id 31107

ORIGINAL RESEARCH

 

Nursing presenteeism: repercussions on workers' health and patient safety

 

Manoel Luís Cardoso VieiraI, Elias Barbosa de OliveiraII, Norma Valéria Dantas de OliveiraIII, Marcia Tereza Luz LisboaIV, Jane Marcia ProgiantiV, Carolina Cabral Pereira da CostaVI

I Nurse. Master's Degree in Nursing. State University of Rio de Janeiro. Brazil. E-mail: mlcv22@bol.com.br
II Nurse. PhD in Nursing. Associate Professor, State University of Rio de Janeiro. Brazil. E-mail: eliasbo@oi.com.br
III Nurse. PhD in Nursing. Associate Professor, State University of Rio de Janeiro. Brazil. E-mail: norval_souza@yahoo.com.br
IV Nurse. PhD in Nursing. Associate Professor, Federal University of Rio de Janeiro. Brazil. E-mail: marcialuzlisboa@gmail.com
V Nurse PhD in Nursing. Associate Professor, State University of Rio de Janeiro. Brazil. E-mail: jmprogi@uol.com.br
VI Nurse. Master's Degree in Nursing. State University of Rio de Janeiro. Rio de Janeiro. Brazil. E-mail: carolcuerj@hotmail.com

DOI: https://doi.org/10.12957/reuerj.2018.31107

 

 


ABSTRACT

Objective: to examine the repercussions of presenteeism on the nursing work process in a teaching hospital. Methods: this qualitative, descriptive study, set in a university hospital in Rio de Janeiro city in 2015, used a semi-structured interview technique with 39 nursing workers, and applied content analysis to their accounts. The project was approved by the research ethics committee. Results: health problems, such as the osteomuscular and respiratory conditions reported by workers, can be intensified as a result of the demands of working in the hospital environment. There are repercussions on performance, because of workers' limitations and delays in performing care, resulting in team overload, interpersonal conflicts and interference in service quality. Conclusion: institutional policy is needed to minimize the occurrence of presenteeism at work and the harm it causes to service performance and quality.

Descriptors: Nursing; presenteeism; patient safety; Worker's health.


 

 

INTRODUCTION

The current economic situation of the country has been substantially affecting public policies in the health sector, with clear interference in the provision of essential and quality services to the users of the Unified Health System and, especially, in hospital institutions. As a result of this situation, undignified work conditions are evidenced by the lack of human and material resources that cause damage to the quality of service and workers' health.1 This situation has been intensifying as a result of the neoliberal policies in force, in which the labor relations are flexible, the personnel expenses are reduced, and there is no public call for tenders, resulting in several managerial and care difficulties for managers and other workers in the microsystem hospital.2

It is understood that the participation of nurses in the replacement/expansion of the nursing human resources framework is essential, and it is believed that the data obtained substantiate the discussions with the competent Organs, in order to provide sufficient personnel in search of a better quality of care. However, with the current recessive policy disseminated by the state, the nurse services manager faces much difficulty regarding the adequate dimensioning of nursing personnel (DNP) in order to ensure safe and quality care.3

This situation is aggravated by the flexibilization of the labor relations with the reduction of the public machine, reduction that has the size of the organizations, high unemployment rates and increase of temporary contracts. In addition, it is possible to mention the low investment in infrastructure and insufficient material inputs; factors that negatively impact the work process and the health of professionals in university hospitals.4

As an aggravating circumstance, the DNP may be impaired due to the presenteeism; a phenomenon in which workers attend the service even with chronic or acute health problems. The presenteeism is a consequence of the excessive work and the feeling of job insecurity on the part of the worker, also involving the managers and causing negative repercussions for both. Although, most of the time, this result is not properly diagnosed. 5 It should be added that in nursing there is a high rate of absenteeism, which unbalances the work teams even more, with negative consequences for the institution and for the care provision. Although the absenteeism has been extensively studied, the investigations that evaluate the presenteeism, the factors associated with its occurrence, and the consequences for the organizations in the health sector are scarce.6

In view of the above and in order to contribute to the production of knowledge and discussion of the problems caused by the presenteeism to the worker and to the organization of the nursing work, this article aimed at analyzing the repercussions of the presenteeism to the nursing work process in a teaching hospital.

 

LITERATURE REVIEW

The expression presenteeism was used for many years only as opposed to absenteeism, or to emphasize the good performance of the worker in their employment. It is a phenomenon that has been considered in the last decade of the current century as an enemy of productivity. European and American researchers in countries such as England, the Netherlands, the United States and Canada have concluded in their studies that the costs of the presenteeism in the private sector are above those of the absenteeism. In Brazil, despite the increased interest in this phenomenon, there are few studies that show the social and financial costs faced by most managers. 7

The presenteeism occurs when, even with a health problem, the professional will work and this impacts on their productivity, and it may have several causes, which are not always linked to diseases or health problems, but to organizational and personal factors that interfere with worker's productivity. Among the types of presenteeism, there are those in which the person has some disease and yet comes to work, despite feeling bad and adding little in terms of productivity. The other group is of the workers who are not very committed and who do not present any disease, but are dissatisfied due to personal or organizational problems.8

In its origin, the presenteeism has been associated with diseases (skeletal muscle disorders, anxiety disorders, allergies, headaches and gastrointestinal disorders); personal and organizational problems. As for personal problems, there is the individual's belief that no one else can do their job, loyalty to one's own professional image, obligation and commitment to their colleagues, clients and organization, incapacity to work for lack of competence, low level of commitment to the organization. The organizational problems are related to the social pressure at work, and to managers who are also presenteeist, loss of bonuses or incentives related to performance, risk of not being promoted because of absences/leaves.9

A cross-sectional study carried out with 129 nurses working in the direct care of critical and potentially critical patients showed that the presenteeism was directly related to the accomplishment of health treatment, occurrence of absences and, indirectly, to the time of work in the unit. Despite the low percentage of lost productivity (4.84% of the 75% of the sample), there are indications that there are coexistences and consequences of the presenteeism to professionals and to the quality of care provided. The physical demand or capacity to perform tasks that require body strength, resistance, movement, coordination and flexibility was perceived by nurses as the most influential limitation for loss of productivity.5

In order to support the study on nursing presenteeism, a survey of the state of the art in the Virtual Health Library (VHL) was conducted in an integrated manner with the Nursing Database (BDENF - Base de Dados de Enfermagem) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), through the Capes journals. In the selection of the material, complete articles of free access have been used, in Portuguese, English and Spanish, with a temporal cutout from 2012 to 2017, using the theme words: presenteísmo e enfermagem, presenteeism and nursing and presentismo y enfermería. With the exception of the review articles, only 14 studies were found, mostly in other languages, evidencing the need to discuss this problem in Brazilian nursing.

 

METHODOLOGY

Descriptive study with a qualitative approach, in which the knowledge about people is possible from the description of the human experience, as it is lived and defined by the actors themselves, providing a free field to explore the potential of perceptions and subjectivities.10 The project was approved by the Research Ethics Committee of the Institution in which the study was carried out and filed in the National Ethics Committee in Research with the number of CAAE - 23356414.6.0000.5259. The field was a large university hospital, located in the city of Rio de Janeiro.

In compliance with the Resolution No. 466/12, 39 nursing professionals (14 nurses and 25 nursing technicians) were enrolled in the Clinical Nursing Service, after signing the Free and Informed Consent Term, by means of the following inclusion criteria: to have worked for at least one year in a medical clinic unit, to have a statutory, part-time and/or temporary contract. Workers with less than one year of service, on vacation, on a medical leave or other types of leave were excluded.

It was informed that the participation of the deponents would be voluntary and that they would have the right to withdraw from the research at any stage. The anonymity of the statements was guaranteed and it was ratified that the results would be presented in events and published in scientific journals. In the transcript of the statements, the following conventions were adopted: nurses (E) and nursing technicians (TE), followed by a number according to the order of entry in the text.

The data collection took place in the second half of 2014, at the professionals' own workplace, after the selection and invitation of the professionals to participate in the study. The semi-structured interview technique was used,10 through a script that combined closed and open questions, with possibilities for the individual to discuss the theme being approached, favoring the contextualization of experiences and senses. In the register of the sociodemographic and professional characteristics of the participants, an instrument was made by the authors with the following items: gender, age, marital status, professional category, schooling, type of employment relationship, number of employment contracts, type of shift and family income.

After the transcription was made, the text corpus was submitted to a thematic content analysis11, which consisted of a set of systematic and objective procedures for describing the content of the messages, indicators (quantitative or not) that allowed the inference of knowledge regarding the conditions of production/reception (inferred variables) of the messages. At the last moment, using the criteria of representativeness, homogeneity, reclassification and aggregation of the elements of the set, the following categories were elaborated: presenteeism and the aggravation of preexisting diseases and the presenteeism and patient safety.

 

RESULTS AND DISCUSSION

Characteristics of the participants

A total of 14 (35.8%) nurses and 25 (64.1%) nursing technicians participated in the study; 32 (82%) are female and 7 (17.9%) are males, whose age range was between 25 and 44 years old (64.1%). They self-reported being married 19 (48.7%), unmarried 18 (46.1%), divorced 1 (2.5%) and widowed 1 (2.5%). According to a survey that outlined the nursing profile in Brazil, 85.1% of the professionals are female, highlighting the growing number of men in the profession. More than 1 million and 100 thousand (61.7%) professionals are up to 40 years old, characterizing nursing as a profession in full rejuvenation.12

Regarding the correlation between age and presenteeism, the study evidenced the statistically significant difference between the means of the variable age, being that workers up to 40 years old demonstrated, by means of the lower presenteism means, the workers who had a decrease in performance due to the presented health problem. Women presented lower means of presenteeism, although they were more affected by the presenteeism at work than men.5

Regarding the employment relationships, 22 (56.4%) participants reported not having employment stability (temporary contract) and 17 (43.6%) were civil servants (statutory), and it should be highlighted that all the temporary workers stated that they had more than one contract and work hours exceeding 50 hours per week. The low remuneration of the nursing workers in the health services has led the category to accumulate more than one employment relationship, as a strategy to improve their income, with damage to their health due to the long hours of work, over-commitment to work and overload; factors that contribute to a decline in performance, premature aging and illness.13,14

The categories emerging from the content analysis of the professionals' statements are mentioned below.

Presenteeism and the aggravation of preexisting diseases

Due to the musculoskeletal disorders mentioned by the participants, it was possible to establish a relationship between these diseases and the reduction of the physical and mental capacity for work with impairments to the performance and overload of other professionals, as reported:

There is a professional here in the ward who has a spinal problem [low back pain] and people do not let her to carry weight so it does not get worse. Because there is no way! She is never going to get better! (TE2)

I have advanced degenerative disc disease! I have to live with it! I live with the pain and produce less! Sometimes I get stuck! But it is possible to do something. (TE18)

When there is someone who is sick or has a problem, such as I have this problem [back pain], I cannot pick up or put the patient on the chair, my co-worker puts the patient on the chair for me. (TE1)

Health problems, especially musculoskeletal disorders, in addition to having detrimental consequences to the health and well-being of the nursing professionals, they reduce the psychophysical capacity for work, making that the future leaves for medical treatment are longer. In nursing, such problems can be aggravated by caring for bedridden patients with varying degrees of dependence, which requires the worker to perform physical effort and energy expenditure by assuming inadequate body positions and weight lifting. Other factors that favor such affections are gender, age, strength and muscular endurance.5,16

From the perspective of the study participants, other health problems that favor the presenteeism are acute and respiratory infections, which decrease the concentration, disposition, accentuate tiredness and discomfort with clear interference in performance. Such symptoms can be aggravated due to the demands of the workplace and the fact that the hospital is an unhealthy and risky work environment.

I have already worked with fever and sore throat! Then the concentration drops! The performance as well! It is not the same thing: it takes the attention and the disposition. (E3)

I have already come to work with the flu and the work becomes more difficult and complicated, especially for being a boss, I had meetings and could not miss them. It was very hard! The price you pay for your performance is tiredness, malaise, headache. (E14)

Coming to work sick makes it hard to work, even here! In the practice itsefl! If the person does not have conditions, how will they bathe the patient? We see this happen every time and the work increases. (E1)

Despite the social pressure of the work and the demands imposed by the organization, once the worker is clear about their labor rights, their limitations and that their state of health interferes in the performance of their duties, it is possible to work on such resources and improve the individual's ability to cope with adverse situations in their occupational environment. After all, there is scientific evidence that shows that keeping the worker away from work for treatment can reduce the number of days for absenteeism due to disease.5,17

Other issues related to the world of contemporary work also reinforce the presenteeism, among them: the job insecurity due to the fragility of labor contracts, competitiveness and increasing incentives to productivity, making individuals avoid to miss a working day.18 There are also aspects that involve the subjectivity of the worker as the symbolic rewards arising from the work social environment due to good interpersonal relationships, the sense of belonging and the possibility of exchanges. On the other hand, rigid organizations, marked by competition and individualism, can also favor the presenteeism7

The scarcity of studies that establish the causal nexus between the presenteeism due to acute respiratory infections and infection of patients under the care of the professional does not eliminate this possibility. This is a problem that must be analyzed with caution by the managers, because it involves ethical issues of the professional practice, ratifying the need to leave the worker with the intention of preserving the safety of the patient and of the team itself.5,6,18

Presenteeism and the safety of the patient at risk

It was evidenced that the presenteeism affects the quality of the nursing care and the dynamics of the service, since the permanence of the professional with weak health in service requires the nurse to redistribute the activities in the team, which generates overload and conflicts between the other components and users that resent the slowness of service:

Undoubtedly the quality of the service is diminished. The care is of a lower quality, no doubt. Especially if it is an emotional issue, then the person cannot talk and give attention. I believe it is impaired. (TE5)

The person came to work sick and at some point they get slower, that is, the work process becomes more slow! The whole dynamics of the work changes! The colleagues become dissatisfied! The companions demand it! Because you start failing to provide the ideal care. (TE14)

I think this can lead to conflicts between patients and professionals. Because when there are professionals who are not well physically and the work is compromised, since we have to put this professional to carry out other activities. (E4)

The presenteeism involves direct and indirect costs to the organizations due to the loss of productivity by the workers, in general, caused by acute affections and other health problems. The costs are more difficult to be measured since the loss occurs during the execution of the tasks due to the drop in the productivity caused by the slowness. There is a consequent adverse impact on the quality of service, which generates more social and economic burdens than the absenteeism.6 From the perspective of some managers, the postponement by the worker to request the absence of the work for a health treatment can be an advantage, since theoretically the costs with the temporary hiring of another professional are reduced. On the other hand, companies are starting to realize how this kind of attitude can be harmful to both the worker and the company, given the drop in productivity and quality of service. It is added that there is a possibility of worsening in the state of health of the professional according to the work damands.5, 19

By itself, the hospital nursing work is exhausting, both due to the demands of the activities and because of the specificity and diversity of the functions performed, since it is often permeated by uncertainties, instabilities and immediacy, as well as the need to cope with high variability situations.15

The damages caused to the clients under the care of the nursing team as a result of technical failures, in the view of the workers, may have as contribution the presenteeism factor, especially in the situations in which there is a decrease in the concentration in the work performance. Thus, it is imperative that managers assume the responsibility for the evaluation of the worker, avoiding that they remain at work without physical and mental conditions, due to the risks to the integrity of patients.

I also think it can generate errors, because the person does not have the attention to on the tasks, a mistake in the medication, a patient exchange. (E4)

There is the risk of making mistakes! It is possible to stop doing something because you are feeling sick! If you have a headache you can forget the name of the medicine, because attention is deviated! A lot goes into oblivion. (TE25)

I think when someone is sick, the clinical look of that person for the patient is different, the attention changes. So, the care changes a bit, and it can harm the patient. (E15)

With the intensification of the work and physical and/or emotional problems, there is a decrease in the professional's ability to concentrate, which can negatively interfere in the productivity and quality of the service offered, contributing to the increase of medication administration errors and falls of patients.20 The occurrence of errors in the performance of procedures of a therapeutic nature, especially the invasive ones, is a relatively frequent event in the health sector, especially in the hospital area, having as results the commitment with the well-being and the integrity and/or the life of the users of the services. In this perspective, there is a concern that the presenteeism, a relatively new phenomenon in the context of the health work, may contribute to the occurrence of adverse events that increase the social and financial burden of hospitals due to the length of hospital stay and greater risk of complications.21

It is warned that it is not possible to organize the health services without considering that the professionals can make mistakes and it is up to the system to create mechanisms to avoid that the error reaches the patient. In this sense, care professionals and managers must take responsibility for their own safety and that of the team, patients and family, prioritizing safety over financial and operational goals. Managers should promote resources, structure and accountability for an effective maintenance of the security, whose issues related to the topic should be part of a culture that encourages the reward, identification, notification and resolution of problems that will have adverse effects on users.22

 

CONCLUSION

It was evidenced that the presenteeism from the perspective of the study participants is a dialectical phenomenon that involves workers, managers and users, due to the fact that this event affects the productivity and the quality of the service. The presenteeism, in addition to contribute to the aggravation of chronic diseases, due to the non-removal of the worker for medical treatment, also affects the interpersonal relationships, generating conflicts and slowness in care. There is a possibility of errors and adverse effects to the patients under the care of the teams.

In view of the problems identified in the study, it is necessary to have an institutional policy focused on the identification, monitoring and adoption of measures that minimize or eliminate the occurrence of the presenteeism in the nursing work environment. There are ethical issues involved in providing care that may jeopardize the patient safety, since the worker with chronic or acute health problems has their performance affected, with attention being diminished and increased fatigue and malaise.

In the analysis of the presenteeist attitude on the part of the worker, the subjective aspects should be considered such as the feeling of belonging, of contributing to the improvement of the patient and the commitment with the institution and the team. It should be highlighted that fragile employment relationships, especially those with no job stability, can also influence presenteeism due to the absence of social protection and fear of unemployment.

Despite the limitations of the study and the impossibility of generalizations to other work contexts, its relevance is confirmed because it is a topic of great interest to nursing and health service managers. There is also an incipience of studies of this nature that highlight the perceptions, feelings and coping mechanisms adopted by nursing workers in their workplaces and the social pressure they suffer to attend work even with a poor health.

 

REFERENCES

1.Mauro MYC, Paz AF, Mauro CCC, Pinheiro MAS, Silva VG. Condições de trabalho da enfermagem nas enfermarias de um hospital universitário. Esc. Anna Nery Rev. enferm. [internet]. 2010 [cited 2018 Jan 13]; 14(2): 244-52. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-81452010000200006&lng=en . http://dx.doi.org/10.1590/S1414-81452010000200006 .

2.Gonçalves FGA, Souza NVDO, Pires AS, Santos DM, Brecht, Ribeiro LV. O modelo neoliberal e suas repercussões para a saúde do trabalhador de enfermagem. Rev. enferm. UERJ. [internet] 2014 [cited 2017 Aug 21]; 22:519-25. Available from: http://www.facenf.uerj.br/v22n4/v22n4a14.pdf .

3.Menegueti MG, Nicolussi AC, Scarparo AF, Campos LF, Chaves LDP, Laus AM. Dimensionamento de pessoal de enfermagem nos serviços hospitalares: revisão integrativa da literatura. Rev. eletrônica enf. [internet] 2013 [cited 2017 Oct 02]; (2):551-63. Available from: http://dx.doi.org/10.5216/ree.v15i2.18559 . doi: http://dx.doi.org/10.5216/ree.v15i2.18559 .

4.Alves MP, Coelho MCR, Borges LH, Cruz CAM, Massaro¬ni L, Maciel PMA. A flexibilização das relações de trabalho na saúde: a realidade de um hospital universitário federal. Ciênc. saúde coletiva (Online). [internet] 2015 [cited 2017 Dec 12]; 20:3043-50. Available from: http://www.scielo.br/scielo.php?pid=S1413-81232015001003043&script=sci_abstract&tlng=pt

5.Umann J, Guido LA, Grazziano ES. Presenteísmo em enfermeiros hospitalares. Rev. latino-am. enferm. (Online) 2012 [cited 2018 Jan 03]; 20(1):[8 telas]. Available from: http://www.scielo.br/pdf/rlae/v20n1/pt_21.pdf .

6.Paschoalin HC, Griep RH, Lisboa MTL, Mello DCB. Transcultural adaptation and validation of the standford presenteeism scale for the evaluation of presenteeism for brazilian portuguese. Rev. latino-am. enferm. (Online) 2013 [cited 2018 Jan 16] 21(1):388-95. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692013000100014

7.Ferraz F. Presenteísmo: as perdas diárias e silenciosas. Congresso Nacional de Excelência em Gestão [periódico na internet] 2016 [cited 2018 Jan 07];1-13. Available from: http://www.inovarse.org/sites/default/files/T16_188.pdf

8.Widera E, Chang A, Chen HL. Presenteeism: a public health hazard. Journal of General Internal Medicine [Online] 2010 [cited 2018 jan 16]; 25(11):1244-7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2947637/

9.Gosselin E, Lemyre L, Corneil W. Presenteeism and abseteeism: differentiated understanding of related phenomena. Journal of occupational health psychology [Online] 2013 [cited 2018 Jan 14]; 18(1):75-6. Available from: http://www.gapsante.uottawa.ca/newSite/Articles-PDF/86-Gosselin.pdf

10.Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 13ª ed. São Paulo: Hucitec; 2013.

11.Bardin L. Análise de conteúdo. 3ª ed. Lisboa(Pt): Edições 70; 2011.

12.Machado MH, Oliveira E, Lemos W, Lacerda WF, Wilson Filho A, Wermelinger M et al. Mercado de trabalho da enfermagem: aspectos gerais. Rev. enferm. foco. [internet] 2016 [cited 2018 Jan 03]; 7(esp):35-2. Available from: http://revista.portalcofen.gov.br/index.php/enfermagem/article/view/691/301

13.Grazziano ES, Ferraz Bianchi ER. Impacto do estresse ocupacional e burnout para enfermeiros. Enfermeria Global [periódico na internet] 2010 [citado em 05 jan 2018]; 18: 1-20. Available from: http://scielo.isciii.es/pdf/eg/n18/pt_revision1.pdf

14.Sampaio MRFB, Franco CS. Mercado de trabalho da enfermagem: aspectos gerais. Rev. Enferm. foco. [internet] 2016 [cited 2018 Feb 04]; 7(esp): 35-2. Available from: http://revista.portalcofen.gov.br/index.php/enfermagem/article/view/700/309

15.Petersen RS, Marziale MHP. Lombalgia caracterizada pela resistência da musculatura e fatores ocupacionais associados à enfermagem. Rev. latino-am. enferm. (Online) 2014 [cited 2017 Dec 21]; 22(3): 386-93. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692014000300386&lng=en . http://dx.doi.org/10.1590/0104-1169.3321.2428

16.June KJ, Cho SH. Low back pain and work-related factors among nurses in intensive care units. J Clin Nurs [Online] 2011 [cited 2018 Jan 10]. 20(3-4):479-87. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20673308 . doi: http://dx.doi.org/10.1111/j.1365-2702.2010.03210.x .

17.Johns G. Presenteeism in the workplace: a review and research agenda. J. Organiz. Behavior [Online] 2010 [cited 2018 Jan 13]; 31:519-42. Available from: http://psycnet.apa.org/index.cfm?fa=search.displayRecord&UID=2010-08125-003 .

18.Vieira MLC, Oliveira EB, Souza NVDO, Lisboa MTL, Xavier T, Rossone FO. Precarização do trabalho em hospital de ensino e presenteísmo na enfermagem. Rev. enferm UERJ. [internet] 2016 [cited 2018 Jan 12]; 24(4):e23580. Available from: DOI: http://dx.doi.org/10.12957/reuerj.2016.23580

19.Mitchell RJ, Bates P. Measuring health-related productivity loss. Population Health Management [Online]. 2011 [cited 2018 Jan 03]; 14(2):93-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3128441/pdf/pop.2010.0014.pdf .

20.Levak SA, Ruhm CJ, Gupt SN. Nurses' presenteeism and its effects on self-reported quality of care and costs. American Journal of Nursing [Online] 2012 [cited 2018 Feb 06] 112(2): 30-8. Available from: https://pdfs.semanticscholar.org/cdfa/d478477f72445a2b0b981f8359a78a7ce78c.pdf

21.Reyes RJF. Presentismo en enfermería. Implicaciones en seguridad del paciente: posibilidades de control y reducción. Enferm Glob. [Online] 2014 [cited 2018 Jan 10]; 13 (35): 362-73. Available from: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1695-61412014000300020&lng=es .

22.Ministério da Saúde (Br). Documento de referencia para o Programa Nacional de Segurança do Paciente. 2014 [cited 2018 Jan 10]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/documento_referencia_programa_nacional_seguranca.pdf