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ARTÍCULO DE REVISIÓN
Brazilian nursing specific situation, middle and micro-range theories: a bibliometric study
Revista Brasileira de Enfermagem. 2024;77(4):e20230520
20/09/2024
Resumo
ARTÍCULO DE REVISIÓNBrazilian nursing specific situation, middle and micro-range theories: a bibliometric study
Revista Brasileira de Enfermagem. 2024;77(4):e20230520
20/09/2024DOI 10.1590/0034-7167-2023-0520
Visualizações0ABSTRACT
Objectives:
to map the nursing theories developed in stricto sensu graduate programs in nursing in Brazil.
Methods:
a bibliometric study, carried out on the Coordination for the Improvement of Higher Education Personnel Theses and Dissertations Portal in October 2023. The controlled descriptors “Nursing Theory” and “Nursing Models” and the uncontrolled descriptors “Theories” and “Middle-Range Theory” were used. Selected studies were cataloged for analysis, which was conducted by the study authors, who have a doctoral degree and expertise in research on nursing theories.
Results:
thirty-nine nursing theories were mapped, with a predominance of middle-range theories (79.5%), focusing on nursing diagnostic concepts and use of the theoretical-methodology strategy of theoretical-causal validity.
Conclusions:
the study identified nursing theories developed in Brazil, recognizing trends, development strategies, theorized objects of disciplinary interest and investments necessary for practical application in Brazilian contexts.
Palavras-chave: BibliometricsHealth Postgraduate ProgramsNursing ModelsNursing ResearchNursing TheoryVer mais -
ARTÍCULO ORIGINAL
Sociocognitive factors determining compliance with standard precautions by nursing professionals during the COVID-19 pandemic
Revista Brasileira de Enfermagem. 2024;77(4):e20230301
20/09/2024
Resumo
ARTÍCULO ORIGINALSociocognitive factors determining compliance with standard precautions by nursing professionals during the COVID-19 pandemic
Revista Brasileira de Enfermagem. 2024;77(4):e20230301
20/09/2024DOI 10.1590/0034-7167-2023-0301
Visualizações0Ver maisABSTRACT
Objectives:
to assess the socio-cognitive factors determining adherence to standard precautions by nursing professionals in care practice during the COVID-19 pandemic in Brazil.
Methods:
an analytical cross-sectional study, carried out with 9,039 nursing professionals in Brazil, using an electronic form containing participant sociodemographic, training and work variables, and the Brazilian version of the Standard Precautions Questionnaire. Descriptive and inferential statistics were used using the statistical software R.
Results:
participants recognize standard precautions as effective measures to reduce infections and report intention to perform them. Training regarding standard precautions was evidenced as a facilitator of adherence (4.72; SD: 0.73), and problems related to materials (3.78; SD: 1.45) were a hindrance.
Conclusions:
among the determining factors, facilitating organization presented the highest score, followed by intention to perform. Facilitating and hindering factor identification makes it possible to develop intervention strategies to strengthen patient safety and reduce occupational risks among professionals.
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ARTÍCULO ORIGINAL
Middle-range theory for nursing for care in the context of cardiovascular risk
Revista Brasileira de Enfermagem. 2024;77(4):e20240190
20/09/2024
Resumo
ARTÍCULO ORIGINALMiddle-range theory for nursing for care in the context of cardiovascular risk
Revista Brasileira de Enfermagem. 2024;77(4):e20240190
20/09/2024DOI 10.1590/0034-7167-2024-0190
Visualizações0ABSTRACT
Objectives:
to develop a middle-range nursing theory for care in the context of cardiovascular risk.
Methods:
a theoretical development study, through induction through research and ICNP® practice standards, carried out in six stages: concept analysis; ICNP® terminological subset structuring; theory contextualization and purpose; proposition construction; modeling; and assumption construction.
Results:
the Theory of Care in the Context of Cardiovascular Risk has a middle-range scope, describing care, prescribing actions to promote health and reduce cardiovascular risk. Thirteen propositions were constructed in three categories (nursing metaparadigm, central and factorial concepts), two models and 16 assumptions.
Final Considerations:
the theory contributes to the construction of knowledge arising from the nursing process for care in the context of cardiovascular risk, generating propositions, assumptions and modeling, which will enable theoretical testing.
Palavras-chave: Concept FormationHeart Disease Risk FactorsNursing TheoriesStandardized Nursing TerminologyTheoretical ModelsVer mais -
ARTÍCULO ORIGINAL
Content validity of guidance on self-care in the post-operative period for breast cancer
Revista Brasileira de Enfermagem. 2024;77(4):e20240188
20/09/2024
Resumo
ARTÍCULO ORIGINALContent validity of guidance on self-care in the post-operative period for breast cancer
Revista Brasileira de Enfermagem. 2024;77(4):e20240188
20/09/2024DOI 10.1590/0034-7167-2024-0188
Visualizações0Ver maisABSTRACT
Objectives:
to validate the content of a guidance guide on self-care in the postoperative period of breast surgery for breast cancer.
Methods:
a methodological study with content validity, carried out with 15 expert nurses and physiotherapists, between May and July 2022. Recruitment took place from the Lattes Platform, using snowball sampling. The level of relevance and representativeness for each item was verified using the Content Validity Index (CVI). It was considered valid when CVI was equal to or greater than 78% (0.78).
Results:
from the initial total of 37 items, two were excluded, as they had insufficient practical relevance and theoretical relevance, and another five items which, although presenting a CVI lower than the established cut-off, were suggested to be rewritten and grouped with other similar items.
Conclusions:
thirty items were considered valid and demonstrated important and significant characteristics, constituting suitable material for application in clinical practice.
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ARTÍCULO ORIGINAL
Construction and enhancement of a prototype for a medical-hospital equipment for hypodermoclysis: a qualitative study
Revista Brasileira de Enfermagem. 2024;77(4):e20240059
20/09/2024
Resumo
ARTÍCULO ORIGINALConstruction and enhancement of a prototype for a medical-hospital equipment for hypodermoclysis: a qualitative study
Revista Brasileira de Enfermagem. 2024;77(4):e20240059
20/09/2024DOI 10.1590/0034-7167-2024-0059
Visualizações0ABSTRACT
Objectives:
to construct a Subcutaneous Hydration Device semi-functional prototype and gather initial information to improve this prototype design and realize its acceptance potential.
Methods:
a qualitative, descriptive and exploratory study, which used focus group, following the Technology Acceptance Model. The group was held at the Escola Superior de Enfermagem de Coimbra, Portugal, in December 2022, composed of nine participants from six different disciplinary areas, and followed thematic analysis.
Results:
four topics emerged associated with the device components: elastomeric infusion pump; needle/access device; clamp; administration set. From these topics, topics were triggered that highlighted: characteristics about the target population; ease of use and accessories; patient comfort and safety; and device application context.
Final Considerations:
the Subcutaneous Hydration Device semi-functional prototype is viable and interesting for the clinic. The results support its improvement and direct future investments for experimental studies.
Palavras-chave: Equipment and SuppliesHypodermoclysisInfusionsSubcutaneousTechnologyUser-Centered DesignVer mais -
ARTÍCULO ORIGINAL
Middle-range theory of the existential dimension of being-in-the-world of chronic kidney disease: Grounded Theory
Revista Brasileira de Enfermagem. 2024;77(4):e20230152
20/09/2024
Resumo
ARTÍCULO ORIGINALMiddle-range theory of the existential dimension of being-in-the-world of chronic kidney disease: Grounded Theory
Revista Brasileira de Enfermagem. 2024;77(4):e20230152
20/09/2024DOI 10.1590/0034-7167-2023-0152
Visualizações0Ver maisABSTRACT
Objectives:
to develop a middle-range theory of the existential dimension of being-in-the-world of chronic kidney disease in the light of humanistic nursing theory.
Methods:
exploratory-descriptive, qualitative, Grounded Theory study, whose guiding question was: what theoretical relationships can be established between clinical practice carried out in the context of renal replacement therapies and the concepts of humanistic nursing theory? Data were collected through semi-structured interviews with nursing staff and chronic kidney disease patients.
Results:
a theory was developed that describes and explains the existential dimension of being-in-the-world of chronic kidney disease, identifying the qualitative evidence present in this context.
Final Considerations:
the theory contributes to clinical nursing practice qualification in nephrology, consolidating nursing as an art and science, because it arises from care practice and research, in addition to rescuing what differentiates it within the health disciplines, which is care par excellence.
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ARTÍCULO ORIGINAL
Transgender people’s knowledge about the adverse effects of cross-hormonization: challenges for nursing
Revista Brasileira de Enfermagem. 2024;77(4):e20230346
20/09/2024
Resumo
ARTÍCULO ORIGINALTransgender people’s knowledge about the adverse effects of cross-hormonization: challenges for nursing
Revista Brasileira de Enfermagem. 2024;77(4):e20230346
20/09/2024DOI 10.1590/0034-7167-2023-0346
Visualizações0Ver maisABSTRACT
Objectives:
to identify trans women’s and men’s knowledge about the adverse effects of cross-hormonization and understand the repercussions of hormonization practices on trans women’s and men’s health.
Methods:
exploratory, descriptive, qualitative research, developed with 41 participants, from July 2019 to February 2020, in a trans health outpatient clinic. Thematic-categorical content analysis was used.
Results:
from the analysis, the categories emerged: Knowledge about the adverse effects of cross-hormonization; and Cross-hormonization practices and their meaning.
Final Considerations:
nursing practices, based on the identification of knowledge about adverse effects and the understanding of cross-hormonization practices in trans women’s and men’s health, can result in more inclusive care.
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EDITORIAL
Potencial de la Inteligência Artificial en la Práctica de Enfermería Basada en la Evidencia
Revista Brasileira de Enfermagem. 2024;77(5):e770501
09/09/2024
Resumo
EDITORIALPotencial de la Inteligência Artificial en la Práctica de Enfermería Basada en la Evidencia
Revista Brasileira de Enfermagem. 2024;77(5):e770501
09/09/2024DOI 10.1590/0034-7167.2024770501es
Visualizações0La práctica basada en la evidencia (PBE) se ha consolidado como un pilar fundamental en enfermería, impulsando una toma de decisiones clínicas eficaz basada en investigaciones científicas de alta calidad. El objetivo principal de la PBE es garantizar que los pacientes reciban la atención más adecuada y segura, basada en la mejor evidencia disponible. En […]Ver mais
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ARTÍCULO ORIGINAL
Fatores associados ao bem-estar materno em situação de parto de puérperas em Minas Gerais
Revista Brasileira de Enfermagem. 2024;77(6):e20230304
16/12/2024
Resumo
ARTÍCULO ORIGINALFatores associados ao bem-estar materno em situação de parto de puérperas em Minas Gerais
Revista Brasileira de Enfermagem. 2024;77(6):e20230304
16/12/2024DOI 10.1590/0034-7167-2023-0304pt
Visualizações1RESUMO
Objetivos:
analisar os fatores associados ao bem-estar materno em situação de parto de puérperas em Minas Gerais.
Métodos:
estudo transversal, aninhado a uma coorte, realizado com puérperas em um município mineiro. Foi adotada a escala Bem-Estar Materno em Situação de Parto 2. Estimaram-se as prevalências do bem-estar materno em situação de parto. A magnitude da associação entre mal-estar materno e práticas assistenciais foi estimada pela Razão de Prevalência (RP), utilizando-se a regressão de Poisson.
Resultados:
participaram 183 puérperas com idade entre 15 e 46 anos, sendo que 26,2%, 27,9% e 45,9% relataram, respectivamente, ótimo, adequado e mal-estar na assistência ao parto. O mal-estar materno foi mais prevalente entre puérperas que passaram por parto cesárea (RP = 1,60) e que não receberam informações sobre amamentação (RP = 1,59).
Conclusões:
observou-se elevada prevalência de mal-estar no parto, associada à realização de cesáreas e à falta de informações sobre amamentação.
Palavras-chave: Assistência ao PartoBem-Estar MaternoHumanização da AssistênciaParto ObstétricoPeríodo Pós-PartoVer mais -
ARTÍCULO ORIGINAL
The nursing practice environment and hospital sociotechnical complexity: a mixed-methods study
Revista Brasileira de Enfermagem. 2024;77(6):e20230315
16/12/2024
Resumo
ARTÍCULO ORIGINALThe nursing practice environment and hospital sociotechnical complexity: a mixed-methods study
Revista Brasileira de Enfermagem. 2024;77(6):e20230315
16/12/2024DOI 10.1590/0034-7167-2023-0315
Visualizações1ABSTRACT
Objectives:
to analyze the relationship between the nursing practice environment and hospital sociotechnical complexity as perceived by nurses.
Methods:
a sequential explanatory mixed-methods study was conducted in a hospital in southern Brazil. The Brazilian version of the Practice Environment Scale-Nursing Work Index and the Complexity Characterization Questionnaire were administered to 132 nurses. Subsequently, semi-structured interviews were conducted with 18 participants, and the data were subjected to thematic analysis. Data integration was achieved through a connection approach.
Results:
the nursing practice environment was found to be favorable, except in the subscale concerning Staffing and Resource Adequacy, where complexity was present in the activities. The three emerging categories explained human and technical aspects related to complexity in the practice environment, quality of care, and patient safety. Unexpected variability was inversely correlated with the practice environment.
Conclusions:
the study results indicate a relationship between these constructs, with implications for the quality and the safety of care.
Palavras-chave: Complexity AnalysisHealth Facility EnvironmentNursingPatient SafetyQuality of Health CareVer mais -
ARTÍCULO DE REVISIÓN
Recommendations for guidelines for promoting mental health in the workplace: an umbrella review
Revista Brasileira de Enfermagem. 2024;77(6):e20240086
16/12/2024
Resumo
ARTÍCULO DE REVISIÓNRecommendations for guidelines for promoting mental health in the workplace: an umbrella review
Revista Brasileira de Enfermagem. 2024;77(6):e20240086
16/12/2024DOI 10.1590/0034-7167-2024-0086
Visualizações1Ver maisABSTRACT
Objectives:
to summarize the recommendations of guidelines for promoting mental health in the workplace.
Methods:
an umbrella review, according to Joanna Briggs Institute and Preferred Reporting Items for Systematic reviews and Meta-Analyses methodological assumptions. Data collection was carried out in January 2021 and updated in July 2023 in the American Psychological Association, Cochrane Library, EMBASE, National Library of Medicine, and Scopus databases. Systematic reviews that assessed guidelines with recommendations for mental health care for workers were included. PROSPERO registration CRD42023461845.
Results:
four systematic reviews published between 2015 and 2018 were identified. The abstracts highlighted actions that facilitate and inhibit the recommendations as well as three categories of intervention: primary prevention – worker protection; secondary prevention – promoting workers’ mental health; and tertiary prevention – supporting, monitoring and rehabilitating workers upon returning to work.
Conclusions:
the interventions are based on prevention, promotion and early recognition, support and rehabilitation of mental health problems.
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ARTÍCULO ORIGINAL
Qualidade de vida de idosos institucionalizados com e sem sinais de depressão
Revista Brasileira de Enfermagem. 2019;72:127-133
05/12/2019
Resumo
ARTÍCULO ORIGINALQualidade de vida de idosos institucionalizados com e sem sinais de depressão
Revista Brasileira de Enfermagem. 2019;72:127-133
05/12/2019DOI 10.1590/0034-7167-2018-0316
Visualizações0RESUMO
Objetivo:
comparar a qualidade de vida (QV) de idosos residentes em instituições de longa permanência com ou sem sinais de depressão, e identificar variáveis sociais, de atividade física, lazer, saúde e atividades básicas da vida diária (ABVD) que se correlacionam aos escores de QV.
Método:
estudo transversal realizado com 101 idosos institucionalizados. A regressão linear múltipla foi usada para a análise dos dados.
Resultados:
sinais de depressão alteraram negativamente a QV nos domínios: autonomia, atividades presentes, passadas e futuras, participação social, intimidade e escore total; idosos dependentes para a realização das ABVD apresentaram QV inferior nos domínios: autonomia, participação social e escore total; dançar sem limitação de movimento, gostar do residencial e não apresentar sinais de depressão foram as variáveis que influenciaram positivamente a QV dos idosos.
Conclusão:
suporte social e psicológico, boas condições de moradia e assistência estimuladora podem melhorar a QV de idosos institucionalizados.
Palavras-chave: Atividades CotidianasDepressãoIdosoInstituição de Longa Permanência para IdososQualidade de VidaVer mais -
ARTÍCULO ORIGINAL
Nurses defending the autonomy of the elderly at the end of life
Revista Brasileira de Enfermagem. 2019;72(6):1639-1645
21/10/2019
Resumo
ARTÍCULO ORIGINALNurses defending the autonomy of the elderly at the end of life
Revista Brasileira de Enfermagem. 2019;72(6):1639-1645
21/10/2019DOI 10.1590/0034-7167-2018-0768
Visualizações0Ver maisABSTRACT
Objective:
to understand how nurses deal with the elderly’s autonomy at the end of life.
Method:
qualitative, exploratory study, guided by the Grounded Theory. Ten nurses, eight doctors and 15 nursing technicians were interviewed between November 2016 and May 2017 at a university hospital in Rio de Janeiro/Brazil.
Results:
nurses deal with the elderly’s autonomy in compliance with the code of ethics and exercise leadership in actions and interactions to defend this right, evaluating, guiding and listening to the preferences of the elderly; interacting with the family; and sharing information with the health team.
Final considerations:
the elderly’s autonomy must be ensured in care planning, based on patient-centered communication and developed in the interaction among agents involved in care. The discussion on “Living Wills” Health Care Directives and principles of palliative care must be encouraged.
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ARTÍCULO ORIGINAL
Spirituality and religiousity in the experience of suffering, guilt, and death of the elderly with cancer
Revista Brasileira de Enfermagem. 2020;73:e20190034
08/07/2020
Resumo
ARTÍCULO ORIGINALSpirituality and religiousity in the experience of suffering, guilt, and death of the elderly with cancer
Revista Brasileira de Enfermagem. 2020;73:e20190034
08/07/2020DOI 10.1590/0034-7167-2019-0034
Visualizações0Ver maisABSTRACT
Objective:
to understand spirituality and religiosity in the experience of suffering, guilt, and death of the elderly with cancer.
Method:
qualitative research based on Viktor Frankl’s Existential Analysis. Twenty phenomenological interviews were conducted with people over 60 years old undergoing chemotherapy treatment at an oncology unit of a hospital in the city of Salvador, Bahia State, Brazil, between August and October 2018.
Results:
the following categories emerged: Experiences spirituality and religiosity in the face of the tragic triad and existential emptiness; Uses spirituality/religiosity as resilience strategies. After apprehension of ontic aspects, it was possible the ontological understanding of spirituality and religiosity in the face of suffering, guilt, and death experienced in the elderly with cancer’s daily life.
Final considerations:
spirituality and religiosity were understood as coping strategies used in the unstable experience of the elderly with cancer, providing comfort and resilience.
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INFORME DE EXPERIENCIA
Collaborative practices from health care teams to face the covid-19 pandemic
Revista Brasileira de Enfermagem. 2020;73:e20200470
26/10/2020
Resumo
INFORME DE EXPERIENCIACollaborative practices from health care teams to face the covid-19 pandemic
Revista Brasileira de Enfermagem. 2020;73:e20200470
26/10/2020DOI 10.1590/0034-7167-2020-0470
Visualizações0ABSTRACT
Objective:
To report the experience of collaborative practices facing the COVID-19 pandemic.
Methods:
This is a report about the experience of collaborative practices conducted by health care teams in emergency service in the Emergency Care Units facing of COVID-19 pandemic in the city of Fortaleza, State of Ceará, in the first semester of 2020.
Results:
Collaborative actions, cooperation and effective communication among nursing and medical team contribute to the management of mild and complex cases of COVID-19, as well as qualify them in suitable and necessary care and confrontation measures.
Final considerations:
The report shows the need for collaborative practices to minimize negative effects on the population in the face of the new coronavirus pandemic.
Palavras-chave: Coronavirus InfectionsEmergenciesInterdisciplinary PracticesNursing, TeamPatient Care TeamVer mais -
ARTÍCULO ORIGINAL
Ansiedade e depressão em cuidadores informais de idosos dependentes: um estudo analítico
Revista Brasileira de Enfermagem. 2020;73:e20190851
21/09/2020
Resumo
ARTÍCULO ORIGINALAnsiedade e depressão em cuidadores informais de idosos dependentes: um estudo analítico
Revista Brasileira de Enfermagem. 2020;73:e20190851
21/09/2020DOI 10.1590/0034-7167-2019-0851
Visualizações0Ver maisRESUMO
Objetivo:
Analisar os sintomas de ansiedade e depressão em cuidadores informais de idosos dependentes em domicílio.
Métodos:
Estudo analítico, transversal, realizado no município de Teresina (PI), com cuidadores informais de idosos dependentes. A coleta de dados ocorreu no período de novembro de 2017 a fevereiro de 2018, por meio de um formulário de caracterização do idoso dependente e seu cuidador, Inventário de Ansiedade de Beck (BAI) e Inventário de Depressão de Beck (BDI). Utilizou-se o modelo de regressão linear forward para identificação das variáveis preditoras de ansiedade e depressão.
Resultados:
Constatou-se que 18,4% dos cuidadores apresentaram sintomas de depressão; e 14%, ansiedade moderada a severa. Houve correlação entre ansiedade e depressão (p = 0,000).
Conclusão:
Os achados deste estudo possibilitam a avaliação da ansiedade e depressão nos cuidadores de idosos dependentes, sendo possível, mediante tais parâmetros, visualizar o perfil e as demandas de cuidado dessa população.
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ARTÍCULO ORIGINAL
Estresse e qualidade do sono em alunos de graduação em Enfermagem
Revista Brasileira de Enfermagem. 2020;73:e20180227
15/05/2020
Resumo
ARTÍCULO ORIGINALEstresse e qualidade do sono em alunos de graduação em Enfermagem
Revista Brasileira de Enfermagem. 2020;73:e20180227
15/05/2020DOI 10.1590/0034-7167-2018-0227
Visualizações0Ver maisRESUMO
Objetivo:
analisar o nível de estresse e a qualidade do sono em estudantes de enfermagem por períodos do curso.
Método:
pesquisa descritiva e transversal desenvolvida em uma instituição de ensino superior do Nordeste brasileiro com 167 estudantes. Utilizaram-se, para coleta de dados, informações sociodemográficas e uma escala de avaliação do estresse e qualidade do sono em estudantes de enfermagem.
Resultados:
identificou-se diferença estatística significante entre os domínios da escala de estresse e os períodos do curso de graduação, e entre a qualidade do sono e os períodos do curso, como no quarto e sexto períodos. Conclusão: os diferentes escores do estresse demonstram que o semestre do estudante que mais o preocupa é o quinto. A qualidade de sono mostrou-se de boa qualidade para o primeiro, terceiro, quinto, sétimo e oitavo períodos; e qualidade ruim de sono para o quarto e sexto períodos.
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EDITORIAL
Investigación cualitativa en tiempos de pandemia
Revista Brasileira de Enfermagem. 2021;74:e74Suppl101
11/06/2021
Resumo
EDITORIALInvestigación cualitativa en tiempos de pandemia
Revista Brasileira de Enfermagem. 2021;74:e74Suppl101
11/06/2021DOI 10.1590/0034-7167.202174Suppl101
Visualizações0INTRODUCCIÓNLa investigación cualitativa permite comprender realidades singulares difíciles de aprehender desde una única perspectiva, asumiéndose cada vez más como un campo inter y transdisciplinario–, con métodos y técnicas específicas que implican la relación entre el investigador y los participantes para la recolección, análisis y validación de transcripciones y análisis realizados por el investigador.La pandemia SARS-CoV-2 […]Ver mais -
ARTÍCULO ORIGINAL
Quality of life of nurse practitioners during the COVID-19 pandemic
Revista Brasileira de Enfermagem. 2022;75:e20201382
18/10/2022
Resumo
ARTÍCULO ORIGINALQuality of life of nurse practitioners during the COVID-19 pandemic
Revista Brasileira de Enfermagem. 2022;75:e20201382
18/10/2022DOI 10.1590/0034-7167-2020-1382
Visualizações0Ver maisABSTRACT
Objective:
to assess the quality of life of nurse practitioners during the COVID-19 pandemic and analyze related factors.
Methods:
cross-sectional and analytical study carried out with nurse practitioners. A questionnaire on sociodemographic characterization, work activities and changes perceived with the pandemic and WHOQOL-bref were used. To compare the groups of interest, analysis of covariance was used.
Results:
572 professionals participated, who had a mean total quality of life score of 56.79 (SD=13.56). In the relationship of variables with WHOQOL-bref, having two or more jobs and being a nurse were associated with better quality of life, but being a woman and working more than 50 hours a week was associated with a worse perception of the construct.
Conclusions:
the factors analyzed indicate a lower perception of quality of life associated with the social domain, requiring interventions that reduce the damage to professionals’ health and contribute to quality of care provided.
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