Content validity of a Safe Nursing Care Checklist for a neonatal unit.

BACKGROUND: Nursing checklists have been shown to improve communication, reduce the occurrence of adverse events, and promote safe, quality care in different care settings. However, to date, there is no validated patient care safety checklist for nurses caring for infants in Neonatal Intensive Care Units (NICU). AIM: To describe development and content validation of the "Safe Nursing Care Checklist for Infants Hospitalized in the Neonatal Intensive Care Unit". STUDY DESIGN: Online Survey. METHODS: Based upon an integrative literature review, we developed a checklist focused on safe nursing care for infants in the NICU. Nursing experts participated in three rounds of a content validation process where they rated the items online. An agreement level ≥0.90 was required for inclusion in the checklist. Forty- three expert nurses with experience working in the NICU and who were certified in neonatal nursing or had a master's or doctoratal degree in child health provided content validation of the patient care checklist. RESULTS: The final checklist contained 45 items with content validation index scores greater than 90%. The instrument was structured into six dimensions including patient identification, effective communication, medication safety, infection prevention, fall prevention, and pressure injuries/skin injuries prevention. CONCLUSION: Content validity was established for the "Safe Nursing Care Checklist for Infants Hospitalized in the Neonatal Intensive Care Unit" which can identify strengths and weaknesses in safe nursing care for infants in the NICU as well as direct educational interventions to promote nursing care based on scientific evidence. RELEVANCE TO CLINICAL PRACTICE: This checklist can potentially be used by bedside nurses to promote provision of safe care to infants in the NICU and to guide corrective strategies and encourage evidence-based decision-making. Validation in the clinical setting is needed.

Randomized trial of surveillance with abbreviated MRI in women with a personal history of breast cancer- impact on patient anxiety and cancer detection.

BACKGROUND: Abbreviated breast MRI (A-MRI) substantially reduces the image acquisition and reading times and has been reported to have similar diagnostic accuracy as a full diagnostic protocol but has not been evaluated prospectively with respect to impact on psychological distress in women with a prior history of breast cancer (PHBC). This study aimed to determine if surveillance mammography (MG) plus A-MRI reduced psychological distress and if A-MRI improved cancer detection rates (CDR) as compared to MG alone. METHODS: This prospective controlled trial of parallel design was performed at a tertiary cancer center on asymptomatic women with PHBC who were randomized into two groups: routine surveillance with MG or intervention of MG plus A-MRI in a 1:1 ratio. Primary outcome was anxiety measured by four validated questionnaires at three different time-points during the study. Other parameters including CDR and positive predictive value for biopsy (PPV3) were compared between imaging modalities of MG and A-MRI. Tissue diagnoses or 1 year of follow-up were used to establish the reference standard. Linear mixed models were used to analyze anxiety measures and Fisher's exact test to compare imaging outcomes. RESULTS: One hundred ninety-eight patients were allocated to either MG alone (94) or MG plus A-MRI (104). No significant group difference emerged for improvement in trait anxiety, worry and perceived health status (all Time-by-surveillance group interaction ps > .05). There was some advantage of A-MRI in reducing state anxiety at Time 2 (p < .05). Anxiety scores in all questionnaires were similarly elevated in both groups (50.99 ± 4.6 with MG alone vs 51.73 ± 2.56 with MG plus A-MRI, p > 0.05) and did not change over time. A-MRI detected 5 invasive cancers and 1 ductal carcinoma in situ (DCIS), and MG detected 1 DCIS. A-MRI had higher incremental CDR (48/1000(5/104) vs MG 5/1000(1/198, p = 0.01)) and higher biopsy rates (19.2% (20/104) vs MG 2.1% (2/94), p < 0.00001) with no difference in PPV3 (A-MRI 28.6% (6/21) vs MG 16.7% (1/6, p > .05). CONCLUSION: There was no significant impact of A-MRI to patient anxiety or perceived health status. Compared to MG alone, A-MRI had significantly higher incremental cancer detection in PHBC. Despite a higher rate of biopsies, A-MRI had no demonstrable impact on anxiety, worry, and perceived health status. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02244593 ). Prospectively registered on Sept. 14, 2014.

Local Environment Induces Differential Gene Expression in Regenerating Nerves.

INTRODUCTION: Approximately 80% of amputations are complicated by neuromas. Methods for neuroma management include nerve translocation into bone and implantation into skeletal muscle grafts, which have also facilitated the development of regenerative neural interfaces to enable fixation of prosthetics with motor and sensory feedback. However, molecular-level differences between nerves in these environments have not been investigated. This study aimed to elucidate the physiology of regenerating nerves in different settings by assessing gene expression. MATERIALS AND METHODS: New Zealand white rabbits underwent transfemoral amputation with sciatic nerve transposition into the femur or tacked to skeletal muscle. At 5 wk, ribonucleic acid (RNA) sequencing of samples of distal nerve terminating in bone or muscle and nerve of the contralateral limb (control) identified differentially expressed genes (DEGs) and biochemical pathways (α = 0.05). RESULTS: Three samples of nerve housed in bone, four of nerve tacked to muscle, and seven naïve controls were analyzed. Relative to controls, nerve housed in bone had little within-group variation and 13,028 DEGs, and nerve tacked to muscle had dramatic within-group variation and 12,811 DEGs. These samples upregulated the following pathways: lysosome, phagosome, antigen processing/presentation, and cell adhesion molecule. Relative to nerve housed in bone, nerve tacked to muscle had 12,526 DEGs, demonstrating upregulation of pathways of B-cell receptor signaling, focal adhesion, natural killer-cell mediated cytotoxicity, leukocyte transendothelial migration, and extracellular matrix-receptor interactions. CONCLUSIONS: Nerve housed in bone has a more predictable molecular profile than does nerve tacked to muscle. Thus, the intramedullary canal may provide a more reliable setting for neuroma prevention and neural interfacing.

The Effect of Tension on Gene Expression in Primary Nerve Repair via the Epineural Suture Technique.

INTRODUCTION: The precise mechanism through which excessive tension confers poor outcomes in nerve gap repair is yet to be elucidated. Furthermore, the effect of tension on gene expression in regenerating nerves has not been characterized. This study investigated differential gene expression in transected nerves repaired under high and minimal tension. METHODS: Male Lewis rats underwent right sciatic nerve transection with either minimal-tension or high-tension repair. Fourteen weeks postoperatively, segments of the right sciatic nerves were harvested along with equal-length segments from the contralateral, healthy nerve to serve as internal controls (naïve nerve). Differentially expressed genes (DEGs) and differentially regulated biochemical pathways between the samples were identified. RESULTS: Seventeen animals were studied. The gene expression profiles of naïve nerve and minimal-tension repair demonstrated minimal within-group variation, whereas that of high-tension repair demonstrated heterogeneity. Relative to naïve nerve, high-tension repair samples had 4276 DEGs (1941 upregulated and 2335 downregulated) and minimal-tension repair samples had 3305 DEGs (1479 upregulated and 1826 downregulated). High-tension repair samples had 360 DEGs relative to minimal-tension repair samples (68 upregulated and 292 downregulated). Upregulated biological pathways in all repaired nerves included steroid biosynthesis, extracellular matrix-receptor interaction, and ferroptosis. Finally, upregulated pathways in high-tension repair samples relative to minimal-tension repair samples included tumor necrosis factor signaling, interleukin-17 signaling, cytokine-cytokine receptor interaction, and mitogen-activated protein kinase signaling. CONCLUSIONS: The improved outcomes achieved with minimal-tension nerve repair may take root in a favorable gene expression profile. Future elucidation of biochemical pathways in nerve regeneration may identify potential therapeutic targets to optimize primary nerve repair outcomes.

Missed Breast Cancer: Effects of Subconscious Bias and Lesion Characteristics.

Medical errors are a substantial cause of morbidity and mortality and the third leading cause of death in the United States. Errors resulting in missed breast cancer are the most common reason for medical malpractice lawsuits against all physicians. Missed breast cancers are breast malignancies that are detectable at retrospective review of a previously obtained mammogram that was prospectively reported as showing negative, benign, or probably benign findings. Investigators in prior studies have found that up to 35% of both interval cancers and screen-detected cancers could be classified as missed. As such, in conjunction with having awareness of the most common misleading appearances of breast cancer, it is important to understand the cognitive processes and unconscious biases that can impact image interpretation, thereby helping to decrease the number of missed breast cancers. The various cognitive processes that lead to unconscious bias in breast imaging, such as satisfaction of search, inattention blindness, hindsight, anchoring, premature closing, and satisfaction of reporting, are outlined in this pictorial review of missed breast cancers. In addition, strategies for reducing the rates of these missed cancers are highlighted. The most commonly missed and misinterpreted lesions, including stable lesions, benign-appearing masses, one-view findings, developing asymmetries, subtle calcifications, and architectural distortion, also are reviewed. This information will help illustrate why and how breast cancers are missed and aid in the development of appropriate minimization strategies in breast imaging. ©RSNA, 2020.

Breast pain and cancer: should we continue to work-up isolated breast pain?

PURPOSE: To assess the cancer detection rate (CDR) in patients presenting with isolated breast pain. METHODS: A retrospective review was performed of consecutive patients presenting to a large tertiary care academic center or an affiliated hospital with isolated breast pain from October 1, 2013 to September 30, 2015. Medical records were reviewed for patient demographics, pain characteristics, imaging findings, and outcome. RESULTS: The study cohort was comprised of 971 exams in 953 patients, with a median age of 50 years. A total of 62.5% (607/971) of the cases were assessed by mammography and ultrasound, 24.4% (237/971) by ultrasound only, and 13.1% (127/971) by mammography only. Including the abnormalities detected in the asymptomatic breast, 88.7% (861/971) of the cases were negative or had benign findings (BI-RADS 1 and 2), 6.8% (66/971) were probably benign (BI-RADS 3), 3.9% (38/971) were suspicious (BI-RADS 4), and 0.6% (6/971) were highly suggestive of malignancy (BI-RADS 5). CDR on initial work-up was 0.8% (8/953), of which 0.6% (4/690) was in average-risk patients while 1.5% (4/263) was in higher-than-average risk patients. CONCLUSIONS: CDR in patients presenting with isolated breast pain overall was low, comparable to the expected incidence of breast cancer in asymptomatic women. Work-up for isolated breast pain may therefore be unnecessary and lead to overutilization of healthcare resources. Routine screening mammography should be encouraged and higher-than-average risk patients may benefit from additional tests.

Human Leukocyte Antigen-Haploidentical Transplantation for Relapsed/Refractory Hodgkin Lymphoma: A Multicenter Analysis.

Reduced-intensity-conditioned allogeneic stem cell transplantation (SCT) remains a potentially curative approach for patients with relapsed/refractory Hodgkin lymphoma (HL) after an autologous stem cell transplantation. In the absence of an HLA-identical donor, haploidentical SCT (haplo-SCT) with post-transplantation cyclophosphamide (PT-Cy) has been evaluated with favorable preliminary results. We evaluated 24 patients who underwent haplo-SCT for relapsed/refractory HL. The conditioning regimen consisted of cyclophosphamide, fludarabine, and total body irradiation. Graft-versus-host disease (GVHD) prophylaxis consisted of a calcineurin inhibitor, mycophenolate mofetil, and PT-Cy (50 mg/kg/day for 2 days) for all patients. After a median follow-up of 2 years, the cumulative incidence (CI) of nonrelapse mortality was 26% and the CI of grades II to IV acute GVHD and chronic GVHD were 17% and 24%, respectively. Estimation of progression-free and overall survival at 2 years were 54% and 66%%, respectively. Haplo-SCT is a valuable option for relapsed/refractory HL patients after a failed autologous SCT, with favorable survival and relatively low risk of GVHD.

A comparison of false positives in retinal nerve fiber layer, optic nerve head and macular ganglion cell-inner plexiform layer from two spectral-domain optical coherence tomography devices.

BACKGROUND: The incidence of false positive (FP) results of optic coherence tomography (OCT) retinal nerve fiber layer (RNFL) color code in healthy subjects can be very high with Cirrus OCT. Recent evidence has shown that OCT parameters derived from macular ganglion cell-inner plexiform layer (GCIPL) have excellent ability to discriminate between normal eyes and eyes with early glaucoma. METHODS: This was a prospective, cross-sectional study. One hundred eyes from 50 healthy volunteers underwent circumpapillary scanning by Cirrus and Spectralis OCT and macular scanning using Cirrus OCT. FP rates for each of the OCT parameters, using predefined criteria for an abnormal test were calculated. Comparative analysis was performed using the McNemar test. A generalized estimating equations model (GEE) was used to compare demographic and clinical factors between the eyes with normal findings and eyes with abnormal results. RESULTS: The overall RNFL color-code FP rate was significantly higher for Cirrus (39 %) than for Spectralis (18 %) (P = 0.000). The Spectralis RNFL FP rate showed no significant difference when compared to the FP rate by Cirrus GCIPL (13 %) and ONH (11 %) analysis. Axial length, mean spherical equivalent, presence of peripapillary atrophy, and tilted disc were significantly related to the RNFL FP occurrence displayed by both devices. CONCLUSIONS: Spectralis might be more specific than Cirrus when evaluating the RNFL thickness for Caucasians and moderate myopic population. GCIPL and ONH analysis might be more useful than RNFL thickness to evaluate this population using Cirrus OCT.

Lipoprotein(a) Levels in Disaggregated Racial and Ethnic Subgroups Across Atherosclerotic Cardiovascular Disease Risk Levels.

Background: Lipoprotein(a) [Lp(a)] is a causal risk factor for atherosclerotic cardiovascular disease (ASCVD). Objectives: The authors assessed differences in Lp(a) testing and levels by disaggregated race, ethnicity, and ASCVD risk. Methods: This was a retrospective cohort study of patients from a large California health care system from 2010 to 2021. Eligible individuals were ≥18 years old, with ≥2 primary care visits, and complete race and ethnicity data who underwent Lp(a) testing. Race and ethnicity were self-reported and categorized as follows: non-Hispanic (NH) White, NH-Black, Hispanic (Mexican, Puerto Rican, other), NH-Asian (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, other). Logistic regression models tested associations between elevated Lp(a) (≥50 mg/dL) and race, ethnicity, and ASCVD risk. Results: 13,689 (0.9%) individuals underwent Lp(a) testing with a mean age of 54.6 ± 13.8 years, 49% female, 28.8% NH Asian. Over one-third of those tested had Lp(a) levels ≥50 mg/dL, ranging from 30.7% of Mexican patients to 62.6% of NH-Black patients. The ASCVD risk of those tested varied by race: 73.6% of Asian Indian individuals had <5% 10-year risk, whereas 27.2% of NH-Black had established ASCVD. Lp(a) prevalence ≥50 mg/dL increased across the ASCVD risk spectrum. After adjustment, Hispanic (OR: 0.76 [95% CI: 0.66-0.88]) and Asian (OR: 0.88 [95% CI: 0.81-0.96]) had lower odds of Lp(a) ≥50 mg/dL, whereas Black individuals had higher odds (OR: 2.46 [95% CI: 1.97-3.07]). Conclusions: Lp(a) testing is performed infrequently. Of those tested, Lp(a) levels were frequently elevated and differed significantly across disaggregated race and ethnicity groups. The prevalence of elevated Lp(a) increased with increasing ASCVD risk, with significant variation by race and ethnicity.

The Design of Multi-target Drugs to Treat Cardiovascular Diseases: Two (or more) Birds on One Stone.

Cardiovascular diseases (CVDs) comprise a group of diseases and disorders of the heart and blood vessels, which together are the number one cause of death worldwide, being associated with multiple genetic and modifiable risk factors, and that may directly arise from different etiologies. For a long time, the search for cardiovascular drugs was based on the old paradigm "one compound - one target", aiming to obtain a highly potent and selective molecule with only one desired molecular target. Although historically successful in the last decades, this approach ignores the multiple causes and the multifactorial nature of CVDs. Thus, over time, treatment strategies for cardiovascular diseases have changed, and, currently, pharmacological therapies for CVD are mainly based on the association of two or more drugs to control symptoms and reduce cardiovascular death. In this context, the development of multitarget drugs, i.e., compounds having the ability to act simultaneously at multiple sites, is an attractive and relevant strategy that can be even more advantageous to achieve predictable pharmacokinetic and pharmacodynamics correlations as well as better patient compliance. In this review, we aim to highlight the efforts and rational pharmacological bases for the design of some promising multitargeted compounds to treat important cardiovascular diseases like heart failure, atherosclerosis, acute myocardial infarction, pulmonary arterial hypertension, and arrhythmia.

M-Triad: An improvement of the sediment quality triad.

The traditional sediment quality triad generally uses three lines of evidence (LOE) in the assessment, integrating environmental chemistry, ecology and ecotoxicology. However the assessment is performed without considering the multivariate structure within LOE. In order to improve the sediment quality assessment, the M-Triad is proposed. Instead of averaging the values within a LOE, the new approach is based on the Euclidean distance between each sampling station and the reference station (s) for each LOE. These distances are then plotted in a radar-chart to obtain the area of the triangle and the quality assessment is subsequently obtained from the difference between the triangle areas of the impacted and the reference station. Three studies were selected to test the applicability of the M-Triad. In two cases, the M-Triad returned a more realistic ranking of the stations as observed in the principal component analysis (PCA) from each LOE By including the Euclidean distance, the use of M-Triad is advantageous when multiple variables with negative or uncorrelated patterns within a LOE are analyzed simultaneously. The combination of the M-Triad and the results of the PCA allows one to identify multiple contamination gradients and how biota and bioassays respond to each of these gradients. In comparison to the traditional method, the M-Triad reduces the uncertainty of the final analysis, permitting a more comprehensive ecological assessment.

Patient safety in the prevention and care of skin lesions in newborns: integrative review.

OBJECTIVE: to describe the main evidence available in the literature on safe practices in the prevention and care of skin lesions in newborns admitted to Neonatal Intensive Care Units. METHODS: integrative literature review in the PubMed, BDENF, LILACS, MEDLINE, SciELO and Cochrane Library databases between 2013 and 2018. We included primary articles on: lesion prevention and skin care in newborns in Portuguese, English or Spanish and excluded editorials, thesis, dissertations and duplicate articles. For the evidence level, we used the Melnyk and Fineout-Overholt classification, which classifies studies between weak to strong evidence. RESULTS: a total of 10 articles with moderate to weak evidence on thermoregulation, bathing, lesion prevention, use of patches and skin antisepsis. FINAL CONSIDERATIONS: there was a shortage of publications with high evidence, and it is necessary to invest in research that seeks to support safer skin care practices.

Genomic Analysis of SXT/R391 Integrative Conjugative Elements From Proteus mirabilis Isolated in Brazil.

Integrative conjugative elements (ICEs) are widespread in many bacterial species, often carrying antibiotic resistance determinants. In the present work, we screened a collection of Proteus mirabilis clinical isolates for the presence of type 1 SXT/R391 ICEs. Among the 76 isolates analyzed, 5 of them carry such elements. The complete sequences of these elements were obtained. One of the isolates carried the CMY-2 beta-lactamase gene in a transposon and is nearly identical to the element ICEPmiJpn1 previously described in Japan, and later shown to be present in other parts of the world, indicating global spread of this element. Nevertheless, the Brazilian isolate carrying ICEPmiJpn1 is not clonally related to the other lineages carrying the same element around the world. The other ICEs identified in this work do not carry known antibiotic resistance markers and are diverse in variable gene content and size, suggesting that these elements may be responsible for the acquisition of other advantageous traits by bacteria. Some sequences carried by these elements in Brazilian strains were not previously found in other SXT/R391 variants.

Multiple aseptic liver abscesses as the initial manifestation of Crohn's disease: report of a case.

Aseptic liver abscesses preceding the diagnosis of Crohn's disease are extremely rare. We report a patient with multiple liver abscesses that yielded negative microbiologic investigation and failed to develop full remission under antibiotic therapy. Diagnosis of Crohn's disease of small and large bowel was later established and she was started on sulfasalazine and azathioprine with total regression of the hepatic abscesses. This case illustrates the rare possibility of aseptic liver abscesses as an initial manifestation of Crohn's disease, which could be interpreted in the light of recent data on aberrant homing of gut T memory/effector lymphocytes in the liver.

Facial Paralysis as Initial Manifestation of Light-chain Amyloidosis.

Light-chain (AL) amyloidosis is a systemic disease capable of damaging virtually all body tissues. Neurologic involvement is commonly manifested by dysautonomia and peripheral nervous system affection. However, from 1970 to 2018, only 12 cases of cranial nerve injury associated with AL amyloidosis were identified. Eight months before hospital admission, a previously healthy 61-year-old man complained to his general practitioner of episodes of lipotimia while walking and, three months later, he developed a left facial nerve paralysis assumed, at that time, to be idiopathic. After two months, he started complaining of dyspnea and lower limb edema. Physical examination at admission revealed hypotension, exuberant peripheral edema, jugular venous distention, periorbital purpura and left peripheral facial paralysis. He had elevated troponin and brain natriuretic peptide, mild proteinuria and a monoclonal gammopathy IgG/lambda. Bone marrow biopsy revealed 20% plasmocytes and cardiac ultrasound showed diffuse hypokinesia and restrictive filling pattern. AL amyloidosis with major cardiac involvement was considered and a rectal biopsy revealed amyloid protein. Chemotherapy protocol to AL amyloidosis was initiated but cardiac disease progressed leading to death. Persistent facial nerve paralysis should be considered as a rare initial manifestation of AL amyloidosis allowing an earlier diagnosis.

Disseminated Nocardiosis: A Case Report.

Disseminated nocardiosis is a rare infection associated with underlying immunosuppression, and patients usually have some identifiable risk factor affecting cellular immunity. Due to advances in taxonomy and microbiology identification methods, infections by Nocardia species are more frequent, making the discussion of its approach and choice of antibiotherapy increasingly relevant. A 77-year-old man presented to the emergency department with marked pain on the right lower limb, weakness, and upper leg edema. He had been diagnosed with organized cryptogenic pneumonia one year before and was chronically immunosuppressed with methylprednisolone 32 mg/day. Blood cultures isolated Nocardia cyriacigeorgica. Computed tomography revealed a gas collection in the region of the right iliacus muscle with involvement of the gluteal and obturator muscles upwardly and on the supragenicular plane inferiorly. Triple therapy with imipenem, amikacin, and cotrimoxazole was started, and the patient was submitted for emergent surgical decompression, fasciotomy, and drainage due to acute compartment syndrome. The patient had a good outcome and was discharged from the hospital after 30 days of intravenous therapy. This case illustrates the severity of Nocardia infection and highlights the need for a meticulous approach in the diagnosis and treatment of these patients.

Increased mutability to fosfomycin resistance in Proteus mirabilis clinical isolates.

In the present study, we screened a collection of 77 Proteus mirabilis clinical isolates for the presence of mutators, using the frequency of both rifampicin and fosfomycin resistance mutants as markers of spontaneous mutagenesis. We found that none of the strains in our collection are mutators for the rifampicin resistance (RifR) marker. Nevertheless, a significant fraction of the isolates (17%) show high frequencies of fosfomycin resistant mutants (FosR). We show that this increased mutability to FosR correlates with a low level of resistance to Fosfomycin (MICs 8-64µg/ml). These strains also show high frequencies of single step mutants with clinically relevant FosR resistance levels (MIC ≥256µg/ml). Our findings point out to the risk of fosfomycin resistance emergence in P. mirabilis.

Strategies for coping with moral distress adopted by nurses in tertiary care: a scoping review / Estrategias para afrontar el sufrimiento moral adoptadas por enfermeros en el nivel terciario de atención: scoping review / Estratégias para o enfrentamento do sofrimento moral por enfermeiros na atenção terciária: scoping review

ABSTRACT Objective: to map the scientific evidence on strategies for coping with moral distress adopted by nurses in the context of health services in tertiary care. Method: this is a Scoping Review based on the PRISMA-ScR recommendations. The searches were performed in September 2020 in the MEDLINE®, National Library of Medicine, Scopus, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane and Biblioteca Virtual en Saúde databases. The eligibility criterion was to include studies that discussed strategies for coping with moral distress adopted by nurses in tertiary care, finding 2,041 studies, which were organized and screened in the Endnote software. The data were organized in Excel spreadsheets and analysis of the results was performed using the ATLAS.ti software. Results: the final selected sample consisted of 23 studies, which were grouped in two axes: strategies and recommendations. Four articles were included in the "strategies" axis, which reported actions taken to face moral distress, detailing the intervention and their results. The others, included in the "recommendations" axis, are articles whose focus was the experience of moral distress, suggesting important aspects to face it. Conclusion: recognition of moral distress by nurses and the opportunity for collective discussion and exchange of experiences are ways of collectively facing the situations. In addition, the institution's active participation in carrying out interventions was recommended. However, gaps were noticed in the production of studies that actually go deeper into intervention actions to cope with moral distress.

RESUMEN Objetivo: mapear las evidencias científicas sobre diversas estrategias para afrontar el sufrimiento moral adoptadas por enfermeros en el contexto de los servicios de salud en el nivel terciario de atención. Método: Scoping Review basada en las recomendaciones PRISMA-ScR. Las búsquedas se realizaron en septiembre de 2020 en las siguientes bases de datos: MEDLINE®, National Library of Medicine, Scopus, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane y Biblioteca Virtual de Saúde. El criterio de elegibilidad fue incluir estudios que debatieran estrategias para afrontar el sufrimiento moral adoptadas por los enfermeros en el nivel terciario de atención, con lo que se encontraron 2.041 estudios, que se organizaron y seleccionaron en el software Endnote. Los datos se organizaron en planillas de Excel y se realizó un análisis de los resultados con la ayuda del software ATLAS.ti. Resultados: la muestra final seleccionada compuesta por 23 estudios, que fueron agrupados en dos ejes: estrategias y recomendaciones. Cuatro artículos se encuadraron en el eje de "estrategias", y reportaron acciones adoptadas para afrontar el sufrimiento moral, detallando la intervención y sus resultados. Los demás, incluidos en el eje de "recomendaciones", son artículos cuyo enfoque fue la experiencia del sufrimiento moral, con sugerencias relacionadas con aspectos importantes para afrontarlo. Conclusión: el reconocimiento del sufrimiento moral por parte de los enfermeros y la oportunidad de debate colectivo e intercambio de experiencias son formas de afrontar las situaciones en forma colectiva. Además, se recomendó la participación activa de la institución al implementar las intervenciones. Sin embargo, se percibieron deficiencias en la producción de estudios que, de hecho, profundicen en acciones de intervención para afrontar el sufrimiento moral.

RESUMO Objetivo: mapear as evidências científicas sobre estratégias para o enfrentamento do sofrimento moral por enfermeiros no contexto dos serviços de saúde na atenção terciária. Método: trata-se de uma Scoping Review com base nas recomendações PRISMA-ScR. As buscas foram realizadas em setembro de 2020 nas bases de dados MEDLINE®, National Library of Medicine, Scopus, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane e Biblioteca Virtual de Saúde. O critério de elegibilidade foi incluir estudos que discutissem estratégias para o enfrentamento do sofrimento moral pelos enfermeiros na atenção terciária, encontrando assim 2.041 estudos, os quais foram organizados e triados no software Endnote. Os dados foram organizados em planilhas do Excel e uma análise dos resultados foi realizada mediante auxílio do software ATLAS.ti. Resultados: a amostra final selecionada foi de 23 estudos, os quais foram agrupados em dois eixos: estratégias e recomendações. Quatro artigos foram enquadrados no eixo "estratégias", os quais relataram ações realizadas para enfrentamento do sofrimento moral, detalhando a intervenção e os seus resultados. Os demais, incluídos no eixo "recomendações", são artigos cujo enfoque foi a vivência do sofrimento moral, com sugestão de aspectos importantes para o seu enfrentamento. Conclusão: o reconhecimento do sofrimento moral pelos enfermeiros e a oportunidade de discussão coletiva e troca de experiências são formas de enfrentar, coletivamente, as situações. Ademais, foi recomendado a participação ativa da instituição na realização de intervenções. Contudo, perceberam-se lacunas na produção de estudos que de fato aprofundam em ações de intervenções para o enfrentamento do sofrimento moral.