of will in hospital practice
Revista Brasileira de Enfermagem. 2016;69(6):1031-1038
DOI 10.1590/0034-7167-2016-0085
Views0See moreABSTRACT
Objective:
to understand the difficulties and limitations in the implementation of advance directives of will in the hospital context.
Method:
qualitative, exploratory and descriptive study conducted by means of semi-structured interviews with nurses, resident physicians and family caregivers. The data were analyzed by using discursive textual analysis based on the framework of bioethics principles.
Results:
the following categories emerged: Terminality as an expression of loss and cure as an option for care; concerns about legal implications; advance directives of will demand patient autonomy and proper communication.
Conclusion:
limitations and difficulties in practice of advance directives of will from the perspective of the participants show, apart from countless conflicts and dilemmas regarding end-of life matters, that impending death experiences obstruct patients’ wishes.
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01-01-2016
Experience and coping strategies in relatives of addicts
Revista Brasileira de Enfermagem. 2016;69(6):1024-1030
Abstract
Experience and coping strategies in relatives of addicts
Revista Brasileira de Enfermagem. 2016;69(6):1024-1030
DOI 10.1590/0034-7167-2015-0044
Views0See moreABSTRACT
Objective:
to understand the experience and coping strategies in relatives of drug addicts.
Method:
a study was developed with 87 relatives of addicts, registered in two Basic Health Units. The focus group was used as the study method, and content analysis was applied.
Results:
four categories were chosen: perception of relatives about the drug addiction of their family members; feelings and attitudes related to being a relative of an addict; difficulties found in the process; and, coping strategies. The findings reflected the difficulty when mentioning the subject, and the need of being cared for. Relatives believed that the addict needs to have the will to get into treatment, and they faced challenges in dealing with sporadic disappearances. They pointed to feelings of pity, impotence, disgust, hate, shame, fear of aggressiveness, and humiliation.
Conclusion:
the biggest difficulties were dealing with relapses, and the lack of public resources. Religiosity and faith, isolation and advice were used as coping strategies; ambivalence in thoughts and attitudes was demonstrated.
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01-01-2016
Leadership and cooperation: 25 years of mission as a WHO collaborating center
Revista Brasileira de Enfermagem. 2016;69(6):1017-1023
Abstract
Leadership and cooperation: 25 years of mission as a WHO collaborating center
Revista Brasileira de Enfermagem. 2016;69(6):1017-1023
DOI 10.1590/0034-7167-2016-0058
Views0See moreABSTRACT
Objective:
analyse the evolution in the mission and vision of a World Health Organization Collaborating Centre in Nursing in Brazil in the context of the implementation of its terms of reference.
Method:
Historical-social documentary research with a qualitative approach.
Results:
During the 25 years of its activities as a Collaborating Centre, its mission to “promote and stimulate the development of nursing research in the region, with a focus on Latin America” triggered activities in the context of its terms of reference in four areas: Human Resource Formation for Research, Knowledge Production, Knowledge Dissemination, Encouragement of Exchange and Stimulus of Partnerships.
Conclusion:
The activities developed were consolidated through the strengthening of Brazilian and international partnerships, further stimulated by the five redesignations of the Collaborating Centre in the period analysed. Thus, its vision of becoming leader and driving agent of innovations in the academic, care and political context of nursing could be put in practice.
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01-01-2016
ABEn 90 years and the Brazilian Journal of Nursing
Revista Brasileira de Enfermagem. 2016;69(6):1011-1012
Abstract
ABEn 90 years and the Brazilian Journal of Nursing
Revista Brasileira de Enfermagem. 2016;69(6):1011-1012
Views0In this special edition, we celebrate 90 years of the Brazilian Nursing Association (ABEn), at the same time in which we celebrate the creation and maintenance of the first scientific nursing journal in Brazil. Emerging in 1932, it has shone a light on the production of knowledge and the constitution of nursing in Brazil today.As […]See more -
01-01-2016
ABEn 90 anos e a Revista Brasileira de Enfermagem
Revista Brasileira de Enfermagem. 2016;69(6):1011-1012
Abstract
ABEn 90 anos e a Revista Brasileira de Enfermagem
Revista Brasileira de Enfermagem. 2016;69(6):1011-1012
Views0Neste número temático, celebramos os 90 anos da Associação Brasileira de Enfermagem (ABEn), ao mesmo tempo em que comemoramos a criação e manutenção da primeira revista científica de enfermagem do Brasil, que, desde 1932, despontou trazendo luz para a produção do conhecimento e a constituição do que é a enfermagem no Brasil atual.A ABEn, como […]See more -
01-01-2016
ERRATUM
Revista Brasileira de Enfermagem. 2016;69(5):1003-1003
Abstract
ERRATUM
Revista Brasileira de Enfermagem. 2016;69(5):1003-1003
DOI 10.1590/0034-7167.20166905e02
Views1Article “Association between self-care and hospital readmissions of patients with heart failure”, with number of DOI: 10.1590/0034-7167.2016690312i, published in the journal Revista Brasileira de Enfermagem, v69(3):469-74, page 469 that read:“Amanda Chlalup LinnI, Karina AzollinII,III, Emiliane Nogueira de SouzaII,IV“.[…]See more
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01-01-2016
Public actions for control of breast cancer in Brazil: integrative review
Revista Brasileira de Enfermagem. 2016;69(4):793-803
Abstract
Public actions for control of breast cancer in Brazil: integrative review
Revista Brasileira de Enfermagem. 2016;69(4):793-803
DOI 10.1590/0034-7167.2016690424i
Views0See moreABSTRACT
Objective:
to analyze the scientific production on “breast cancer” in the period from 2002 to 2013 and determine the public policies for screening and early diagnosis of breast cancer.
Method:
this is an integrative literature review conducted in the databases MEDLINE, LILACS, SciELO and Google Scholar. Inclusion criteria: year and period of publication; availability of the full article; publication in Brazil; and the cross-check of the keywords Breast Cancer, Primary Health Care, Screening Programs, and Early Detection of Cancer.
Results:
after analysis, four thematic categories were obtained: breast self-examination, clinical examination of breast, mammography, and factors that hinder the adherence to the screening.
Conclusion:
health professionals have deficits of knowledge on the area, indicating the need for other studies on the subject addressed and greater investment in continuing education of professionals.
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01-01-2016
Nursing diagnoses in patients with cerebral vascular accident: an integrative review
Revista Brasileira de Enfermagem. 2016;69(4):785-792
Abstract
Nursing diagnoses in patients with cerebral vascular accident: an integrative review
Revista Brasileira de Enfermagem. 2016;69(4):785-792
DOI 10.1590/0034-7167.2016690423i
Views0See moreABSTRACT
Objective:
to verify the nursing diagnoses in patients affected by CVAs.
Method:
this is an integrative review of the literature. The search was conducted on LILACS, Scielo, Medline, CINAHL, and Scopus databases between February and March 2015, using the following keywords: “Enfermagem”, “Acidente Vascular Cerebral”, “Diagnóstico de Enfermagem”; and “Nursing”, “Stroke”, and “Nursing Diagnosis”.
Results:
we found 9 articles published between 2009 and 2015; most of them were Brazilian, cross-sectional, and exploratory, with a level of evidence of 6. The evidence from the publications was classified as: “Evaluation and validation of specific nursing diagnoses for subjects affected by CVAs” and “Application of the nursing process on subjects affected by CVAs”.
Conclusion:
we noticed the publications focused on nursing diagnoses related to motor disorders, such as risk of falls and impaired physical mobility. Domains regarding safety/protection (domain 11) and sleep/resting (domain 4) were present in most evaluated publications.
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01-01-2016
Impact of educational interventions in reducing diabetic complications: a systematic review
Revista Brasileira de Enfermagem. 2016;69(4):773-784
Abstract
Impact of educational interventions in reducing diabetic complications: a systematic review
Revista Brasileira de Enfermagem. 2016;69(4):773-784
DOI 10.1590/0034-7167.2016690422i
Views0See moreABSTRACT
Objective:
To identify in the literature evidence of the effectiveness and efficacy of educational interventions in reducing metabolic and/or vascular complications in adults with diabetes mellitus.
Method:
A systematic review performed in LILACS, IBECS, CUMED, CINAHL and Medline databases and in the online library SciELO with studies published from 2004 to 2014.
Results:
Eleven studies were included (5 randomized clinical trials and 6 quasi-experimental). We only identified studies that analyzed vascular complications.
Conclusion:
Two clinical trials demonstrated efficacy in reducing cardiovascular complications, of cataract or retinopathy and nephropathy and all the quasi-experimental studies showed effectiveness in reducing feet ulcers, peripheral neuropathy and vasculopathy, and maintenance of kidney function.
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01-01-2016
The communication process in Telenursing: integrative review
Revista Brasileira de Enfermagem. 2016;69(4):765-772
Abstract
The communication process in Telenursing: integrative review
Revista Brasileira de Enfermagem. 2016;69(4):765-772
DOI 10.1590/0034-7167.2016690421i
Views0See moreABSTRACT
Objective:
to identify scientific evidence about the communication process in Telenursing and analyze them.
Method:
integrative review performed in March 2014. The search strategy, structured with the descriptors “telenursing” and “communication”, was implemented in the databases Medline, Bireme, Cinahl, Scopus, Web of Science, Scielo, and Cochrane.
Results:
ten studies were selected after inclusion and exclusion criteria. The main challenges were: the clinical condition of patients, the possibility for inadequate communication to cause misconduct, the absence of visual references in interactions without video, and difficulty understanding nonverbal communication.
Conclusion:
distance imposes communicative barriers in all elements: sender, recipient and message; and in both ways of transmission, verbal and nonverbal. The main difficulty is to understand nonverbal communication. To properly behave in this context, nurses must receive specific training to develop abilities and communication skills.
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01-01-2016
Health care for patients with acute coronary syndrome according to quality indicators
Revista Brasileira de Enfermagem. 2016;69(4):757-764
Abstract
Health care for patients with acute coronary syndrome according to quality indicators
Revista Brasileira de Enfermagem. 2016;69(4):757-764
DOI 10.1590/0034-7167.2016690420i
Views0See moreABSTRACT
Objective:
to assess in-hospital care for patients with Acute Coronary Syndrome according to quality indicators.
Method:
a longitudinal quantitative study was performed between November 2012 and March 2013 with 94 patients, including interviews and medical records.
Results:
a total of 39.4% of patients had unstable angina and 60.6% had myocardial infarction, of which 34% had ST segment elevation. Patients with TIMI and GRACE scores higher than four and 140 (p<0.05) respectively died. Admission to the intensive care unit totaled 2.1%; assessment of left ventricular (LV) ejection fraction, 83.0%; ASA within 24 hours of admission, 77.8%; statins, 72.7%; angiotensin-converting enzyme inhibitor, 62.8%; anti-smoking counseling, 53.3%; and timely reperfusion, 62.5%. Of all participants, 12.0% underwent an invasive strategy in 24h and 50.0% in 72h. Door-to-ECG time was 68.3±104.3 min and door-to-balloon time, 122±54.5 min.
Conclusions:
health care protocols are required to standardize practice and improve these indicators.
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01-01-2016
Quality of working life of call-center workers
Revista Brasileira de Enfermagem. 2016;69(4):751-756
Abstract
Quality of working life of call-center workers
Revista Brasileira de Enfermagem. 2016;69(4):751-756
DOI 10.1590/0034-7167.2016690419i
Views0See moreABSTRACT
Objective:
to analyze the profile and quality of working life (QWL) of call-center workers.
Method:
quantitative research, conducted in one call-center of the city of São José do Rio Preto – SP, using the QVP-35 questionnaire.
Results:
profile was composed by: 80.2% women; 66.3% were single, with high school diploma and 6 hours of daily working hours; mean age of 28 years; 92.9% had only one job with mean working experience of 3 years. Positive aspects of QWL: intrinsic motivation, working ability, available resources and social support. Negative aspects of QWL: workload and organizational support.
Conclusion:
the data obtained indicate the need for better organization of call-center working processes in the company and suggests other researches in this context.
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01-01-2016
Stressors perceived by patients in the immediate postoperative of cardiac surgery
Revista Brasileira de Enfermagem. 2016;69(4):741-750
Abstract
Stressors perceived by patients in the immediate postoperative of cardiac surgery
Revista Brasileira de Enfermagem. 2016;69(4):741-750
DOI 10.1590/0034-7167.2016690418i
Views0See moreABSTRACT
Objective:
to investigate stressors perceived by patients in the immediate postoperative of cardiac surgery and their association with sociodemographic and clinical characteristics.
Method:
a prospective correlational study conducted in a city in São Paulo, between August 2013 and December 2014. A non-probabilistic sample included patients submitted to their first coronary artery bypass graft or mitral valve surgery. The “Environmental Stressor Questionnaire” adapted to Portuguese was used.
Results:
105 patients participated in the study. The item “being thirsty” was evaluated as the most stressful and “the nursing staff member does not introduce himself/herself by the name” as the least stressful. Among sociodemographic and clinical variables (gender, age, type and time of surgery, pain, intubation time, use of psychotropic medications and length of stay in the intensive care unit), only pain presented a significant association with the stressors.
Conclusion:
knowing stressors can help implement practices associated with their reduction, favoring patients’ recovery.
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01-01-2016
Concepts and practices of teaching and exercise of leadership in Nursing
Revista Brasileira de Enfermagem. 2016;69(4):733-740
Abstract
Concepts and practices of teaching and exercise of leadership in Nursing
Revista Brasileira de Enfermagem. 2016;69(4):733-740
DOI 10.1590/0034-7167.2016690417i
Views0See moreABSTRACT
Objective:
to identify, describe and analyze characteristics of leadership, head nurses and participants in the teaching-learning process of leadership in Nursing, according to nurse professors who performed studies on this theme and taught such content between 1972 and 1994 in nursing schools of the state of São Paulo, southeastern Brazil.
Methods:
Thematic Oral History was used. A total of four nurse professors were interviewed, whose reports were submitted to content analysis.
Results:
the following aspects were approached in this study: the context in which students developed leadership, the influence of previous experiences on leadership qualification, its attributes, the importance of leadership, the value of teaching it, the possibilities of emancipation of a head nurse, the repercussions of teaching leadership for one’s professional life, the relationships between qualification and job market, the aspects of teaching qualification and students’ characteristics.
Conclusion:
although not essential for nursing qualification, leadership had a symbolic capital.
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