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01-01-2016
Modified early warning score: evaluation of trauma patients
Revista Brasileira de Enfermagem. 2016;69(5):906-911
Abstract
Modified early warning score: evaluation of trauma patients
Revista Brasileira de Enfermagem. 2016;69(5):906-911
DOI 10.1590/0034-7167-2015-0145
Views0See moreABSTRACT
Objective:
to identify the severity of patients admitted to an emergency trauma.
Method:
A cross-sectional and retrospective study with 115 trauma patients classified as orange (Manchester System), from June 2013 to July 2014. The data were presented as mean and standard deviation, in addition to the Pearson Chi-square test, One-Way ANOVA and Tukey tests.
Results:
from the sample, 81.7% were male with mean age of 39.46±19.71 years. Higher incidence of major trauma (48.7%) and traumatic brain injury (37.4%). At the end of the outcome and MEWS, most cases that had score 1 to 3 were referred to the operating room and the ICU.
Conclusion:
the start point of MEWS was 2 to 3 points, with significant increase in the severity of the situation of patients seen after 6 hours, and approximately half of the individuals underwent surgery, indicating that the scale is a good predictor of severity.
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01-01-2016
Occupational health nurses: interdisciplinary experience in occupational health
Revista Brasileira de Enfermagem. 2016;69(5):897-905
Abstract
Occupational health nurses: interdisciplinary experience in occupational health
Revista Brasileira de Enfermagem. 2016;69(5):897-905
DOI 10.1590/0034-7167-2015-0113
Views0See moreABSTRACT
Objective:
to analyze the relationship of occupational health nurses with the other members of the Specialized Service in Safety Engineering and Occupational Medicine (SESMT) and characterize joint actions of these professionals in occupational health.
Method:
qualitative, exploratory, and descriptive study with 34 professionals of seven companies from the South Macroregion of the state of Rio Grande do Sul. Interviews and observations were conducted for content analysis of Bardin.
Results:
the SESMTs are multidisciplinary and intersectoral workers. Nurses have working relations of an interpersonal, technical/legal, and management of logistics/organizational nature, influenced by the technical division of work and by the division in the work environment of the staff, which distances areas, generates conflicts, and fragments the actions of the service.
Conclusion:
SESMT faces challenges to develop a work befitting their legal objectives, once staff and companies need to understand the importance of interdisciplinarity for the success of actions on the workers’ health and safety.
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01-01-2016
Translation and adaptation of a pediatric early warning score
Revista Brasileira de Enfermagem. 2016;69(5):888-896
Abstract
Translation and adaptation of a pediatric early warning score
Revista Brasileira de Enfermagem. 2016;69(5):888-896
DOI 10.1590/0034-7167-2015-0096
Views0See moreABSTRACT
Objective:
to translate and adapt the BPEWS for the Portuguese language, with the purpose of verifying its applicability in the Brazilian context studied.
Method:
methodological study guided by international and nationally accepted recommendations for translation and adaptation of health measurement instruments. Stages of conceptual, item, semantic, operational and pre-test equivalence are described for obtaining the BPEWS Portuguese version to be used in Brazil.
Results:
the BPEWS version translated and adapted for Brazilian Portuguese (BPEWS-Br) identified, in the pilot study, that 26.6% of children were presenting warning signs for clinical deterioration.
Conclusion:
the BPEWS-Br seems to be applicable for the context studied, and its use might help nurses in the recognition and documentation of warning signs for clinical deterioration in hospitalized Brazilian children.
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01-01-2016
Validation of the Nursing Activities Score in Portuguese intensive care units
Revista Brasileira de Enfermagem. 2016;69(5):881-887
Abstract
Validation of the Nursing Activities Score in Portuguese intensive care units
Revista Brasileira de Enfermagem. 2016;69(5):881-887
DOI 10.1590/0034-7167-2016-0147
Views0See moreABSTRACT
Objective:
to describe the process of adaptation and validation of the Nursing Activities Score to the Portuguese context.
Method:
this was a pilot study of adaptation and validation of the Nursing Activities Score with a sample consisting of 67 patients hospitalized in the intensive care units of three Portuguese hospitals. The construct validity was assessed through factor analysis procedures and the internal consistency of the items was measured through the Cronbach’s alpha coefficient.
Results:
a mean workload value of 63.04% (SD = 14.25; Median = 61.30) was obtained. Psychometric data revealed a Cronbach’s alpha of 0.71 in the total scale, indicating an acceptable accuracy. Confirmatory factor analysis suggested an appropriate adjustment between the model and the data (χ2(199) = 214.5, p = 0.214; CFI = 0.95; RMSA = 0.035).
Conclusion:
in the present study, the Portuguese version of the Nursing Activities Score was found to be a valid instrument, enabling a safe assessment of the workload of nurses.
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01-01-2016
Managing educational practices for qualified nursing care in cardiology
Revista Brasileira de Enfermagem. 2016;69(5):872-880
Abstract
Managing educational practices for qualified nursing care in cardiology
Revista Brasileira de Enfermagem. 2016;69(5):872-880
DOI 10.1590/0034-7167-2015-0032
Views0See moreABSTRACT
Objective:
to understand significances attributed by nurses who manage nursing care to the individual affected by cardiovascular disease to relations, interactions and associations of the educational practices in a cardiovascular reference hospital. To elaborate a theoretical explanatory model based on significances attributed in the light of the complex thinking.
Method:
qualitative study, which used Theory Based on Data (TBD) as methodological reference. Twenty-two professionals of nursing participated in the study.
Results:
the results indicate need of professional qualification to ensure the safety of patients, institutional support for the realization of educational practices, attitude of openness and availability of dialogue of the health professionals and other institutional conformations for the workers’ development.
Conclusion:
the study presents a new space for the nurse’s action that can be used to qualify and optimize the nursing practice, as it provides visibility to management and care in health institutions.
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01-01-2016
Social representations of biosecurity in nursing: occupational health and preventive care
Revista Brasileira de Enfermagem. 2016;69(5):864-871
Abstract
Social representations of biosecurity in nursing: occupational health and preventive care
Revista Brasileira de Enfermagem. 2016;69(5):864-871
DOI 10.1590/0034-7167-2015-0114
Views0See moreABSTRACT
Objective:
to understand the biosecurity social representations by primary care nursing professionals and analyze how they articulate with quality of care.
Methods:
exploratory and qualitative research based on social representation theory. The study participants were 36 nursing workers from primary health care in a state capital in the Northeast region of Brazil. The data were analyzed by descending hierarchical classification.
Results:
five classes were obtained: occupational accidents suffered by professionals; occupational exposure to biological agents; biosecurity management in primary health care; the importance of personal protective equipment; and infection control and biosecurity.
Conclusion:
the different positions taken by the professionals seem to be based on a field of social representations related to the concept of biosecurity, namely exposure to accidents and risks to which they are exposed. However, occupational accidents are reported as inherent to the practice.
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01-01-2016
Clinical validation of nursing diagnosis “Willingness for improved infant development”
Revista Brasileira de Enfermagem. 2016;69(5):855-863
Abstract
Clinical validation of nursing diagnosis “Willingness for improved infant development”
Revista Brasileira de Enfermagem. 2016;69(5):855-863
DOI 10.1590/0034-7167-2015-0131
Views0See moreABSTRACT
Objective:
to conduct the clinical validation of nursing diagnosis “Willingness for improved infant development”.
Method:
a cross-sectional study, conducted in a Centro de Saúde da Família (Family Health Care center), with 45 healthy breastfed infants. The instrument for collecting the data was prepared based on the literature and validated by nurses. It contained the following variables: sociodemographic, gestational, and obstetrical variables; breastfed infant’s nutritional profile; evaluation of the defining characteristics of the proposed nursing diagnosis.
Results:
all the defining characteristics were found to have high sensitivity values (>90%), positive predictive values (>65%), negative predictive values (>66%); however, low specificity values (<32%). In this study, the defining characteristics we found to have estimates (>0.50) within the ROC curve, which provides good sensitivity and specificity.
Conclusion:
this study verified the structural elements of the proposed nursing diagnosis to be relevant in the clinical context, which justifies the need for its being employed with children, taking into account its contribution to improving nursing care.
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01-01-2016
Oral drugs at a hospital unit: adequacy for use via enteral feeding tubes
Revista Brasileira de Enfermagem. 2016;69(5):847-854
Abstract
Oral drugs at a hospital unit: adequacy for use via enteral feeding tubes
Revista Brasileira de Enfermagem. 2016;69(5):847-854
DOI 10.1590/0034-7167-2015-0081
Views0See moreABSTRACT
Objective:
to describe the profile of standardized oral drugs at a hospital unit and assess their adequacy for use via enteral feeding tubes, according to recommendations from the literature.
Method:
descriptive study, with data on drugs collected from the Pharmacy Service Dispensing System. Specific recommendations for the use of these drugs via enteral feeding tubes were found after searches in literary databases, books, manuals, guidelines and package insert collections.
Results:
among the 236 dispensed oral drugs, 86% were in solid form; of those, 32 were “non-crushable”, with the liquid form available at the institution. Twenty-eight drugs with potential interactions with enteral nutrition were identified. Sixty percent of those presented specific recommendations on their administration via enteral feeding tube.
Conclusion:
the joint participation of multidisciplinary nutritional therapy and care teams and the implementation of programs for continuous training are suggested strategies for the prevention of potential problems in the administration of drugs in the hospital setting.
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01-01-2016
Discoveries of Biological Sciences and their implications for nursing practice
Revista Brasileira de Enfermagem. 2016;69(4):619-620
Abstract
Discoveries of Biological Sciences and their implications for nursing practice
Revista Brasileira de Enfermagem. 2016;69(4):619-620
DOI 10.1590/0034-7167.2016690401i
Views1For the longest time, the production of knowledge in the field of biological sciences was viewed as the exclusive responsibility and competence of medical professionals. This scenario has changed in light of the worldwide trend of improvements in other health professions, which includes the need to implement the use of evidence-based methodology in nursing practice. […]See more -
01-01-2016
Descobertas das Ciências Biológicas e as implicações para a prática da Enfermagem
Revista Brasileira de Enfermagem. 2016;69(4):619-620
Abstract
Descobertas das Ciências Biológicas e as implicações para a prática da Enfermagem
Revista Brasileira de Enfermagem. 2016;69(4):619-620
DOI 10.1590/0034-7167.2016690401i
Views1A produção de conhecimento na área das ciências biológicas, durante muito tempo, foi vista como de responsabilidade e competência exclusivamente de profissionais médicos. Esse cenário alterou-se frente à tendência mundial de aperfeiçoamento dos demais profissionais de saúde, incluindo-se a necessidade de se concretizar a utilização da metodologia da prática baseada em evidência na atuação do […]See more -
01-01-2016
The importance of civilian nursing organizations: integrative literature review
Revista Brasileira de Enfermagem. 2016;69(3):610-618
Abstract
The importance of civilian nursing organizations: integrative literature review
Revista Brasileira de Enfermagem. 2016;69(3):610-618
DOI 10.1590/0034-7167.2016690326i
Views0See moreABSTRACT
Objective:
to identify and analyze evidence from studies about the importance of civilian nursing organizations.
Method:
an integrative literature review, for which searches were conducted in the databases LILACS, PubMed/MEDLINE, SciELO, BDENF, and Scopus.
Results:
sixteen articles published between the years 2004-2013 were selected, 68.75% of which were sourced from Brazilian journals and 31.25% from American journals.
Conclusion:
civilian nursing organizations are important and necessary, because they have collaborated decisively in nursing struggles in favor of the working class and society in general, and these contributions influence different axes of professional performance.
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01-01-2016
Effects from acupuncture in treating anxiety: integrative review
Revista Brasileira de Enfermagem. 2016;69(3):602-609
Abstract
Effects from acupuncture in treating anxiety: integrative review
Revista Brasileira de Enfermagem. 2016;69(3):602-609
DOI 10.1590/0034-7167.2016690325i
Views0See moreABSTRACT
Objective:
to evaluate the scientific evidence that is available in the literature on the effects of acupuncture for treating anxiety and on the quality of such studies.
Method:
the study is an integrative review of CINAHL, LILACS, PUBMED-PICO, SciELO, and The Cochrane Library between 2001 and 2014. Keywords anxiety, acupuncture therapy, acupuncture, and anxiety disorders were combined among themselves to ensure a wide search of primary studies.
Results:
among 514 articles, 67 were selected to be fully read and 19 were included. Among these, 11 were found to have strong evidence levels. Among the six articles about randomized clinical studies, five were found to be of reasonable quality. Two studies used acupuncturist nurses to perform their interventions. Its results showed positive and statistically significant effects from using acupuncture for treating subjects with anxiety.
Conclusion:
acupuncture seems to be a promising treatment for anxiety; however, there is a need for improving the methodological quality of the research on this field.
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01-01-2016
Palliative care and spirituality: an integrative literature review
Revista Brasileira de Enfermagem. 2016;69(3):591-601
Abstract
Palliative care and spirituality: an integrative literature review
Revista Brasileira de Enfermagem. 2016;69(3):591-601
DOI 10.1590/0034-7167.2016690324i
Views0See moreABSTRACT
Objective:
to analyze scientifi c articles published in international online journals about palliative care and spirituality.
Methods:
an integrative literature review with data collected in September 2014 from the LILACS, SCIELO, MEDLINE/PubMed, and IBECS databases.
Results:
thirty-nine publications were identifi ed and their textual analysis facilitated through four thematic approaches: the meaning of spirituality in the context of palliative care; palliative care and spiritual support; spirituality and relief of pain and other symptoms in patients under palliative care; and instruments to evaluate the spiritual dimension of the scope of palliative care.
Conclusion:
this study examined the relevance of the spiritual dimension in the care of patients with palliative care and the need for developing new studies to disseminate knowledge about this topic.
Descriptors:
Palliative Care; Palliative Care at End of Live; Spirituality; Religion; Health.
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01-01-2016
Educational technologies to encourage (self) care in postpartum women
Revista Brasileira de Enfermagem. 2016;69(3):582-590
Abstract
Educational technologies to encourage (self) care in postpartum women
Revista Brasileira de Enfermagem. 2016;69(3):582-590
DOI 10.1590/0034-7167.2016690323i
Views0See moreABSTRACT
Objective:
to evaluate national and international literature regarding the use of educational technologies to encourage self care in postpartum women.
Method:
an integrative review of the literature. The articles were collected from the CINAHL, SCOPUS, PubMed, SciELO, LILACS and Cochrane databases; the time period for the articles referred to January/2004 to July/2014; the languages used in the articles were Portuguese, English, Spanish and French; the articles were selected from the following descriptors: postpartum care period, educational technology, nursing and self care. Twenty-seven articles were selected for analysis
Results:
based on the information found, the scales, counseling and home visits were among the most recommended educational technologies.
Conclusion:
the technologies promote communication, but are sometimes dependent on computer and internet access, which hinder their use by low-income women.
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01-01-2016
Patients with HIV/Aids and ulcer risk: nursing care demands
Revista Brasileira de Enfermagem. 2016;69(3):574-581
Abstract
Patients with HIV/Aids and ulcer risk: nursing care demands
Revista Brasileira de Enfermagem. 2016;69(3):574-581
DOI 10.1590/0034-7167.2016690322i
Views0See moreABSTRACT
Objective:
to analyze the demand for nursing care and the risk of pressure ulcers (PU) of patients with HIV/Aids.
Method:
quantitative survey, carried out from December 2012 to March 2013 in a public hospital of Teresina, state of Piauí, Brazil.
Results:
the sample of 31 patients was predominantly male, mean age 36.6 years, average care demand 49.4%, most showing some risk of developing PU. The variables correlated with PU risk were care demand and clinical outcome (death). Those associated with care demand were age and clinical outcome (death).
Conclusion:
the results showed that patients require moderate nursing care needs and most of them present risk of developing PU.
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01-01-2016
Lack of anticipated support for care for community-dwelling older adults
Revista Brasileira de Enfermagem. 2016;69(3):566-573
Abstract
Lack of anticipated support for care for community-dwelling older adults
Revista Brasileira de Enfermagem. 2016;69(3):566-573
DOI 10.1590/0034-7167.2016690321
Views0See moreABSTRACT
Objective:
to identify the factors associated with lack of anticipated support for care for community-dwelling older adults.
Method:
this study presents comparison and logistic regression analyses of data from 671 individuals who took part of the multicentric study entitled “Frailty in older Brazilians” – a quantitative, epidemiologic and transversal investigation carried out between 2008 and 2009.
Results:
the subjective evaluation of anticipated support for care for community-dwelling older adults was a good indicator of risk for lack of anticipated support for care in women, older adults who live alone and those with poor self-rated health.
Conclusion:
it is necessary to reflect upon the formal support system currently available for older people in Brazil, considering that those who most frequently presented lack of anticipated support for care are an increasing population. The study also highlights the importance of using subjective methods for the evaluation of the adequacy of older adults’ support network.
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01-01-2015
Health technologies for spatial analysis and situational diagnosis of the territories: contributions to nursing
Revista Brasileira de Enfermagem. 2015;68(6):999-1000
Abstract
Health technologies for spatial analysis and situational diagnosis of the territories: contributions to nursing
Revista Brasileira de Enfermagem. 2015;68(6):999-1000
DOI 10.1590/0034-7167.2015680601i
Views0In order to establish an organizational basis for work processes in primary health care geared towards a new social practice, it is important to recognize territories and their contexts, as these materialize human interactions, conflicts, health problems and human needs.In the process of recognition and situational diagnosis of territories, technologies for spatial analysis can facilitate […]See more -
01-01-2015
Tecnologias em saúde para análise espacial e diagnóstico situacional dos territórios: contribuições para a enfermagem
Revista Brasileira de Enfermagem. 2015;68(6):999-1000
Abstract
Tecnologias em saúde para análise espacial e diagnóstico situacional dos territórios: contribuições para a enfermagem
Revista Brasileira de Enfermagem. 2015;68(6):999-1000
DOI 10.1590/0034-7167.2015680601i
Views0Para a constituição de uma base organizativa dos processos de trabalho na Atenção Primária à Saúde em direção a uma nova prática social é importante o reconhecimento dos territórios e seus contextos, pois estes materializam as interações humanas, os conflitos, os problemas de saúde e necessidades humanas.Nesse processo de reconhecimento e diagnóstico situacional dos territórios, […]See more -
01-01-2015
CARTA DE FORTALEZA PARA A ENFERMAGEM BRASILEIRA
Revista Brasileira de Enfermagem. 2015;68(5):961-962
Abstract
CARTA DE FORTALEZA PARA A ENFERMAGEM BRASILEIRA
Revista Brasileira de Enfermagem. 2015;68(5):961-962
DOI 10.1590/0034-7167.2015680527
Views0APRESENTAÇÃOOs participantes do 18º Seminário Nacional de Pesquisa em Enfermagem (SENPE), promovido pela Associação Brasileira de Enfermagem (ABEn) e realizado pela ABEn Seção Ceará, aprovaram, em Sessão Plenária de Encerramento, no dia 03 de junho de 2015, a “Carta de Fortaleza para a Enfermagem Brasileira”. A ABEn vem a público divulgá-la, ao mesmo tempo em […]See more -
01-01-2015
Delayed surgical recovery: a concept analysis
Revista Brasileira de Enfermagem. 2015;68(5):953-960
Abstract
Delayed surgical recovery: a concept analysis
Revista Brasileira de Enfermagem. 2015;68(5):953-960
DOI 10.1590/0034-7167.2015680526i
Views0See moreABSTRACT
Objective:
analyze the concept of delayed surgical recovery.
Method:
the Rodgers’ concept analysis provided the procedural mechanisms to guide the study, and an integrative review was performed to achieve the second activity of the model adopted. The PubMed, CINAHL, EMBASE and LILACS databases were selected to search for primary studies.
Results:
sixty-six primary studies were included and served as basis to construct the use and meaning of delayed surgical recovery concept. In the analysis, six attributes were outlined, which are interrelated and underpin the research concept definition. Preliminary experience was identified as the antecedent. The consequences of the concept are expressed through clinical manifestations, re-interventions, dependence on care and reduced quality of life.
Conclusion:
the definition of the concept was constructed, and the antecedents and consequents were identified. The use and meaning of the delayed surgical recovery concept point to the use of the qualifier ‘impaired’ instead of ‘delayed’.
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01-01-2015
Total Quality Management and hospital nursing: an integrative literature review
Revista Brasileira de Enfermagem. 2015;68(5):945-952
Abstract
Total Quality Management and hospital nursing: an integrative literature review
Revista Brasileira de Enfermagem. 2015;68(5):945-952
DOI 10.1590/0034-7167.2015680525i
Views0See moreABSTRACT
Objective:
to identify the available evidence in the literature on Total Quality Management in nursing administration.
Method:
integrative literature review of full text articles in Portuguese, English and Spanish, published between 2000 and 2011 in the LILACS, MEDLINE, SciELO and PubMed databases.
Results:
the sample comprises 24 periodical articles grouped by the following thematic categories: Theoretical assumptions; Practical application and Quality indicators. Despite the criticism of models derived from classic administration theories, experiences of success with the deployment of TQM have already marked the health and nursing setting in Brazil.
Conclusion:
Total Quality Management in managing of nursing care has being fully used in some health institutions, while others have adopted several of its principles. Two of the twenty four articles are intervention studies, which characterizes the necessity for clinical research in this area.
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01-01-2015
Association between fatigue and functional capacity in patients with intermittent claudication
Revista Brasileira de Enfermagem. 2015;68(5):937-944
Abstract
Association between fatigue and functional capacity in patients with intermittent claudication
Revista Brasileira de Enfermagem. 2015;68(5):937-944
DOI 10.1590/0034-7167.2015680524i
Views0See moreABSTRACT
Objective:
to characterize fatigue and exertion fatigue in patients with intermittent claudication (IC), and to test their association with sociodemographic and clinical variables, walking capacity and level of physical activity.
Method:
forty-nine participants (66.6 years; 70% male) were studied. Validated questionnaires were used to assess fatigue (DUFS), exertion fatigue (DEFS), level of physical activity (BASIC) and walking capacity (WIQ).
Results:
participants had substantial fatigue (DUFS = 20.4+8.8) and substantial exertion fatigue (DEFS = 20.4+10.8). There was an association between the DUFS and marital status (p = 0,008). There was a statically significant association between DEFS with scores of the BASIC (r = .331; p = .02) and among DEFS with WIQ domains – walking distance (r=.359; p = .011) and climbing stairs (r=.331; p = .02).
Conclusion:
patients with IC have fatigue and exertion fatigue. Exertion fatigue might compromise the engagement of these patients in physical activity, one of the main components of IC treatment.
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01-01-2015
Body mobilization for prevention of pressure ulcers: direct labor costs
Revista Brasileira de Enfermagem. 2015;68(5):930-936
Abstract
Body mobilization for prevention of pressure ulcers: direct labor costs
Revista Brasileira de Enfermagem. 2015;68(5):930-936
DOI 10.1590/0034-7167.2015680523i
Views0See moreABSTRACT
Objective:
to calculate the average total cost (ATC) on the direct labor costs (DLC) of nursing professionals in body mobilization of patients for the prevention of pressure ulcers.
Method:
this is a quantitative, exploratory and, descriptive research. We observed 656 preventive mobilizations and we calculated the cost by multiplying the time spent by professionals at a unitary DLC.
Results:
ATC with DLC for each Unit corresponded to: Medical Clinic R$ 5.38 for bed turning, R$ 5.26 for seating positions, R$ 5.55 for walking aid; Surgical Clinic R$ 2.42 for bed turning, R$ 2.30 for seating positions, R$ 2.96 for walking aid and Intensive Care Unit R$ 8.15 for bed turning, R$ 7.57 for seating positions, R$ 15.32 for walking aid.
Conclusion:
the knowledge generated can support management related to costs of human resources needed to efficiently and effectively nursing care.
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01-01-2015
The mobilization of nurses for the non-interruption of nursing residence
Revista Brasileira de Enfermagem. 2015;68(5):923-929
Abstract
The mobilization of nurses for the non-interruption of nursing residence
Revista Brasileira de Enfermagem. 2015;68(5):923-929
DOI 10.1590/0034-7167.2015680522i
Views0See moreABSTRACT
Objective:
To analyze the strategies employed by nurses to maintain the nursing residence program at the Ophir Loyola Hospital and discuss the potential effects of this interruption on the state of Pará.
Method:
Social-historic research. Data were collected through primary sources, written documents, and oral testimonial; the secondary sources used were manuals and articles that approached the topic in question. The theoretical reference was based on the French sociologist Pierre Bourdieu’s ideas about the concepts of cultural, social, and symbolic capital, in addition to the habitus and field concepts.
Results:
During the nurses’ mobilization there was a strong political influence on the development of the crisis and the interruption of the nursing residence Program at the Ophir Loyola Hospital, with implications for the nurses’ qualifications and the health care delivered to the societyof Pará.
Conclusion:
The analysis showed the prevalence of partisan political interests at the expense of social interests, culminating in the interruption of the nursing residency.
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