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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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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
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
DOI 10.1590/0034-7167-2022-0615
Views1See 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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Palliative care strategies in the management of people with serious cases of COVID-19
Revista Brasileira de Enfermagem. 2023;76:e20220308
Abstract
Palliative care strategies in the management of people with serious cases of COVID-19
Revista Brasileira de Enfermagem. 2023;76:e20220308
DOI 10.1590/0034-7167-2022-0308
Views0See moreABSTRACT
Objectives:
to analyze the assistance strategies in palliative care developed in the COVID-19 pandemic for critically ill patients and their families.
Methods:
an integrative review carried out in August 2021 and updated in April 2022 in the Base de Dados de Enfermagem (BDENF), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), US National Library of Medicine (PubMed), Web of Science databases, and presented in the PRISMA flowchart.
Results:
thirteen works were selected for reading and content analysis, from which emerged the two main themes that reflect the reality evidenced in this context: The sudden advent of COVID-19 with impacts on palliative care; and The strategies used in palliative care to mitigate these impacts.
Final Considerations:
palliative care is the best strategy for providing health care, used as a comfort to bring relief and comfort to patients and families.
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ORIGINAL ARTICLE03-06-2023
Construct elaboration and validity of the Pregnancy Depression Risk Scale
Revista Brasileira de Enfermagem. 2023;76(2):e20220306
Abstract
ORIGINAL ARTICLEConstruct elaboration and validity of the Pregnancy Depression Risk Scale
Revista Brasileira de Enfermagem. 2023;76(2):e20220306
DOI 10.1590/0034-7167-2022-0306
Views0See moreABSTRACT
Objectives:
to elaborate and analyze the Pregnancy Depression Risk Scale psychometric properties.
Methods:
methodological research, in six steps: theoretical model empirical definition; elaboration of scale items with literature review; consultation with five professional health experts and 15 pregnant women; content validity with six experts; pre-test-semantic validity with 24 pregnant women; scale factor structure definition with 350 pregnant women; pilot study with 100 pregnant women, totaling 489 pregnant women and 11 experts. Data were analyzed by content analysis, exploratory factor analysis, multitrait-multimethod analysis and internal consistency.
Results:
sixty-eight risk factors were identified for item formulation. The final version of the scale consisted of 24 items in five domains. The scale demonstrated satisfactory construct content, semantic, validity and reliability.
Conclusions:
the scale proved to be valid in terms of content and semantics, with a factor structure defined according to the adopted theoretical model and satisfactory psychometric properties.
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ORIGINAL ARTICLE03-06-2023
Medication reconciliation in pediatrics: a validation of instruments to prevent medication errors
Revista Brasileira de Enfermagem. 2023;76(2):e20210755
Abstract
ORIGINAL ARTICLEMedication reconciliation in pediatrics: a validation of instruments to prevent medication errors
Revista Brasileira de Enfermagem. 2023;76(2):e20210755
DOI 10.1590/0034-7167-2021-0755
Views0ABSTRACT
Objectives:
to develop and validate the content of two instruments for promoting medication reconciliation for the transition of care of hospitalized children.
Methods:
methodological study, conducted in five stages: scope review for conceptual structure; elaboration of the initial version; content validation with five specialists using the Delphi technique; reassessment; and construction of the final version of the instruments. A content validity index of at least 0.80 was adopted.
Results:
three rounds of evaluation were carried out to reach the validity index of the proposed contents, whereas a new analysis of 50% of the 20 items of the instrument aimed at families, and 28.5% of the 21 items aimed at professionals was necessary. The instrument aimed at families reached an index of 0.93, and the instrument for professionals, 0.90.
Conclusions:
the proposed instruments were validated. It is now possible to proceed with practical implementation studies to identify their influence on safety during medication reconciliation at transition of care.
Keywords:Medication errorsMedication ReconciliationPatient SafetyPediatricsProfessional-Family RelationsSee more -
ORIGINAL ARTICLE03-06-2023
Organizational politics and professional struggles in nursing
Revista Brasileira de Enfermagem. 2023;76(1):e20220180
Abstract
ORIGINAL ARTICLEOrganizational politics and professional struggles in nursing
Revista Brasileira de Enfermagem. 2023;76(1):e20220180
DOI 10.1590/0034-7167-2022-0180
Views0See moreABSTRACT
Objective:
to analyze the professional struggles between nursing organizational entities, in Rio de Janeiro, during the Regional Nursing Council’s electoral process (1990-1993 administration).
Method:
historical study. We used journalistic articles, normative documents, legislation and semi-structured interviews with five nursing professionals who participated in this process. Interpretation of findings was supported by Bourdieu’s concepts of habitus, field, capital, and symbolic power.
Results:
Electoral Code changes of the aforementioned council, under the influence of administration (1987-1990), candidate for re-election, influenced the disclosure and eligibility criteria, making it difficult for broad participation, especially of Associação Brasileira de Enfermagem Rio de Janeiro Section.
Final considerations:
nursing, in this period, generated a field of disputes related to positions of power and gender, which was evidenced in the electoral process studied, which highlighted using limiting strategies by a group, making it difficult for the entire category to participate.
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Proyecto Termómetro Social COVID-19: articulaciones transnacionales para abordar poblaciones en situación de vulnerabilidad social
Revista Brasileira de Enfermagem. 2023;76:e76suppl201
Abstract
Proyecto Termómetro Social COVID-19: articulaciones transnacionales para abordar poblaciones en situación de vulnerabilidad social
Revista Brasileira de Enfermagem. 2023;76:e76suppl201
DOI 10.1590/0034-7167.202376suppl201es
Views0El COVID-19 es una enfermedad infecciosa que ha impactado significativamente diferentes contextos alrededor del mundo, directa y/o indirectamente, y en mayor escala en países pobres y/o en vías de desarrollo(). No sabemos con certeza los efectos acumulativos del COVID-19 en las poblaciones (trastornos mentales, insomnio, ansiedad, trombosis, déficit cognitivo, problemas de memoria, etc.) tras la […]See more -
COVID-19 Social Thermometer Project: transnational articulations to approach populations in situations of social vulnerability
Revista Brasileira de Enfermagem. 2023;76:e76suppl201
Abstract
COVID-19 Social Thermometer Project: transnational articulations to approach populations in situations of social vulnerability
Revista Brasileira de Enfermagem. 2023;76:e76suppl201
DOI 10.1590/0034-7167.202376suppl201
Views0COVID-19 is an infectious disease that has significantly impacted different contexts around the world, directly and/or indirectly, and on a larger scale in poor and/or developing countries(). We do not know for sure the cumulative effects of COVID-19 on populations (mental disorders, insomnia, anxiety, thrombosis, cognition deficit, memory problems, etc.) after exposure to infection by […]See more
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Risk classification in pediatrics: development and validation of a guide for nurses
Revista Brasileira de Enfermagem. 2015;68(5):913-922
Abstract
Risk classification in pediatrics: development and validation of a guide for nurses
Revista Brasileira de Enfermagem. 2015;68(5):913-922
DOI 10.1590/0034-7167.2015680521i
Views0See moreABSTRACT
Objective:
to develop and validate a short guide for the protocol to user embracement with risk classification in pediatrics.
Method:
methodological study developed in two stages: development of the guide, and face and content validation. The development involved the stratification of the protocol contents into five risk indicators according to the level of complexity; subsequently it was submitted to validation by nine experts divided in two groups: professors who were also researchers, and nurses.
Results:
in the face validation the experts considered the 25 items of the guide clear and understandable, with agreement levels above 70%. In the content validation, 17 (68%) items were considered relevant by 88.9% of the experts. The eight items considered irrelevant were changed according to suggestions of the experts, yielding an overall content validity index of 0.98.
Conclusion:
the study resulted in a guide for the classification of risks in pediatrics that is valid to assess children in emergency services.
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Components of social learning theory in a tool for teaching Nursing
Revista Brasileira de Enfermagem. 2015;68(5):906-912
Abstract
Components of social learning theory in a tool for teaching Nursing
Revista Brasileira de Enfermagem. 2015;68(5):906-912
DOI 10.1590/0034-7167.2015680520i
Views0See moreABSTRACT
Objective:
to identify key components of the social learning theory in a computational tool to aid in teaching the reasoning process for the preparation of a nursing diagnosis.
Method:
qualitative study that analyzed the statements collected through a focus group of 18 teachers and students from two Brazilian nursing schools.
Results:
the themes were grouped into four categories related to the components of the theory and into 13 subcategories.
Conclusion:
the meaning of learning can be extended by the teacher’s didactics and corroborated by the relationship between systematization and reasoning. To learn by doing, some prerequisites are required as is a process of motivation and qualification, which are also inherent to learning by forming an identity in the group. In the feeling of belonging to a particular group, aspects related to the profession become visible as opposed to the aspects of belonging to a community of practice of learning.
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Telephone call for post-discharge surveillance: validation and application of tool for video-assisted surgery
Revista Brasileira de Enfermagem. 2015;68(5):899-905
Abstract
Telephone call for post-discharge surveillance: validation and application of tool for video-assisted surgery
Revista Brasileira de Enfermagem. 2015;68(5):899-905
DOI 10.1590/0034-7167.2015680519i
Views0See moreABSTRACT
Objective:
to validate an instrument for post-discharge surveillance by telephone for video assisted surgeries.
Method:
a multi-method study with development, validation and application of the instrument. The validation was performed by experts considering the relevance, clarity and completeness of the contents in the calculation of the content validity index and valid questions that demonstrated 80% agreement. For the application of the instrument, the sample consisted of 68 women undergoing video-assisted surgery, and we conducted a descriptive analysis.
Results:
there was disagreement among experts in the first evaluation, and the instrument was redesigned obtaining agreement in the second evaluation. The response rate to the telephone contact was 88.2% (60/68). Complaints of abdominal pain, bleeding and incisional edema were more frequent. No patients presented with infection.
Conclusion:
the questionnaire was validated and applied and is available for use.
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Managerial competences of coordinators of undergraduate nursing courses
Revista Brasileira de Enfermagem. 2015;68(5):890-898
Abstract
Managerial competences of coordinators of undergraduate nursing courses
Revista Brasileira de Enfermagem. 2015;68(5):890-898
DOI 10.1590/0034-7167.2015680518i
Views0See moreABSTRACT
Objective:
to analyze the experiences of how the managerial competences of coordinators, ideal and real, of undergraduate nursing course coordinators from the city of Belo Horizonte, Minais Gerais.
Method:
the theoretical framework presented a conceptual model of eight managerial roles (director, producer, monitor, coordinator, mentor, facilitator, broker and innovator) and three specific competences to the exercise of each one of them. Descriptive and qualitative research with 14 interviews conducted using semi-structured scripts, whose data were subjected to content analysis.
Results:
we highlighted the roles: mentor, director and facilitator as the most prominent, whose competences can be continually improved as a result of differentiated and permanent demands which the subject face, in addition to the natural ambiguities and contradictions of management function.
Conclusion:
the higher education institution can adjust their selection and evaluation processes for this position, including the difficulties of professional competences training required in the exercise of managerial function.
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RESEARCH01-01-2015
Participação familiar para a reabilitação de idosos com fratura de fêmur
Revista Brasileira de Enfermagem. 2015;68(5):883-889
Abstract
RESEARCHParticipação familiar para a reabilitação de idosos com fratura de fêmur
Revista Brasileira de Enfermagem. 2015;68(5):883-889
DOI 10.1590/0034-7167.2015680517i
Views1See moreRESUMEN
Objetivo:
verificar si el modo de cuidar adoptado por los cuidadores favoreció la recuperación de la independencia funcional de los ancianos con y sin la presencia de enfermedad en el sistema nervioso y trastornos mentales y comportamentales y si enfermedades interfirieron en la independencia funcional.
Método:
estudio trasversal, con seguimiento por 12 meses de 89 ancianos brasileños (≥ 60 años), sometidos a cirugía de fémur proximal y sus cuidadores familiares.
Resultados:
los scores de la Medida de Independencia Funcional disminuyeron 0,7 puntos por año vivido y, en el caso de enfermedad en el sistema nervioso y trastorno mental y comportamental, esa pérdida aumentó para 20,5 puntos. El incentivo a la deambulación aumentó 18,9, al autocuidado 12,8 y al ocio 11,5 puntos de la Medida de Independencia Funcional.
Conclusión:
se recomienda el incentivo al movimiento y a la deambulación, al autocuidado y a las actividades de ocio, principalmente en aquellos ancianos con enfermedades en el sistema nervioso y trastorno mental y comportamental.
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Family participation to elderly rehabilitation with femoral fracture
Revista Brasileira de Enfermagem. 2015;68(5):883-889
Abstract
Family participation to elderly rehabilitation with femoral fracture
Revista Brasileira de Enfermagem. 2015;68(5):883-889
DOI 10.1590/0034-7167.2015680517i
Views0See moreABSTRACT
Objective:
verify if the mode of care adopted by caregivers favored functional independence recovery by elderly with and without the presence of nervous system disease and mental and behavioral disorders; and, if disease interfered with their functional independence.
Method:
transversal study, with 12-month follow-up of 89 Brazilian elders (≥ 60 years) after proximal femoral surgery, and their family caregiver.
Results:
the Functional Independence Measure scores decreased by 0.7 points per year of life, and in the case of presenting nervous system disease and mental and behavioral disorders, this loss amounted to 20.5 points.
Conclusion:
The incentive to ambulate increased by 18.8 for self-care, 12.8 for self-care, and 11.5 for leisure activities on the Functional Independence Measure. Encouraging movement and ambulation, self-care and leisure activities, especially with those elderly with nervous system diseases and mental and behavioral disorders, is recommended.
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Absenteeism – illness of the nursing staff of a university hospital
Revista Brasileira de Enfermagem. 2015;68(5):876-882
Abstract
Absenteeism – illness of the nursing staff of a university hospital
Revista Brasileira de Enfermagem. 2015;68(5):876-882
DOI 10.1590/0034-7167.2015680516i
Views0See moreABSTRACT
Objective:
to analyze absenteeism – illness of the nursing staff.
Method:
this was a retrospective study of a university hospital in the city of Goiânia, Goiás, Brazil, using a quantitative approach. Data were collected from functional records of the staff during the period from 2008 to 2012.
Results:
of 602 workers, 435 had 1574 medical certifi cates. Diseases of the musculoskeletal system and connective tissue, followed by mental and behavioral disorders were the major diseases for sick leave. The occupation with the highest number of medical certifi cates was the nursing technician. Females and the age group between 41-50 years prevailed in the sample. Ambulatory was the area with most frequent events, followed by the medical clinic and emergency room.
Conclusion:
absenteeism-illness affects the functioning of the service, the nursing staff and users, promoting work overload, and interfering in the quality of nursing care.
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The nurse faced with early weaning in child nursing consultations
Revista Brasileira de Enfermagem. 2015;68(5):869-875
Abstract
The nurse faced with early weaning in child nursing consultations
Revista Brasileira de Enfermagem. 2015;68(5):869-875
DOI 10.1590/0034-7167.2015680515i
Views0See moreABSTRACT
Objective:
analyze the role of the nurse regarding early weaning in children younger than 6 months old.
Method:
qualitative and descriptive study. The nurses who performed the study did nursing consultation to children programmatically in family health units in Cuiabá – Mato Grosso. Data were collected in January and February 2012, through participant observation of nursing consultations. For data analysis, content analysis was used.
Results:
that nurses, in most cases, used appropriate strategies for the management of common problems in breastfeeding, although some behaviors have not yet proven scientifi c evidence about the benefi ts and/or damage to its practice.
Conclusion:
nurses addressed important aspects of breastfeeding during consultations and worked for the promotion and resumption of exclusive breastfeeding.
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