RESEARCH ARTICLES

Elastic compression stockings: strategy for health promotion of emergency nurses

Ronilson Gonçalves Rocha^I; Priscila de Castro Handem^II; Nébia Maria Almeida de Figueiredo^III; Iraci dos Santos^IV; Denilson Campos de Albuquerque^V

^INurse, PhD. through the Nursing Graduate Program at the State University of Rio de Janeiro, Clinical research coordinator of the Rede D'or São Luiz.  Professor in the postgraduate program in Neurosciences at the D'or Institute.  Professor of Undergraduate Nursing at the Souza Marques School. Email: ronilsonprof@gmail.com
^IINurse, PhD. through the Biosciences Graduate Program at the State University of Rio de Janeiro, Assistant professor at the Federal University of  the State of Rio de Janeiro. Email: priscilahandem@yahoo.com.br
^IIINurse. PhD in Nursing Sciences. Full professor at the Federal University of  the State of Rio de Janeiro. Researcher for the National Council of Scientific and Technological Development, Emeritus Professor at the Federal University of  the State of Rio de Janeiro. Email: nebia43@gmail.com
 ^IVNurse, PhD in Nursing Sciences. Full Professor at the State University of Rio de Janeiro, Professor of the Graduate Program in Nursing at the State University of Rio de Janeiro, Email: iraci.s@terra.com.br
^VDoctor. PhD in Cardiology through the  Federal University of São Paulo. Assistant Professor the School of Medical Sciences, State University of Rio de Janeiro. Professor of Graduate Programs in Medicine and Nursing at the State University of Rio de Janeiro. Email: denilsoncalbuquerque@gmail.com

ABSTRACT: The objective was to determine whether nurses wear elastic compression stockings (ECS), aiming at the protection and promotion of health; identify what causes these professionals to use the ECS or not. This a descriptive exploratory study using a quantitative method, developed in an emergency unit of Rio de Janeiro-Brazil, between 2012/04 and 2013/10. Involving 40 subjects and the results indicated that only 20% of the study population is wearing elastic compression stockings and so only 12.5% those to use in according of literature. The main reason for not wearing was high cost. A category analysis emerged ‘Care and forgetting to take care - the lack of benefits of using ECS’. In this, the subjects justify the non-use of ECS by considering its high cost and the lack of benefits, pointed out by most professionals - 90.4%. It was concluded that the high cost associated with the lack of these resources determines the non-use of ECS.

Keywords: Nursing care; occupational health; health promotion; self care.

INTRODUCTION

The health of the active nursing staff in emergency units has been a concern for researchers and professionals in this area, since the characteristics of work in these units have generated several negative repercussions on their bodies both in the short and the long term.

Habitually the actions performed in the emergency are linked to an excessive number of calls, implying physical wear and which has been consistently reported by these professionals intense mental, and the lack of using health promoter and protector devices, which are not always considered.

The high number of complaints referencing signs and symptoms are highlighted such as severe headaches, back pain, pain and edema in the lower extremities, myalgia, redness of eye, fatigue, agitation, mood changes, and other factors associated.

These complaints are noted in studies that indicate the hospital environment as hostile to the integrity of the nursing workers, who work continuously suffer punctures, falls, slips, become ill and exhibit pain arising from their activities^1-3.

In a preliminary analysis of what these professionals deal about the health issues presented daily, identifies a precipitate judgment to the illness and the cause of so many negative repercussions. Almost all of these professionals indicates insufficient human resources as a predictor of injuries and causing the overload of tasks performed by them.

This direction led to the investigation of the practice and working conditions of nursing in an emergency from the viewpoint of occupational health, considering ergonomic aspects such as body postures assumed when performing their functions, the non-use of devices for the prevention of health injuries and the institutional compliance with legislation that regulates and scales the number of professionals in these units.

From this analysis, it is identified that a lack of adaptation to work in emergency exposes these professionals to numerous risks such as ergonomic, generating overloads on their body structures by extended staying standing, lifting and transport weight manually, repetitiveness and occurrence of postures^4,5, among others.

Despite the excessive complaints and of the pointing of quite varied signs and symptoms exhibited by the subjects in this study, it is understood that a thorough approach to the most recurrent problem in their speeches, which are pain and swelling in the lower limbs it is appropriate, because it correlates directly with the use or nonuse of protective devices for health, given the excess of actions performed in the standing position which may indeed be a consequence of a reduced number of professionals.

Furthermore, emergency departments are responsible by presenting clients offering medium or high ergonomic risk for the nursing workers⁶. And it must be considered that these risk factors are the cause of great discomfort in the development of nursing activities. It is also noticed in these professionals, the inexistence of the habit of using technologies to improve such conditions, such as elastic compression stockings (ECS) that act as facilitators of venous return and allow greater relief of muscles of the lower limbs, which are highly required for actions in emergency care.

ECS devices are those which exert a sustained pressure evenly over the entire surface of the distribution calves, reducing the size of the superficial veins of the legs and favoring a greater flow in the deep vessels^7,8. They lower the damming - stasis - of venous blood and stimulates its return to the heart.

Considering that the nursing activities are many and varied, encompassing from personnel management to the achievement of customer developments, screening receptions in emergencies, performing physical examination, electrocardiogram, peripheral venous access puncture, clothing customer, intensive care for poly-trauma, among other actions that happen without a proper body posture, it is worrying from the point of view of prevention of health risks, because it devalues ​​the potential risk of harm to their health in the future.

Despite dealing with patients in a variety of pathologies, apparently ignorant of the use of these devices, whose purpose is to prevent the onset of health problems to themselves, and it is believed that other factors may be related to non-use and is essential to investigate what has led these professionals to dispense, or not their use
Thus, the object of study is the use of elastic compression stockings for active nursing professionals in emergency units, aiming at the promotion and protection of their own health. This was the guiding question:
Do nursing professionals who work in emergency units use devices and/or technologies that prevent harm to their own health?

The objective proposed for this research: to verify whether nurses in an emergency department use ECS; to identify the reasons for the use of professionals or not ECS; to discuss the implications of the findings for the health of the nursing workers.

LITERATURE REVIEW

Considering the conditions to which the emergency professionals undergo in their daily lives, a possible quality to promote the health of these workers a possible way to invest in studies that indicate the impact and the negative repercussions of easily preventable diseases, which may even lead to indefinite withdrawal from their work activities.

During the construction of knowledge for nursing, one realizes numerous critical to the acceptance of various conditions imposed on professionals, who are working in the healthcare practice, which permeates covertly, the lack of questioning on the charges by institutions and even by supervisors who ignore work limits in this profession. On the other hand, there are also those workers that have various employments, implying, over the years, various diseases and health problems.

In this sense, it is necessary to provoke questions to make them realize that they are acting agents in the maintenance, construction and transformation of their space / environment and able to produce a new way of thinking and acting⁹.

Clearly, it is still necessary for a greater number of investigations on this subject, not being depleted in this study, the exploration of this problem. It is known that many health problems can lead to irreversible consequences and such a process could be avoided in part by the use of protective devices such as the ECS, as well as the correct postures during the development of their care activities.

Thus, it becomes increasingly important to help ensure that nurses perceive that they have the ability to promote, in the workplace, the emergence of new and emerging systemic strategies to the problems encountered and thus building a healthy and sustainable environment⁹.

Thus, it becomes increasingly important to help ensure that nurses perceive that they have the ability to promote, in the workplace, the emergence of new and emerging systemic strategies to the problems encountered and thus building a healthy and sustainable environment^10,11.

What correlates to the importance of the use of ECS is that over the years the trend is the formation of varicose veins occurs is very common in women and in people whose occupations require standing for long periods, like salespeople, teachers, health professionals, including nurses, technicians and nursing assistants, doctors, dentists and construction workers⁷.

Some studies indicate varicose veins among the diseases that affect nurses, being illustrated in an investigation, conducted with 53 nursing staff in maternal and child health unit of a Federal Hospital of Rio de Janeiro, in which they found that 31 of these professionals were affected by varicose veins¹².

The formation of varicose veins is due to the incompetency of the venous valve leaflets that by not staying closed hinder blood return and prevent it from reaching the heart⁷. This blood reflux results in venous stasis, which is a decrease of blood flow in a particular region of the body, and may cause an increased risk for cardiovascular diseases, including the formation of varicose veins, which results in venous thromboembolism (VTE).

Is worth noting that the nursing workforce is mainly characterized by the significant number of women and so the health concerns of these professionals should be even higher, justifying the need for the use of ECS for the same, which is ideal for preventing of injuries and consequent health promotion, i.e., their own self-care^10,11.

Thus, based on the concepts of health promotion, we note that it is necessary to develop strategies with this group seeking its mobilization to effect change some lifestyle habits and behavioral attitudes which effectively has significant impact on their quality of life / health / wellness^10,11,13.

Some specific conditions of women as pregnancy, postpartum or puerperal, the hormone replacement therapy and oral contraception are highlighted in some studies^14,15 as determinants for the increased incidence of VTE.

Given the hormonal fluctuations, their own pregnancy, there is an increase in blood coagulability in women, which increases the risk of VTE, including outpatients13. It is known that nurses are at risk of diseases of this nature and at some point in their lives will go through the hospitalization process. The years of work without the use of health-promoting technologies can, in a situation of hospitalization, even to give birth, represent a significant increase in the risk of contracting VTE.

Other studies^16-18 impact generators on clinical practice highlight the increased incidence of venous thromboembolism in the female population, therefore the use of hormonal contraceptives and also due to hormone replacement therapy.
Among the major health problems of nursing workers, recent study conducted by Brazilian nurses, found that in a group of 34 professionals, 44.1% had musculoskeletal and vascular problems through complications with varicose veins. Of this group 41.2% reported back pain and 38.2% reported headaches¹³.

Also in a study on morbidity of nursing staff, the results showed that 57.23% of a total of 173 workers, had varicose veins and 84% of them were female¹⁹.

The occurrence of VTE is due mainly to the presence of some risk factors, independent of the reason for admission, as more than 40 years old, more than 24 hours hospitalization, presence of varices and / or chronic venous insufficiency, use of hormone replacement or contraceptives, obesity and prolonged immobility itself, a natural consequence of some admissions²⁰.

The main risk factors for VTE, according to related consensus and guidelines^21-23 are described below: cerebrovascular accident (CVA); cancer (CA); central catheters and Swan-Ganz; surgery with time longer than thirty minutes of anesthesia; inflammatory bowel disease; severe respiratory disease; Acute rheumatic disease; pelvis, femur or tibia fracture; pregnancy and postpartum; previous history of VTE; acute myocardial infarction (AMI); congestive heart failure (CHF); age greater than 40 years; prolonged immobilization; infection (except thoracic); arterial insufficiency; ICU admission; obesity; paresis or paralysis of the lower limbs; chemotherapy or hormone therapy; hormone replacement therapy, contraception; nephrotic syndrome; thrombophilia; varicose veins, chronic venous insufficiency. 

This data supports the view that nurses should really worry about their working conditions and the consequent implications for their well-being10,11and seeks to develop it consciously and risk free, in order to prevent injuries and reduce the possibility of being present in future work related diseases²⁴.

Given the above, the health of nursing staff, especially the Emergency physicians, is at risk, and in view of this it is necessary to know the reasons that prevent them from using the ECS for the protection and promotion of health.

METHODOLOGY:

Descriptive exploratory study with a quantitative approach allowing to evaluate information and perform statistical calculations favoring better approach and understanding of the phenomenon studied^25,26, i.e., by analyzing the set of measurable data (variables).

In this sense, the variables translated each in its own way, the joints between the individual, the individual and the collective, present in health and disease processes²⁷ and were evaluated in the context of actions to protect the health of emergency nurses when they develop their activities.

The study subjects were nursing professionals working in the emergency unit of the Rio de Janeiro, Brazil, in shifts, with a scale of 12 for 36 hours, becoming an exclusive sample of nurses and nursing technicians.

The study was carried out from April 2012 to October 2013. The emergency department has a total of 46 nurses who take care of clients (12 nurses and 34 nursing technicians). It took into consideration the number of professionals who were away for vacation, leave and other reasons, it can be inferred that the sample number (n) equal to 40 subjects is representative of the population studied, and sufficient to meet the proposed objectives. Of the total participants, 29 were female and 11 male.

In order to obtain the information a form with five discursive and optional questions was used. The sample (n) of emergency professionals, study (40) represents 87% of the population (N) of nurses and nursing technicians.

The criterion for inclusion in the study: being a nurse or nursing technician and provide direct care to clients admitted to the emergency unit. On the ethical aspects of the research and procedures for the production of data, it is respected all ethical precepts defined in Resolution No. 466/2012 the National Health Council, which deals with research involving humans. The project was approved by the Research Ethics Committee of the institution through the opinion number 045-05 renewed in October 2013.

RESULTS AND DISCUSSION

Analyzing the information obtained, 40 professional participants of the study were identified, only 8 (20%) make use of ECS during the performance of their activities. We evaluated the frequency of use of the device for these professionals with the intention of investigating if they use it the way recommended in the literature^18,21 thus, arriving at the notes shown in Table 1.

Given the information (frequency of use and reasons for use), a comparison of them with what is recommended in the literature was performed^18,21, concluding that only 1 (2.5%) of these professionals is constant and proper use of ECS, while developing their caring activities in the emergency department.

The high number (32) of professionals who reported not using the ECS confirms the presence of occupational risk in the work of these workers who may be or be hidden environment, so unknown to them, which has been highlighted in research addressing the lack of professionals' perception of the risks to which they are exposed^2,3,5.

Also the reasons that the study subjects understood as determinants for not using the ECS, including those who said they make use of the device were also analyzed. This analysis was based on the choice of one or more among 11 previously justifications of the questionnaire, plus the freedom to point out others.

By analyzing this information the data were arranged in sequence according to the number of times that recurred in the responses of the subjects, as shown in Table 2.

The sample had a total of 63 reasons for not using ECS with a view to promoting and protecting health. It is noted that the factor marked with most number of times (32 professionals) was the high cost of ECS, according to Table 2.

It is noticeable that in addition to professionals indicate the high cost as a reason for non-use, the scale of these shifts for nurses is 12 for 36 hours, which would imply the need for more than one pair of ECS for development their activities.
This appointment was enhanced to identify which of 40 (100%) subjects in the research, 18 (45%) of the sample has another workplace. Two or three jobs has been configured as a reality of many Brazilian nursing professionals, which in low-paid jobs, seek to increase their income through submission to more than one job^1,3,5,11.

This information also draws attention to the need for well-defined policies for this category because the professionals to try to get a higher income to improve their social conditions, proportionally increase the possibility of mistakes in their practices to care because they are most often stressed , tired and susceptible to damage not only their own health but the health of their clients.
 
It was evident that not only the cost of the product is crucial for their non-use factor. They demonstrated also that they do not use because they have no knowledge about the benefits and the importance of using them for disease prevention to health. Besides reporting that a product is difficult to handle, lacking appropriate location in the hospital for putting them on and that they lack time to put them on.

This information promotes further reflection, drawing attention to the fact that these professionals may not be realizing what it is also necessary take care of their health, so that they can take care of the health of clients^10,11. Then emerged a category of analysis in the study called -Care for their clients and not caring for themselves - the ignorance of benefits of using ECS.

The other justifications showed ignorance about the use of a product that, over the years, can prevent diseases in nursing professionals who work long hours in the standing position. As described in the literature^1-3,5 involving this subject has strengthened the idea that these professionals do not have sufficient knowledge about the risks involved in their work activities, especially regarding the importance of using ECS by the workers in the emergency unit.
Therefore, it is urgent to disseminate this knowledge to educational institutions for nursing professionals and for hospitals. This is a way to change what is happening in clinical nursing practice, as identified in this study, including the fact that many institutions, which served as the field for this study, yields a minimum number of products and subsidizes buying others like coats, shoes and protective eyewear.

It is understood that, given the importance of the use of ECS for protection and health promotion, support such a product can bring benefits both for professionals and for healthcare institutions, can reduce subsequent morbidity and mortality from preventable diseases through their use.

It is also relevant to reflect on how to make accessible to all nursing professionals the ECS, not just for those of complementary health network, but also those who work in the public network.

This concern extends not only to the results of this study, but other studies that show that occupational nursing workers are exposed in their daily lives, requiring porting of actions for the protection of their health risks.

Thus it emphasizes the need for actions undertaken by the Ministry of Labor and the Ministry of Health, aimed at formulating programs, action plans, guidance manuals and protocols that aim to guide and provide access to information and devices that lead to promotion health, such as ECS with nursing workers.

CONCLUSION

This study pointed out what has prevented emergency professionals from making use of ECS to develop their nursing activities.

 It was identified that the institution strictly follows current legislation with regard to the sizing of nursing teams and their permanence for performing extra shifts.

The professionals are prevented from carrying out subsequent shifts greater than 24 hours, avoiding consequences related to quality of services and the health of these workers, despite the scale of work is 12 hours of work by 36 hours off.

The results indicated that professionals have an incipient knowledge about the importance of using ECS, something close to common sense knowledge. It was found that one of the main justifications of professionals for not using ECS is their high cost, apparently preventing the purchase of this product.

It was evident also that many professionals are unaware of the benefits of using ECS, both short and long term, something likely to change from the return of the findings of this research for the host institution of the same and also through the publication of results found in journals in this area of ​​knowledge.

It is expected that this publication would cause a change in nursing practice in emergency units and encourage other researchers to conduct studies related to the topic. It can also promote the dissemination of this knowledge, contributing to important changes in practice in teaching and propose health policies able to minimize the problems noted.

Finally, it reveals that the results are able to show contributions for both technical level teaching as well as for college level, favoring the increase of scientific knowledge of nursing and its workers.

REFERENCES 

1.Giomo DB, Freitas FCT, ALVES LA, R MLCC. Acidentes de trabalho, riscos ocupacionais e absenteísmo entre trabalhadores de enfermagem hospitalar. Rev enferm UERJ. 2009; 17:24-9. Disponível em http://www.facenf.uerj.br/v17n1/v17n1a05.pdf Internet Explorer. [citado em 02 abr 2014].

2.Souza NVDO, Pires AS, Gonçalves FGA, Cunha LS, Shoji S, Ribeiro LV, et al. Riscos ocupacionais relacionados ao trabalho de enfermagem em uma unidade ambulatorial especializada. Rev enferm UERJ. 2012; 20:609-14.

3.Feitosa Beleza FCM, Gouveia OMT, Robazzi MLCC, Torres CRD, Azevedo GAV. Riscos ocupacionais e problemas de saúde percebidos por trabalhadores de enfermagem em unidade hospitalar.  Cienc Enferm. 2013; [citado em 15 jan 2014] 19(3): 63-71. Disponível em http://www.scielo.cl/pdf/cienf/v19n3/art_08.pdf  Internet Explorer.

4.Ribeiro MCS. A nocividade do trabalho: os riscos à saúde do trabalhador. In: Ribeiro MCS. Enfermagem e trabalho: fundamentos para a atenção à saúde dos trabalhadores. São Paulo: Martinari; 2002. p. 39-50.

5.Mauro MYC, Paz AF, Mauro CCC, Pinheiro MAS, Silva VG. Condições de trabalho da enfermagem nas enfermarias de um hospital universitário. Esc Anna Nery. 2010; 14: 13-8. Disponível em http://www.scielo.br/pdf/ean/v14n2/05.pdf. [citado em 15 jan 2014].

6.Gallasch C, Alexandre NMC. Avaliação dos riscos ergonômicos durante a movimentação e transporte de pacientes em diferentes unidades hospitalares. Rev enferm UERJ. 2003; 11:252-60. Disponível em http://www.facenfuerj.br/f11n3/v11na03.pdf Internet Explorer. [citado em 02 abr 2014].

7.Smeltzer SC, Bare BG. Tratado de Enfermagem médico-cirurgico. 12ª ed. Rio de Janeiro: Guanabara Koogan; 2011.
8.Dilks A, Green J, Brown S.The use and benefits of compression stocking aids. Nursing Times. 2005; [citado em 20 abr 2014]. 101(21):32-34. Disponível em: http://www.nursingtimes.net.

9.Svaldi JSD, Suqueira HCH. Ambiente hospitalar saudável e sustentável na perspectiva ecossistêmica: constribuições da enfermagem. Esc Anna Nery. 2010; 14: 599-604. Disponível em: http://www.scielo.br/pdf/ean/v14n3/v14n3a23.pdf  [citado em 20 abr 2014].

10.Brandão ES, Santos I, Cavalcanti ACD, Santana RF, Queluce GC. Uma sociopoética do autocuidado: comportamento de estudantes visando à promoção da saúde.  Rev Gaúcha Enferm. 2009; 30: 280-8. Disponível em http://seer.ufrgs.br/index.php/RevistaGauchadeEnfermagem/article/view/7653/6686. [citado em 20 abr 2014].

11.Silva AS, Terra MG, Motta MGC, Leite MT, Padoim SMM. Enfermagem e cuidado de si: percepção de si como corpo existencial no mundo.  Rev enferm UERJ. 2013; 21:366-70. Disponível em http://www.facenf.uerj.br/v21n3/v21n3a15.pdf. [citado em 15  jan 2014].

12.Mauro YCM, Veiga AR. Problemas de saúde e riscos ocupacionais: percepções dos trabalhadores de enfermagem de unidade materna infantil. Rev enferm UERJ. 2008; 16: 64-9. Disponível em http://www.facenf.uerj.br/v16n1/v16n1a10.pdf. [citado em 15 jan 2014].

13.Hipolito RL, Mauro MYC, Maurício VC, Gomes SR, Silva LA, Barbosa ECV. Riscos ocupacionais e suas interfaces com a saúde da equipe de enfermagem intensivista no municipio de Campos dos Goytacazes. Rev Pesq Cuidado é Fundamental. 2011; [citado em 15 jan 2014]. 3:1947-58. Disponível em http://proap.unirio.br/index.php/cuidadofundamental/article/view/1285/pdf_395.

14.Samama MM. An epidemiologic study of risk factors for deep vein thrombosis in medical outpatients: the sirius study. Arch Intern Med 2000; [citado em 20 abr 2014]. 160 (34):15-20. Disponível em http://www.ncbi.nlm.nih.gov/pubmed/11112234.

15.Gates S, Brocklehurst P, Davis L. Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period. Cochrane Database of Systematic Reviews; 2004.

16.Franks AL, Atrash HK, Lawson HW, Colberg KS. Obstetrical pulmonary embolism mortality, United States, 1970-85. Am J Public Health 1990; 80:720-2. Disponível em http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1404735/. Acesso em 20 de julho 2013.

17.Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and estrogen/progestin replacement study. Research Group. JAMA 1998; [citado em 20 abr 2014] 280:605-13. Disponível em http://www.ncbi.nlm.nih.gov/pubmed/9718051.

18.Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA. 2002; [citado em 10 abr 2014]. 288:321-33. Disponível em http://www.ncbi.nlm.nih.gov/pubmed/12117397.

19.Maynardes DCD, Sarquis LMM, Kirchhof ALC. Trabalho noturno e morbidades de trabalhadores de enfermagem. Rev Cogitare Enferm. 2009; [citado em 10 abr 2013]. 14:703-8. Disponível em http://www.revenf.bvs.br/pdf/ce/v14n4/a14v14n4.pdf.

20.Academia Brasileira de Neurologia et al. Tromboembolismo venoso: profilaxia em pacientes clínicos-parte II. Rev Assoc Med Bras. 2009; 55(3):229-50. Disponível em http://www.scielo.br/pdf/ramb/v55n3/v55n3a09.pdf. [citado em 10 abr 2014]

21.Fedullo PF, Tapson MD.  The Evaluation of Suspected Pulmonary Embolism. N Engl J Med. 2003. [citado em 10 abr 2014]. 349:1247-56 Disponível em: http://www.ncbi.nlm.nih.gov/pubmed/14507950.

22.Associação Médica Brasileira, Conselho Federal de Medicina. Projeto diretrizes: tromboembolismo venoso profilaxia em pacientes clínicos. Parte I. 2005. p. 1-10.

23.Geerts WH, Berqqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2008. [citado em 10 abr 2014]. 133:381-453. Disponível em: http://www.ncbi.nlm.nih.gov/pubmed/18574271.

24.Elias MA, Navarro VL. A relação entre o trabalho, a saúde e as condições de vida: negatividade e positividade no trabalho das profissionais de enfermagem de um hospital escola. Rev Latino-am Enferm. 2006; [citado em 02 ago 2014]. 14:517-25. Disponível em http://www.scielo.br/pdf/rlae/v14n4/v14n4a08.pdf Internet Explorer.

25.Polit DF, Beck,CT. Fundamentos da Pesquisa em Enfermagem: avaliação de evidências para a prática de enfermagem. Porto Alegre (RS): Artes Médicas; 2011.

26.Minayo MCS, organizadora. Pesquisa social: teoria, método e criatividade. Petrópolis (RJ): Vozes; 2011.

27.Deslandes SF, Assis SG. Abordagens quantitativa e qualitativa em saúde: o diálogo das diferenças. In: Minayo MCS, Deslandes SF, (organizadores). Caminhos do pensamento: epistemologia e método. Rio de Janeiro: Editora Fiocruz; 2002. p. 195-223.