Nurses’ perceptions about the preservation of traces in the care of women exposed to sexual violence

Abstract

Objective  to understand nurses’ perceptions about the preservation of traces in sexual violence against women.

Method  this exploratory and descriptive study, with a qualitative approach, was conducted from January to February 2022 with 20 nurses from the multidisciplinary team caring for women experiencing sexual violence in five public hospitals in the city of Fortaleza, Brazil. Individual semi-structured interviews enabled data collection and analysis, based on Foucault and Le Breton’s assumptions about body and power.

Results  from the data analysis, two thematic categories emerged. The meanings attributed by participants to the preservation of traces reveal divergent ways of thinking, and several obstacles were identified that may interfere with the quality of care provided to women exposed to sexual violence.

Final considerations and implications for practice  participants’ perceptions about the preservation of traces permeate divergent thinking that may, in some way, interfere with their actions during the provision of care to these women. Furthermore, there is a lack of improvements in the physical infrastructure of the services that serve these women.

Keywords:
Sexual Offenses; Forensic Nursing; Women; Violence; Violence against Women

Resumo

Objetivo  compreender as percepções dos enfermeiros sobre preservação de vestígios na violência sexual contra a mulher.

Método  estudo exploratório e descritivo, com abordagem qualitativa, realizado entre janeiro e fevereiro de 2022, com 20 enfermeiros integrantes da equipe multiprofissional na atenção às mulheres em situação de violência sexual de cinco hospitais públicos do município de Fortaleza/Brasil. Entrevistas individuais semiestruturadas viabilizaram a coleta e a análise, nos pressupostos de Foucault e Le Breton, sobre corpo e poder.

Resultados  a partir da análise dos dados, emergiram duas categorias temáticas. Os sentidos atribuídos pelos participantes à preservação de vestígios revelam modos divergentes de pensar. Além disso, foram identificados diversos obstáculos que podem interferir na qualidade da assistência prestada às mulheres expostas à violência sexual.

Considerações finais e implicações para prática  as percepções dos participantes sobre a preservação de vestígios perpassam as divergências no pensar que, de algum modo, podem interferir no agir durante a oferta do cuidado a essas mulheres. Evidencia-se também a carência de melhorias na estrutura física dos serviços que atendem essas mulheres.

Palavras-chave:
Delitos Sexuais; Enfermagem Forense; Mulheres; Violência; Violência contra a Mulher

Resumen

Objetivo  comprender las percepciones de los enfermeros sobre la preservación de los vestigios en la violencia sexual contra las mujeres.

Método  este estudio exploratorio y descriptivo, con un enfoque cualitativo, se realizó entre enero y febrero de 2022, con 20 enfermeros del equipo multidisciplinario que atiende a mujeres víctimas de violencia sexual en cinco hospitales públicos de la ciudad de Fortaleza, Brasil. Entrevistas individuales semiestructuradas permitieron la recopilación y el análisis de datos, con base en los supuestos de Foucault y Le Breton, sobre cuerpo y poder.

Resultados  del análisis de datos, surgieron dos categorías temáticas. Los significados atribuidos por las participantes ante la preservación de las huellas revelan formas divergentes de pensamiento. También se identificaron varios obstáculos que pueden interferir con la calidad de la atención brindada a las mujeres expuestas a la violencia sexual.

Consideraciones finales e implicaciones para la práctica  las percepciones de las participantes sobre la preservación de los vestigios permean un pensamiento divergente que puede, de alguna manera, interferir con sus acciones durante la atención a estas mujeres. Además, existe una falta de mejoras en la infraestructura física de los servicios que atienden a estas mujeres.

Palabras clave:
Delitos Sexuales; Enfermería Forense; Violencia; Mujeres; Violencia contra las Mujeres

Introduction

Sexual violence against women constitutes a serious public health challenge at present and is marked by disparities of power and vulnerability that are deeply rooted in gender perspectives. In view of the need to expand and humanize care for victims of sexual crimes, legal instruments have been established with the objective of preventing revictimization and training health professionals to provide care to this population, with the aim of equipping them appropriately for humanized care.¹

In this context, humanized and qualified care for women exposed to sexual violence necessarily involves the collection and preservation of traces. Traces are understood as signs, stains, or any objects left by an individual that allow forensic services, through technical and scientific methods, to obtain evidence and indications related to a crime and its authorship.²

The importance of this collection is reinforced by legal milestones in Brazil, such as Decree No. 7,958/2013 and Ordinance No. 288/2015, which establish guidelines for the organization and integration of care for victims within the scope of public safety and the Unified Health System (SUS). Ordinance No. 288, of March 25, 2015, for example, establishes as a responsibility of the Ministry of Health the implementation of technical standards for humanized care, including the recording of information and the collection of traces.³,⁴

In Brazil, Forensic Nursing began to be recognized as a specialty by the Federal Nursing Council (COFEN) in 2011. In 2015, the Brazilian Association of Forensic Nursing was created and recognized by COFEN through Opinion No. 31/2015, with the objective of assisting in the dissemination and regulation of the profession.⁴ In addition, there is a subspecialty of forensic nursing in which the professional is qualified to provide care to victims of sexual violence, including the collection of traces, collaborating with criminal investigations.³,⁵

The forensic nurse plays a fundamental role in the humanization of care for victims by acting as a link between health and justice, offering appropriate support and contributing to the guarantee of women’s human rights.⁶ Furthermore, Ordinance No. 204/2016 of the Ministry of Health and Resolution No. 564/2017 of the new Code of Ethics for Nursing Professionals, established by COFEN, by providing for exceptions to professional confidentiality, reinforce the legal duty of nursing to notify any episodes of violence, in accordance with current legislation.⁷

Despite the existence of these regulations within the scope of the SUS, which regulate the collection of traces in health units, gaps still persist regarding legal competencies and professional training, which hinders the effectiveness of care.⁵ For example, there is no specific ordinance that formally recognizes the health professional within the chain of custody of evidence or the validation of traces by criminalistics institutes.⁸

Given the above, and considering the impact of gender-based violence on women’s health, the qualification of nurses for resolutive and humanized support is essential. The sensitization and training of these professionals transform practices and qualify care, and the understanding of trace preservation is a crucial element for holding the perpetrator accountable.⁹

Although the international literature, based on the Sexual Assault Nurse Examiner (SANE) model of the International Association of Forensic Nurses (IAFN),¹⁰ demonstrates the consolidation of a specialized practice, national studies still point to a lack of evidence and standardization of protocols regarding nursing practice in trace collection. Thus, this study is justified by analyzing nurses’ perceptions about the care of women exposed to sexual violence, with emphasis on the preservation of traces, providing support for the improvement of public policies and fostering community debate on this form of violence.¹¹

Based on this context, the following research question emerged: what are nurses’ perceptions about the preservation of traces in the care of women exposed to sexual violence? Thus, the present study aims to understand the perceptions of these professionals regarding the preservation of traces in the context of sexual violence against women.

Method

To understand in greater depth nurses’ perceptions about the preservation of traces in sexual violence, insights from postmodern philosophers were sought, especially in the concepts of Michel Foucault regarding body and power and of David Le Breton regarding corporeality. Foucault¹² states that the social control of the female body constitutes a strategy used by contemporary society, in which the government of biopower directs people’s lives through various mechanisms, often exceeding the simple application of the law.

Although he recognizes the relevance of Foucault for the discussion about the body, Le Breton aligns himself with other thinkers whose ideas diverge from those of the French philosopher, arguing that his focus falls more specifically on “unveiling the social and cultural logics that are intertwined in corporeality.”¹³ In the work The Sociology of the Body, Le Breton states that the body represents our relationship with the world and is shaped by the social and cultural contexts in which the individual is inserted. It is the semantic vector that constructs the evidence of the relationship between the individual and the environment.¹¹

This is an exploratory and descriptive study with a qualitative approach. The research participants were 20 nurses who were members of the multidisciplinary team involved in the care of women in situations of sexual violence in five public hospitals located in the municipality of Fortaleza, Ceará, Brazil, which provide care at different levels of attention and technological density that make up the health care networks. The inclusion criteria comprised professionals who worked directly in the care of these women and/or who had previous experience with this type of care. Professionals who were away from work activities during the data collection period for any reason (vacation, leave, or others) were excluded.

Data collection occurred between January and February 2022 through semi-structured interviews composed of open-ended questions aligned with the objectives of the study. Participants were approached individually and, prior to the interviews, a pilot test was conducted to validate the questions. At the first contact, the objectives of the research were explained and consent was obtained through the signing of the Free and Informed Consent Form. Subsequently, sociodemographic and professional data were collected, followed by the interview based on a script of guiding questions.

The interview script was organized into two thematic blocks: 1) Qualification for the care of women in situations of sexual violence; and 2) Characterization of trace collection in the care of women victims of sexual violence. Block 1 included questions directed at the participants’ educational and professional trajectories, such as: “Did your undergraduate program include any preparation or discussion of how to act in situations of sexual violence? If so, how were you prepared? What courses and training in the area of sexual violence have you undertaken after graduation? What is your experience in the area of sexual violence against women? Did you receive prior training to work in the care of women in situations of sexual violence? Do you feel professionally prepared to care for cases of sexual violence? According to your understanding, what are sexual traces? What care should be taken when identifying them?”

Block 2 aimed to understand the institutional and operational conditions for the care of women victims of sexual violence and consisted of the following questions: “Do you believe that this institution is prepared to care for cases of sexual violence? What are the main difficulties faced in cases of sexual violence? What could be done to improve conditions in the care of victims of sexual violence? In your opinion, what is the role of the nurse in this type of care? What is lacking for nurses to be prepared to care for cases of sexual violence? What are the most effective actions for informing and training nurses about sexual violence?”

The interviews were conducted in a private environment by a professional with a degree in nursing, specialist in women’s health, and with prior experience in qualitative data collection. There was no prior relationship between the researcher and the participants. The average duration was 30 min, and all interviews were recorded using a digital voice recorder for later transcription in full. Only the researcher and the participant were present during data collection. It is noteworthy that no professional refused to participate in the study.

It should also be clarified that the stage of validation of the interviews by the participants was not carried out. Thus, there was no return of the transcribed content to the interviewees for checking or supplementation, and no changes were made to the empirical material, which was analyzed in its original form as produced during the interviews.

To collect the largest possible amount of information on the topic studied, the snowball sampling technique (or network sampling) was used, in which the initial participants indicate new participants who, in turn, indicate other new participants, and so on, until reaching the “saturation point.”¹⁴

Considering that the data collection period coincided with the COVID-19 pandemic, preventive measures were adopted, such as physical distancing, use of masks, hand hygiene, and disinfection of the materials used.¹⁵ Additionally, the researcher prepared field notes during and after the interviews to complement the data analysis.

For the organization and analysis of qualitative data, Thematic Content Analysis was used, whose central concept is the theme. This technique consists of a set of systematic and objective procedures for describing the content of messages, enabling the extraction of indicators, whether quantitative or not, that allow inferences about the conditions of production and reception of these messages.¹⁶,¹⁷

The operationalization of the analysis followed the stages proposed by Minayo:¹⁸ (1) pre-analysis, in which the material is organized and recording units, context units, significant excerpts, and theoretical references are defined according to the objectives of the study; (2) exploration of the material, a longer phase that requires successive readings and application of the defined categories; and (3) treatment of the results and interpretation, a stage intended to reveal content underlying explicit manifestations, without disregarding relevant statistical information.

The project was submitted to the Human Research Ethics Committee of the University of Fortaleza and approved in October 2021 under Opinion No. 5,065,489 (CAAE 52372621.7.0000.5052). To ensure anonymity, participants were identified by the letter “E,” followed by sequential numbering ranging from E1 to E20.

Results

Characterization of participants

Twenty nurses working in the care of women in situations of sexual violence in the health services selected for the study participated in this research. The participants’ ages ranged from 23 to 56 years, with the majority being female (n = 17). Regarding color/race, 11 self-identified as mixed race, eight as White, and one as Asian. In relation to marital status, 11 declared themselves single, eight married, and one participant was divorced.

Regarding religion, 14 participants declared themselves Catholic, three Evangelical, and three reported having no religious affiliation. Regarding monthly family income, five reported having an income between three and five minimum wages; nine between five and seven minimum wages; and six reported an income above seven minimum wages.

Concerning education and professional practice, all participants had postgraduate training: one held a master’s degree, one was enrolled in a master’s program and had a specialization, four had postgraduate training in the residency modality, and 14 were specialists. Length of professional practice ranged from one month to 34 years. Regarding experience in emergency and urgent care services, some participants had recently joined the services (with only one month of practice) but already had prior experience in caring for women exposed to sexual violence, while others reported up to 29 years of experience in this sector. Most interviewees had a weekly workload exceeding 40 h; only one participant worked 30 h per week. In addition, 11 professionals reported having two employment relationships.

Nurses’ thinking and acting regarding the preservation of traces

The meanings attributed by participants to the preservation of traces reveal divergent ways of thinking that, in some way, may interfere with professional practice during the provision of this type of care. The understanding of these traces goes beyond biological aspects, reaching emotional and subjective dimensions, leaving deep and sometimes indelible marks on the lives of the women assisted. This perception is evidenced in the statement of one of the participants:

For me, a trace is when the woman feels hurt; the mark remains on the emotional aspect. (E8)

The conception of what sexual traces are points to gaps in knowledge regarding the definition established by forensic science, which is fundamental to the process of holding the perpetrator accountable. Such lack of knowledge can be observed in the participants’ statements, as presented below:

I was even in doubt when I read the title of the research; I honestly don’t know what sexual traces are […] I don’t have much of an idea. (E15)

They would be traces that remain on the victims’ bodies. (E1)

Some warning sign, some symptom that we can perceive regarding sexual violence, after sexual violence. I had never even heard of this term. (E10)

With regard to the actions performed by the participants, there is a recurrence of referrals, whether to other professionals on the health team or to different services, with the aim of promoting continuity of care flow and, at the same time, avoiding the revictimization of women.

Here we refer the patient to Social Work and then to Psychology, to continue the care flow. (E7)

I also request multiprofessional support; I like to have interdisciplinary care. (E9)

However, some professionals demonstrate a broader understanding of actions related to the provision of comprehensive health care for these women. They highlight the importance of qualified and attentive listening, knowledge of the flow of the protection and support network, and interprofessional practice:

Knowing how to guide without hurting the patient, listening more than speaking or taking any action. Seeking help from other professionals who are more qualified in the area. (E12)

The importance of records as documentary evidence is highlighted, demonstrating the understanding that detailed documentation in medical records or in specific service instruments constitutes probative material that may be requested in the judicial sphere. In addition, clear, objective notes free of ambiguities or illegibility are a requirement of the Nursing Process and constitute a mandatory responsibility for monitoring and evaluating the care provided:

If we find something, we record it in our report, so that, in the future, if the judge comes asking, it will be recorded there. (E6)

The nurse must perform detailed recording of all clinical findings, victim reports, conducts, and referrals made during care. The absence or inadequacy of nursing records may compromise judicial processes.

Barriers faced by nurses in daily work

This category addresses the main barriers faced by nurses in their daily work. The participants’ statements representatively reveal the challenges experienced when dealing with this topic.

Several obstacles were identified that may interfere with the quality of care provided to women exposed to sexual violence. Among them, the lack of infrastructure of services stands out in the results, as described below:

We don’t have privacy; first thing: I attend to patients with a colleague, and when we suspect a case that is different, we close here (door), close here (door), it’s just me, my colleague, and the person reporting. That’s the only way I can ensure privacy. (E16)

Through participants’ statements, it is observed that the environment intended for the care of women exposed to sexual violence has inadequate physical structure, mainly characterized by lack of privacy. This condition often hinders dialog between the professional and the victim and compromises the performance of humanized practices.

Another barrier identified in nurses’ daily work refers to preparation for the care of victims of sexual violence, as evidenced in the following statements:

One hundred percent no, I think what’s missing […] it would be good to have some type of training with an approach more focused on the […] emotional part and even the practical part. (E11)

There's a real lack of training, as I said, I learned everything on the job, in practice. (E16)

Participants’ statements reveal a call for the provision of training in the workplace, indicating that much of the learning occurs predominantly through experience acquired in daily professional practice.

In addition, the topic related to the preservation of traces in sexual violence against women was mentioned by most professionals as absent or insufficient during undergraduate and postgraduate education. When present, it occurs sporadically in some disciplines, without adequate theoretical and practical depth on the topic, as illustrated by the following statements:

I received “lectures” in classes; that was the preparation. There was nothing specific. (E8)

There was, but it was superficial. Nothing very deep. (E13)

There was content both in the Women’s Health discipline and in a psychology discipline we had, but it was more in the sense of welcoming, not in how to deal with […] assistance, only in the sense of welcoming. (E13)

Gaps in nurses’ academic training, resulting from the limited approach to the topic in undergraduate and postgraduate courses, combined with the scarcity of training in health services and lack of knowledge of care flow, contribute to the invisibility of this demand or to the provision of inadequate care, as illustrated by the following statements:

First, it's a very delicate subject; the difficulty of knowing how to approach the victim [...] and like, the lack of knowledge of the professional to know exactly where to direct them, a flow [...]. A well-defined flow so we know, if it happens, where to go? What to do? That doesn't exist. (E18)

In addition, the reports reveal the existence of a fragile relationship of trust on the part of professionals in the support and care network for women exposed to sexual violence regarding the narratives of these victims. Such distrust is fueled by prejudices, stigmas, taboos, and social constructions that reinforce the androcentric structure of society. The statement of participant E11 corroborates this understanding:

[…] there are other professionals who even have prejudice in providing care, right? They distrust what the patient says […]. There is no preparation, really. I have seen situations where professionals think the person is lying […] judging the situation. (E11)

Added to these weaknesses are the reduced number of professionals, the high demand of patients, and the complex dynamics of the service. These factors compromise comprehensive care and hinder the systematization of care based on the user’s needs:

[...] It's more a matter of [...] and also few professionals, because one nurse is outside and the other stays inside, right? So, yes, I believe it's more the high demand, the few professionals to meet that high demand. For me, I consider this problem not the difficulty of attending to that case, but [...] the dynamics of the service. (E4)

The reports indicate that women who seek care end up competing for professional attention with pregnant women, which often generates delays in services and may lead to victims withdrawing from follow-up and continuity of care.

Discussion

The analysis of the results revealed nurses’ perceptions regarding the preservation of traces in sexual violence. The findings highlight the main practices of this professional group, as well as the barriers faced in daily work and the need for continuing education as a strategy for the continuous improvement of professional practice.

Considering that the nursing workforce is predominantly composed of women, it is assumed that this characteristic may positively influence the quality of care provided to women exposed to sexual violence, especially due to the possibility of greater empathy, which contributes to dignified, humanized care centered on the user’s needs.

However, the predominance of women in the professional contingent does not always translate into the consolidation of empathy in the way of thinking and acting in these situations. The management and conduct of care may be crossed by prejudices, ideologies, asymmetries of roles, values, and worldviews that sometimes reproduce new forms of violence, such as institutional violence.¹⁹

The production and reproduction of sexual violence against women are closely related to gender inequality, resulting from a deficit in social education and from patriarchal, sexist, and misogynistic cultural constructs that seek control and domination of the other, exercising relations of power and exploitation.²⁰

The individual socializes through their bodily experiences, and their expression is socially shaped based on these experiences. Thus, it is fundamental to consider that social relations, which involve power and knowledge, directly interfere in the development of individuals and in their way of being in the world and relating to others.²¹

Care for women exposed to sexual violence is complex and requires articulation among various professionals and services that make up the care network, aiming to reduce the damage resulting from the violence suffered. In this perspective, nursing care permeates different conceptions and forms of internalization of violence by health professionals.

Some nurses may understand and reproduce realities permeated by pre-established judgments or unilateral theoretical references, while others demonstrate a more critical and contextualized understanding, resorting to reflective thinking.

Thus, it is essential that nurses, guided by critical and reflective care, understand the entire process involving violence against women, becoming a point of support for the victim, clarifying doubts, and contributing to care directed at singular needs, without judgments.²²

In this context, care should be guided by the specific demands of each case, including immediate reception (preferably up to 72 h after the sexual act), prophylaxis for sexually transmitted infections (STIs), HIV/AIDS, hepatitis B, and pregnancy, notification of the case, referral for reporting at the police station, provision of information about judicial procedures, and other pertinent conducts. Outpatient, social, and psychological follow-up must also be ensured, constituting pillars for the effectiveness of care.²³

In hospital emergency services, nurses, for the most part, establish the first contact with women who seek care and, therefore, play an essential role in the initial reception of these victims, and should act in a humanized manner and based on scientific evidence.²⁴

As members of the multidisciplinary health team, nurses have great potential to provide humane and effective care, collaborating in the identification, collection, and preservation of evidence suggestive of sexual violence. These professionals, due to their technical training, are able to contribute to a welcoming environment and mitigate moments of anguish experienced by victims.²⁵

However, the results of this study show that, despite working in reference units for the care of women exposed to sexual violence, many professionals demonstrate lack of knowledge regarding the concept of trace preservation. This gap invites reflection on the need to strengthen care practice, making it more humanized and evidence-based, in contrast to practices centered only on everyday experience.

It is widely recognized that urgent and emergency services frequently receive victims of different forms of violence. In this scenario, nurses, because they are on the front line of care, play a crucial role in the preservation of traces, collaborating with investigations and assisting the Justice system in clarifying cases.

Previous studies reinforce that a large proportion of nurses working in this context feel unprepared to deal with these situations, either due to the lack of technical and scientific competence or due to the absence of understanding of the functioning of the intersectoral protection network for victims and of their specific and shared attributions in this process.²⁶ This same scenario has also been identified in countries such as India and Turkey, where emergency services in public and private hospitals do not have professionals trained to care for women exposed to sexual violence.²⁷,²⁸

The performance of nurses without prior preparation to deal with the preservation of sexual traces may compromise essential evidence for the clarification of cases of violence, even if unintentionally.¹ It is emphasized that inadequate collection and preservation or those performed outside the appropriate time frame may impair forensic analysis and legal investigation. Therefore, it is indispensable to invest in upskilling through courses, workshops, and training programs, strengthening the role of these professionals.²⁹

The participants’ statements reveal incipient knowledge and fragile accountability regarding the preservation of sexual traces, which may lead to fragmented and palliative care. Even so, nurses’ interest in acquiring new knowledge and technical skills to improve care for women in situations of sexual violence is noted.

For the effectiveness of comprehensive care, it is necessary to articulate the sectors involved in caring for victims, ensure qualified human resources aware of their competencies and roles in the network for confronting violence, and, above all, establish a directed therapeutic itinerary that favors integrality and resoluteness of care.³⁰

In countries where nurse examiners of sexual assault operate, greater intersectoral and interdisciplinary dialog between health and security has been observed, favoring the conduct of new investigations and contributing significantly to increased rates of case clarification.³¹

In this sense, it is imperative to create protocols that guide professionals’ actions and conducts in the care of victims of sexual violence, as well as to ensure that institutions provide adequate training and capacity-building, favoring conceptual and practical mastery of the topic.¹

In the Brazilian context, in addition to the lack of specialized human resources, the importance of creating legislation that guarantees nurses’ participation in the chain of custody is highlighted. Currently, the actions of these professionals are concentrated on clinical treatment, while the collection and preservation of traces remain traditionally under the responsibility of criminal police, despite legislation providing for this stage as part of comprehensive care.¹

Therefore, the need to implement existing public policies, invest in the training of professionals working in health services, and include the topic of trace preservation in the curricular matrix of nursing courses, both at theoretical and practical levels, is evident. Appropriating this knowledge provides professionals with greater security and qualifies the care provided.

In the same way, the creation of legislation that includes the nurse in the chain of custody would allow evidence to be collected within the health services themselves, favoring humanized care and reducing the revictimization of women by avoiding the repetition of their accounts in different instances, such as forensic institutes.

FINAL CONSIDERATIONS AND IMPLICATIONS FOR PRACTICE

It was found that, although nurses in the researched institutions recognize the importance of preserving traces in cases of sexual violence, knowledge on the subject is either lacking or incipient. Professionals do not feel prepared to adequately care for victims, and training and capacity-building are the needs most frequently mentioned.

Additionally, the need to reformulate some existing care flows was also identified, as well as the need for specific training so that nurses can use them effectively. In addition, the lack of improvements in the physical infrastructure of services that care for these women is evident, in order to ensure confidentiality and privacy during care.

The importance of implementing existing public policies, continuous investment in the training of professionals working in these services, and the inclusion of the topic in the curricular matrix of nursing courses, both in theoretical and practical aspects, is also observed. Appropriation of this knowledge provides professionals with greater security and qualifies the care provided.

Likewise, the relevance of creating legislation that formally includes nurses in the chain of custody is highlighted, allowing sexual traces to be collected in health services. This measure would favor more humanized care and mitigate the revictimization of women, reducing the need for repeated reports of violence suffered at criminalistics institutes.

As limitations of the study, it was evidenced that the research was conducted in only five health institutions in the municipality of Fortaleza, as well as the non-inclusion of professionals working remotely or who were away from work activities due to illness. In addition, the fact that the participants themselves were unaware of the central object of the study is highlighted, as well as the use of the snowball sampling technique (or network sampling), which may homogenize participant characteristics

ACKNOWLEDGMENTS

No acknowledgments.

DATA AVAILABILITY RESEARCH

The underlying content of the research text is contained in the article.

• FINANCIAL SUPPORT
  No funding.

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Edited by

• ASSOCIATED EDITOR
  Tassiane Ferreira Langendorf https://orcid.org/0000-0002-5902-7449

• SCIENTIFIC EDITOR
  Marcelle Miranda da Silva https://orcid.org/0000-0003-4872-7252

Publication Dates

• Publication in this collection
  23 Mar 2026
• Date of issue
  2026

History

• Received
  07 Aug 2025
• Accepted
  29 Jan 2026