RESUmo
Este estudo teve como objeivo construir e apresentar a deinição teórica do conceito de gerência do cuidado de enfermagem em cenários hospitalares, a parir de base literária especíica. Optou-se pela uiliza-ção das estratégias para construuiliza-ção de conceitos da Análise de Conceito, as regras de formação de conceito da Análise Arque-ológica e a Análise Lexical como referencial teórico-metodológico. A operacionalização das estratégias e das regras de formação de conceito possibilitou a construção do conceito gerência do cuidado de enferma-gem em cenários hospitalares. O conceito construído apresentou, em sua natureza, a capacidade de integrar dialeicamente os aspectos relaivos ao saber-fazer do cuidar e gerenciar. A deinição teórica do conceito Gerência do Cuidado de Enfermagem em Cenários Hospitalares deu signiicado ao termo, no contexto inicial de construção de uma teoria, a Gerência do Cuidado de Enfermagem em Serviços de Saúde.
dEScRitoRES
Cuidados de enfermagem Gerência
Formação de conceito
Administração dos cuidados ao paciente Recursos humanos de enfermagem no hospital
Nursing care management in
hospital settings: the building
of a construct
*O
riginal
a
r
ticle
AbStRAct
The objecive of this study was to build and present a theoreical deiniion of the con-cept of nursing care management in hospi-tal seings, based on speciic literature. We chose to use Concept Analysis strategies for building concepts, the rules of Archeo-logical Analysis for forming concepts, and Lexical Analysis as the theoreical-method-ological framework. The operaionalizaion of the strategies and rules for forming the concept permited the construcion of the concept of nursing care in hospital seings. The constructed concept presented, by its nature, the capacity to form a dialecic integraion of the aspects relaive to the knowing-doing of care and management. The theoreical deiniion of the concept of Nursing Care Management in Hospital Seings assigned meaning to the term, in the iniial context of the construcion of a theory of Nursing Care Management in Health Services.
dEScRiPtoRS
Nursing care Management Concept formaion Paient care management Nursing staf, hospital
RESUmEN
Construir y presentar la deinición teórica del concepto de administración del cuida-do de enfermería en escenarios hospitala-rios a parir de base literaria especíica. Se optó por la uilización de estrategias para construcción de conceptos del Análisis de Concepto, las reglas de formación de con-cepto del Análisis Arqueológico y el Análisis Lexical como referencial teórico-metodoló-gico. La operacionalización de estrategias y de reglas de formación de conceptos posibilitó la construcción del concepto “ad-ministración de la atención de enfermería en escenarios hospitalarios”. El concepto construido presentó en su naturaleza la ca-pacidad de integrar dialécicamente los as-pectos relaivos al saber/hacer del cuidado y administración. La deinición teórica del concepto Administración de la Atención de Enfermería en Escenarios Hospitalarios dio signiicado al término, en el contexto inicial de construcción de una teoría, la Adminis-tración de Atención de Enfermería en Ser-vicios de Salud.
dEScRiPtoRES
Atención de enfermaría Gerencia
Formación de concepto
Administración de los cuidados al paciente Personal de enfermería en hospital
barbara Pompeu christovam1, isaura Setenta Porto2, denise cristina de oliveira3
Gerência do cuidado de enfermaGem em cenários hospitalares: a construção de um conceito
administración de la atención de enfermería en escenarios hospitalarios: la construcción de un concepto
*taken from the thesis “Gerência do cuidado de enfermagem em cenários hospitalares: a construção de um conceito”, post-graduate nursing program, escola de enfermagem anna nery da universidade federal do rio de Janeiro, 2009. 1ph.d. professor, department of nursing fundamentals and
administration, escola de enfermagem aurora de afonso costa, universidade federal fluminense. rio de Janeiro, rJ, Brazil. [email protected] 2ph.d.
researcher, research Group on hospital nursing. faculty, medical-surgical nursing department and Graduate nursing program, escola de enfermagem anna nery, universidade federal do rio de Janeiro. cnpq researcher. rio de Janeiro, rJ, Brazil. [email protected] 3full professor and coordinator
iNtRodUctioN
The interest in researching on the theme nursing care management in the hospital context emerged from per-sonal concerns when perceiving that, in the 21st century, many nurses sill display a behavior that evidences a di-chotomy between management and care delivery in their discourse and pracice, as if these were two concomitant acivity spheres whose pracice is incompaible. The nurs-es’ conceptual diiculty with nursing care management acions is perceived, to the extent that most of them do not understand that their work process involves care de-livery (direct care acions) and management (indirect care acions), i.e. that nurses’ acions in pracice are directed at nursing care management.
This dichotomy between management and care, how-ever, should not permeate the nurses’ discourse as, since the insituionalizaion of Nursing as a profession, their work process comprises two processes, the
care process and the management process. Florence Nighingale, who is considered the precursor of Modern Nursing and the irst hospital manager, demonstrated the impor-tance of nurses’ knowledge on administra-ive techniques and instruments in diferent studies, with a view to the organizaion of the therapeuic environment and the sys-temizaion of nursing care techniques and procedures(1-2).
The dichotomy between care and admin-istraion can be overcome through a change in nurses’ educaion and know-how in nurs-ing care organizaion in hospital contexts, so that the nursing care delivery standards they put in pracice are based on a systemic model.
In this perspecive, we believe that a Nursing Care Management concept can be
constructed that contains a dialecical instead of a dichot-omous relaion between care and care management. This dialecical relaion involves the social and cultural form and contents of individual and collecive care in the hos-pital context(3).
An extensive Brazilian literature review on nursing care management revealed the inexistence of a structured concept that guided or adhered to the pracice developed in hospital contexts. The contents found derives from relecions that appoint instruments to put in pracice nursing care management and health care, such as: the nurse’s funcion that demands competences to admin-ister the sector, development of technical-care and staf management aciviies(4); administraive acions aim for a
sole product, which is quality care for the client(5); phases
of the administraive process(6); funcion of health team
members(7); object of the management process that falls
upon nursing workers(8); intermediary stage between care
delivery and management of work units(9), among others.
Another fact that stood out in the literature survey was the fact that studies with a clearer and more objec-ive deiniion for care management addressed collecobjec-ive health managementissues(7,10). These literature results
re-inforce the importance of building a nursing care manage-ment concept that can guide the acions the nurses devel-op in the hospital context, Nursing Management teaching and the development of Nursing know-how.
This paper presents the results of a doctoral disserta-ion with the following aims: build and present the theo-reical deiniion of the nursing care management concept in hospital contexts, based on speciic literature.
mEtHod
To build new knowledge and/or trans-form established and insituionalized know-how on a theme, one should know the em-pirically produced and validated knowledge. To construct a scieniic concept, systemized methods need to be applied. To construct the nursing care management concept in hospital contexts, the researchers chose a muli-referenial approach, in which the con-cept construcion strategies of Concon-cept Anal-ysis(11) and the concepion formaion rules of
Archeological Analysis(12) were used, which
were put in pracice through Lexical Analysis of Co-occurrences in Alceste sotware(13-14).
This opion originated in the belief that sci-eniic knowledge construcion is based on concepts created, airmed or transformed(15)
according to their historicity and systemaic descripion of a discourse-object.
The research sample comprised Brazilian producions on the themes: administraion, nursing care and nursing care management. To develop the study, the following guiding quesion was established: What are the essenial components of the nursing care concept in the hospital context originaing in literature? The biblio-graphic survey covered 28 years (irst text found dated back to 1982) and was put in pracice in two phases: (1) search for producions in internaional electronic databases: Lain-American and Caribbean Health Science Literature (LILACS) and the Nursing Database (BDENF) of the Virtual Health Li-brary (BVS/BIREME); (2) manual search in journals, disser-taions, theses and books. The following descriptors were used in all searches: administraion, paient care adminis-traion and nursing care. It is highlighted that care manage-ment is not recognized as a descriptor but as a term.
The selected texts were reined to compose the sam-ple through the applicaion of the following inclusion criteria: a) theoreical-conceptual contribuion in
admin-...believe that a nursing care management concept
can be constructed that contains a dialectical instead of a
dichotomous relation between care and care management. this dialectical relation
istraion, management and nursing care concerning their administraive and management aspects; b) relaionship among the terms administraion, management and nurs-ing care; c) address the meannurs-ings and applicaion of the terms administraion, management and nursing care in themaic contexts with the following characterisics-deiniion: historical, evoluionary and geographic origin; funcion; acion ield; acion result; operaionalizaion and systemizaion; and e) texts of books and papers published in Brazilian and internaional journals in Portuguese, which complied with the above inclusion criteria.
At the end of this process, the sample comprised 75 producions, divided in: research papers n= 17; review papers n= 14; theoreical relecion papers n= 16; confer-ences n = 06; theses n= 10; dissertaions n= 06 and books n= 06. It is highlighted that, out of 75 producions in the research sample, 07 belonged to the Administraion area; 22 to Nursing (producions about care); 45 to Nursing Ad-ministraion; and 01 to Health Administraion. These pro-ducions consituted the corpus of the study analysis. This
corpus was prepared and submited to the speciic proce-dures and operaions of the Alceste sotware.
For the sake of a beter understanding of how the study results were obtained, a short explanaion is due on the references used. It should be highlighted that the approximaion between the theoreical and method-ological frameworks of Concept Analysis, the Archeology of Knowledge and Lexical Analysis used to construct the nursing care management concept was possible because, although concept analysis makes it clear what to do to construct a concept, it does not prescribe operaional phases for this construcion. This permits some freedom to adopt diferent approaches. Next, the theoreical-methodological approaches are presented.
Concept Analysis, the irst reference framework to be addressed, is a set of understandable strategies that can broaden the intuiive processes theoreicians already use to construct concepts, proposals and theories. In this study, strategies are considered the guidelines for the de-velopment of aciviies related to the theoreical focus(11).
The development of a concept is a crucial task to devel-op a theory. Oten, however, phenomena are described, explained or established without the theoreician’s clear understanding of what actually has to be described, ex-plained or established. For the systemaic development of the nursing care management concept in hospital texts, the following strategies were selected for its con-strucion: (1st) Concept Derivaion; (2nd) Concept Synthe-sis; (3rd) Concept Analysis.
The second approach used in the study is Archeologi-cal Analysis, also Archeologi-called Discursive Analysis. Within the archeological perspecive, concept formaion aimed to es-tablish the possibiliies of new knowledge inside already insituted knowledge. Archeological analysis serves to analyze discourse that consitutes new knowledge. Thus,
knowledge comprises a set of elements consituted by a discursive pracice, which is speciied as the domain con-situted by diferent objects that may gain a scieniic sta-tus or not, the space in which the subject can talk about the objects his discourse is referring to, the ield of coor-dinaion and suborcoor-dinaion of the statements in which the concepts appear, are deined, applied and trans-formed. Finally, knowledge is deined by the possible uses and appropriaions the discourse ofers. In this context, the discursive pracices stand out, which consitute the knowledge archeology analyzes, which are inserted in the
archeological territory. The archeological territory is the region where the statements are located that make up the enunciaion or contextual ield, a ield characterisic of the discourse, which is the focus of archeological analysis(12).
Thus, to put in pracice the development strategies of the Concept Analysis(11) concept and the concept
forma-ion rules of Archeological Analysis, the methodological framework of Lexical Analysis was chosen, which is consid-ered a relaion analysis mode, based on the computerized analysis of co-occurrences in the Alceste sotware. Alceste is a computerized technique and a textual data analysis method, to the extent that the program integrates a large quanity of sophisicated staisical methods used in the ideniicaion of the basic informaion contained in a text or set of texts. The program automaically performs the lexical analysis of text contents through quanitaive tex-tual data treatment techniques, among which the Chi-square (x2) test stands out(13).
Alceste works on the premise that, when diferent in-dividuals produce the text corpus, discourse is analyzed in diferent ways, reproduced through a paricular, speciic vocabulary that detects diferent forms of thinking about
the phenomenon of interest. Thus, based on the program’s own dicionary, the data corpus (texts) is analyzed and subdivided, including the ideniicaion of tool-words and full words. Full words are those words that have meaning, characterizing the context units, and reveal the semanic world to be explored in the research. The Alceste analysis is based on the reduced forms of these words that consi-tute the contextual ield. The contextual ield is deined as
the speciic vocabulary of a class characterisic of a certain type of context(13).
re-search. Alceste analysis does not intend to interpret what is said, but to know in what means it is said.
Thus, based on the theoreical-methodological frame-works explained, the nursing care management concept was constructed in two phases, which are: quanitaive and qualitaive. Therefore, a hybrid research method was used, which is the combinaion method. In this strategy, both research models, the quanitaive and the qualita-ive, were used in a complementary and parallel way(16),
with a view to data treatment, organizaion and analysis. In the quanitaive research phase, staisical text analysis was used with the help of Alceste sotware.
In this research phase, staisical analysis was applied to: (a) extract from the analysis corpus the group of atri-butes to deine the management and care concepts that consitute the new phenomenon of interest, nursing care management; and, (b) classify the data related to the phe-nomenon of interest by grouping them based on content similariies and diferences inside a semanic context, pre-sented by the set of statements, i.e. the set of elementary context units (ECU) that consituted the classes resuling from Alceste analysis. It is highlighted that the criterion adopted to select and order the speciic elements of a class and, consequently, speciic for the category it is part of, was the result of the Chi-square test (x2). Elements
with x2 equaling 38 or higher were considered recurring,
i.e. characterisic of a class. The Chi-square (x2) value of 38
resulted from the arithmeic means of the x2 values
calcu-lated based on the 10% highest x2 values for each of the
ive classes that resulted from the Alceste analysis. To construct the analysis categories that resulted from the use of the Alceste method and to elaborate the themaic groups of the classes that composed these cat-egories, the following criteria were used: (a) grouping of similar reduced forms, based on full words or semanic context; (b) the reduced forms of a themaic group were organized based on x2, in decreasing order, to redistribute
the reduced forms in each themaic group; (c) the ainity deriving from the similarity to or approximaion with each themaic group was reviewed by comparing the ECU and the reduced forms of full words in each themaic group; and, (d) the ECU were selected according to the decreas-ing x2 value, based on a minimum cut chosen to use the
ECU, i.e. x2=10, as, below this value, the contexts started
to take distance from the study object.
In the same phase, the concept derivaion and synthe-sis strategies were put in pracice. In the derivaion strate-gy, the following guiding quesions were used to direct the derivaion of the administraion, nursing care and nursing administraion concepts that remit to the new concept of nursing care management: What ideas do the classes present on the administraion/management, nursing care and nursing management concepts? How do the ECU de-ine these concepts? What concept characterisics or at-tributes are appointed in the ECU?
Through the applicaion of the synthesis strategy, the uses and essenial atributes of the nursing care manage-ment concept were ideniied. Therefore, the following guiding quesions were used: What ideas do the classes present about the nursing care management concept? How do the ECU deine this concept? What characteris-ics or atributes of this concept are appointed in the ECU? In this phase, the concept components were also ideni-ied. These components were deined based on the full words that characterized each class, i.e. words with x2 of
38 or higher. To seek the uses and essenial atributes of the concept and its components, the classes present in the ECU results that characterized them were subject to themaic context analysis, also considering the reduced forms of the most signiicant full words in these classes.
In the qualitaive phase, the concept analysis strat-egy was applied, involving the following steps: (a) iden-iicaion of recurring elements in the objects’ discursive formaion: care, management and care management; (b) ideniicaion of the atributes that theoreically de-ine the concept; and, (c) construcion of the concept’s theoreical deiniion, according to the concept formaion rules of the Archeology of Knowledge.
RESULtS
The data found in the ive classes that resuling from the applicaion of the Alceste method to this research’s analysis corpus permited the construcion of three analy-sis categories, which were: (a) Category 1. Care: Dimen-sions, Acions and Interfaces with Professional Pracice – comprises class 4 – Theoreical Dimensions of Care, and class 3 – Care Acions and their Interfaces with Profession-al Pracice; (b) Category 2. Administraion/Management – Historical Evoluion of Teaching, Management Models and Management Pracice in Health – comprises two classes, which are: Class 1. Historical Aspects of Nursing Adminis-traion Teaching; and Class 5. Management Models and the Health Work Process; (c) Category 3. Nursing Care Management: the Nurse’s Acions in Professional Pracice – comprises the inal class that resulted from the Alceste analysis, class 2. Nursing Care Management Acions and the Nurse’s Professional Pracice.
The staisical analysis results of the x2 values found
for the variables associated with the classes that make up each analyic category, i.e. the relaion between the total ECU produced in the corpus and the total ECU belonging to each class evidenced the archeological territories in which the discursive pracices that consitute the knowledge in these classes are located. In this context, the archeologi-cal territory of category 1 is characterized by knowledge about the irst care concept, predominantly produced in the States of Santa Catarina and Rio de Janeiro, mainly originaing in relecion papers and doctoral dissertaions in Nursing Administraion and Health Administraion.
In category 2, this territory is characterized by knowl-edge about the irst management concept, predominantly produced in the States of São Paulo, Rio Grande do Norte and Rio Grande do Sul, mainly originaing in research and relecion papers in Nursing, Nursing Administraion, Health Administraion and Administraion. Category 3 is characterized by knowledge about nursing care manage-ment, mainly produced in the State of Paraíba and pre-dominantly originaing in theses and review papers in Nursing Administraion.
The funcion of concept formaion, from the perspec-ive of concept analysis as well as discursperspec-ive or archeo-logical analysis, is to describe and examine the structural and funcional organizaion of the concept. The structural organizaion of the nursing care management concept, based on the above described categories, permited the ideniicaion, nominaion and classiicaion of recurring elements, i.e. the elements that deine and guarantee the discursive regularity of the enunciaion ield for the pri-mary concepts management and care.
The funcional organizaion of the nursing care man-agement concept permited the outlining of forms of co-existence, i.e. of the relaions established between the management and care objects in the ields of presence and concomitance, which were conigured by puing in pracice the derivaion and synthesis strategies of the pri-mary concepts management and care.
Chart 1 – Recurring elements of management, care and nursing care management objects, which contributed to the establishment of
the Nursing Care Management concept in Hospital Contexts. Rio de Janeiro, 2011.
Analytic Categories Object Recurring elements
Category 1. Care: Dimensions, Actions and Interfaces with
Professional Practice Care
Knowledge, complexity, therapeutic relations,
instrumental nursing care actions and expressive nursing care actions.
Category 2. Administration/Management – Historical Evolution of Teaching, Management Models and Management Practice in Health
Management
Administrative knowledge, management competency, management model, therapeutic relations, professional relations, institutional relations, instrumental management actions and expressive management actions.
Category 3. Nursing Care Management: the Nurse’s Actions in Professional Practice.
Nursing Care Management
Care process, management process, nursing care management skills, assistential models of nursing care management, instrumental nursing care management actions and expressive nursing care management actions.
The elaboraion of the theoreical deiniion of the nursing care management concept in hospital contexts permited declaring the existence of the phenomenon it refers to. Thus, the theoreical deiniion of the Nursing Care Management concept in Hospital Contexts described in this study is:
In its theoreical concepion, nursing care manage-ment involves a dialecical relaion between managemanage-ment know-how and care know-how. The dialecics of the term establishes a game of relaions that results in a dynamic, situaional and systemic process, which ariculates man-agement and care knowledge, permiing the existence of an interface between these two objects in professional pracice. Nursing care management know-how is an-chored in the ontological dimension, which is expressive, to the extent that it involves scieniic, ethical, estheic and personal knowledge about man’s complexity, in terms of singulariies, mulipliciies and individualiies, and their relaion and inserion in the diferent contexts of life. This know-how is also anchored in a technical and technologi-cal dimension, which is instrumental and involves scien-iic and personal knowledge, technical skill, management and care competency. Nursing care management acions are characterized by expressive and instrumental direct and indirect care acions, the ariculaion and interface of technical, poliical, poliics, social, communicaive, cii-zenship development and organizaional aspects, which involve nurses’ pracice in hospital contexts.
diScUSSioN
The nursing care management concept demonstrates a dialecical relaion between management and care, in-stead of a dichotomy between these objects. The dialec-ics between the terms administering and delivering care refers to idenifying the fundamental meanings of both terms and the muliple and someimes disparate relaions between them(17). In this sense, the care management
comple-mentary meanings. The relaionship between these ob-jects constantly establishes a system of relaions through discourse, consituing new knowledge.
In this perspecive, Nursing care management’ know-how covers the ontological, technical and technological dimension, which characterize the expressive and instru-mental acions of care management involved in nurses’ praxis at diferent hierarchical levels in health insituions. Dimension is considered as any level, degree or direcion in which one can accomplish a study or an acion(17-18).
Thus, the care management dimensions are the qualita-ive variaions, degrees or direcions in which direct and indirect nursing care is manifested or can be conducted.
The ontological dimension is based on the help rela-ion for human beings and characterized by knowledge and complexity elements. Knowledge is the product of the teaching-learning process and experience, for nurses as well as other team members as well as for clients. It refers to the way man relates with the world, the context he is inserted in, how he applies the degrees of knowl-edge – observing, perceiving, determining, interpreing, discussing, denying and airming(17-18) and how he applies
the degrees of knowledge.
Complexity is related to man’s aitude and posture in the world, as well as to the relaions he establishes with people, objects and the social context he is inserted in. The individual is single and muliple, a “human complex”, a unit that displays a diversity at all levels – biological, in-dividual and cultural(19).
The technical and technological dimension of care management is characterized by a set of knowledge, tools, instruments and skills needed to organize the nurs-ing team’s work with a view to determinnurs-ing the condiions needed for its maximum performance so as to reach insi-tuional goals(3,17). “Technique” is understood as any
pro-cedure ruled by a set of rules or standards, which direct and make professional aciviies or acions efecive.
Concerning technology, some authors relate the term with the presence of equipment, machinery and cuing-edge materials, and others with technique, tool or instru-ment. This term also means a set of scieniic knowledge that enhances the producion of goods, the delivery of services and the execuion of aciviies in a given area(20).
In a broad perspecive applied to Nursing, technology means a process, which includes objecive and relexive aciviies that are directly implied in empirical knowledge, professional experience, intuiion, interacion and com-municaion. These ariculated components enhance the development of a set of knowledge that supports the or-ganizaion and execuion of nursing care in professional pracice.
To accomplish nursing care management acions, nurses incorporate management tools and instruments to put them in pracice. Tool is a term that can be deined
as the “method, procedure or administraive process em-ployed for administraive management”(20), with a view
to making nurses accomplish nursing care management acions correctly. In this context, the following phases of the administraive process are considered management tools nurses use in nursing care management pracice: planning, execuion, assessment and control. The term in-strument is deined as “the means capable of obtaining a result in any ield of human acivity, whether pracical or theoreical”(17). The management instruments considered
in this study are: coordinaion, supervision, communica-ion, observaion and delegaion.
Nursing care management acions refer to instrumen-tal and expressive direct and indirect care acions, which nurses accomplish in an integrated and ariculated way, aimed at ofering systemized and high-quality care to nursing service clients/users. The term “acion”, when re-lated to an acivity that involves work, means operaing, acing, i.e. the acion is deined as a fundamental element of human acivity in funcional pracice. In this sense, the acion is related to doing, which operates theoreical knowledge, technical skills and interpersonal acions in professional aciviies.
Expressive acions comprise the subjecive aspects that permeate the objecive nursing care management aciviies the nurses perform, to the extent that they pro-duce meanings and efects on the subjects’ experience and familiarity in professional, therapeuic and insituion-al relaions. These acions inluence and are inluenced by the objecive aspects involved in nursing care systemiza-ion and the organizasystemiza-ion of nursing team members’ work. What characterizes instrumental acions is the ac-complishment of technical aciviies aimed at atending to the biological needs expressed in the client’s body, and at the physical care involving this body, with a view to planning and organizing the therapeuic environment and the equipment and material needed to accomplish tech-nical nursing procedures(21-22). The instrumental acions
demand empirical knowledge and technical and manage-ment skills from nurses.
coNcLUSioNS
This study permited the understanding that, depart-ing from a given, established knowledge base, somethdepart-ing new, a concept could be created. In its creaion, this con-cept emerged from knowledge interweaving. At the same ime as it presents a hybrid texture deriving from its mul-iple origins, the nature of this concept displayed the ca-pacity to dialecically integrate the aspects related to the care and management know-how.
of Nursing Administraion, they established a rupture, a transformaion of their knowledge. This transformaion inaugurated a new domain, the outlining of a new space where Nursing know-how is designed. What changed was not the object of Nursing, but the elaboraion of its lan-guage, the way nurses’ discourse exists, which no longer refers only to care or management as dichotomous acivi-ies, to the extent that it incorporates muliple knowledge and pracices, and starts to refer to care and management
in a dialecical way, that is, nurses’ contemporary dis-course becomes that of nursing care management.
In a way, this concept sill lacks validaion. On the oth-er hand, howevoth-er, as it is constructed based on a naional literature body that has mostly been consecrated in the knowledge areas it is part of, it reveals complete adher-ence to the profession. Therefore, it works as a guideline, as a reference point for new studies.
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