Within Australia and in Europe. there is evidence of growth in the incidence of non¬standard forms of employment such as part-time and casual work. Part of this growth can be attributed to changes in the structure of the economy and the increasing importance of service industries where non-standard forms of employment proliferate. There is also evidence, however, that employers at the firm level are progressively expanding their use of non-standard employment and reducing their reliance on full-time labour. One explanation for this organisational-level phenomena has been suggested by Atkinson (1987) in his account of the ‘flexible firm’. Atkinson claims that employers are increasingly attempting to divide the workforce into two major segments: a skilled, full-time core labour force and an unskilled, non-standard segment. This thesis examines Atkinson’s ‘flexible firm’ model through a study of labour-use practices of three acute hospitals in Queensland. A main finding of this thesis is the generalised and substantial growth of non-standard employment in all types of Queensland hospitals. The growth of non-standard hospital labour is not as, Atkinson would suggest, largely the result of demand-side strategies of employers but is also conditioned by supply-side factors. Gender, rather than skill, is found to be an important determinant of the proliferation of non-standard employment. Non-standard employment is not the major labour adjustment mechanism in all sectors of the hospital industry. Labour intensification is a critical and overlooked form of labour adjustment in the public sector. Overall, this thesis concludes that employers’ labour-use practices need to be conceptualised within the context of the opportunities and constraints imposed by the interaction of demand and supply-side factors.

The UK's NHS is the largest employer in Europe with approximately 1.3 million staff. Around 83% of the journeys associated with the NHS are made by private car. In this context, every healthcare authority was required to produce a travel plan by December 2010, including an emphasis on promoting walking and cycling as a means of accessing hospitals. Evidence shows that although the take-up of travel plans is increasing across the NHS, the impact of travel plans in promoting walking as a travel option is relatively low among hospital staff. A scoping study has been conducted aiming to bridge the gap between research and practice by capturing the views of the NHS representatives on hospital travel plans by a nationwide survey and review of hospital travel plans. The survey findings show that despite having a high potential to promote walking as a key travel option among the hospital staff, the measures to promote walking were cited as the least effective. A Spearman's ρ correlation coefficient test was performed to evaluate the correlation between travel plan measures to promote walking and restrictive measures to reduce the use of cars. The results show that the effectiveness of measures to reduce the use of cars is positively correlated with the effectiveness of measures to promote walking. The effectiveness of travel plan measures to secure the targeted outcome is attributed to the methods used to address the determinants for changing travel behaviour whilst designing travel plan measures and the successful adoption of innovative strategies in the given context. A theoretical framework has been developed based on the Theory of Planned Behaviour and five key research hypotheses have been proposed to demonstrate the key determinants for changing travel behaviour. The analysis was based on a nationwide survey among the NHS hospital staff in England in 2013. There were 863 completed responses, out of which 459 responses were from hospital staff, who solely relied on car journeys for commuting purposes. Structural equation modelling was performed to investigate the effects of socio-economic, psychological and situational factors in determining intention to change travel behaviour among the car users only. The model estimation results show that the effects of cognitive attitude towards walking and objective mobility were significant on determining intention to change travel behaviour. The respondents exhibited a habitual nature of travel behaviour, which is characterised by longer commuting distance and journey time than the national UK average. The practical implications of the study were addressed by providing recommendations that need to be considered whilst designing travel plan measures. The recommendations were based on the concept of Model for Planned Promotion. This study provides a basis for further conceptualisation of travel behaviour change and identifies several areas that need further investigation in relation to designing interventions to promote walking in the context of healthcare.

Estimates indicate that by 2010 RN demand will exceed supply by over 400,000 full-time equivalents and by 2020 the RN shortage will increase to over 1 million. Turnover is a major contributor to the nursing shortage and job dissatisfaction is a well-established cause of nursing turnover. Understanding RN job satisfaction is an objective that is critical to keeping experienced nurses working in nursing and minimizing RN turnover. Many facets of RN job satisfaction have been examined in previous studies; however, much of the variance in job satisfaction remains unexplained. The purpose of this study was to explore job strain, body mass index, and background information variables (age, education, ethnicity, number of years in nursing, and perceived general health) as possible predictors of job satisfaction among hospital staff nurses. Resilience was examined for its mediating and moderating effects on the relationships between job strain and job satisfaction and body mass index and job satisfaction. The research design was cross-sectional and correlational. Surveys were mailed to RNs across the state of Texas. Reliable instruments were used to measure hospital staff RN job satisfaction, job strain, and resilience. Body mass index was calculated based on self-reported height and weight. From a sampling frame of full-time, hospital staff RNs purchased from the Texas Board of Nursing, a random sample of 556 RNs was obtained. The response rate was 27.6% (n = 147). Results showed that 25.2% of the RNs sampled reported high job strain. Job strain was significantly related to body mass index, and high job strain was significantly negatively related to job satisfaction. High job strain explained 24.7% of the variance in job satisfaction. None of the background information variables were significantly related to job satisfaction. Resilience had a moderating effect on the relationship between job strain and job satisfaction. Resilience did not mediate or moderate the relationship between body mass index and job satisfaction. Future research should focus on creating a nurse-specific instrument that measures job strain in hospital staff RNs. Intervention studies that investigate the effects of resilience training on the job satisfaction of hospital staff RNs should also be conducted. / text

Purpose. The purpose of the study was to evaluate the level of job satisfaction among the staff of Pärnu County Hospital and to describe variables related to their job satisfaction. Methods. The study was carried out in December 1998. The opinions of staff regarding satisfaction with their jobs were studied using an Estonian translation of the Norwegian Medical Association Job Satisfaction questionnaire, which was distributed to all 673 staff members of the hospital. Three levels of analyses were carried out. Stepwise regression analysis was used to determine which single item factors were most important in job satisfaction for the various groups of hospital staff. Further, global job satisfaction item and a four items construct called nature of job satisfaction (α=60) were selected as dependent variables. The independent variables consisted of constructs measuring: knowledge in planning (3 items α=70), relationship with superior (5 items α=89), strategic knowledge of workplace (5 items α=84), work stress (6 items α=77), unrealistic expectations (5 items α=72), collegial relationships (2 items α=75), discussions with colleagues (3 items α=80), recognition (3 items α=67) and sense of belonging (single item). Pearson correlations were used to determine whether the independent variables were significantly correlated with job satisfaction. Scheffe’s F-test was used to conduct post-hoc analyses of variance for each independent variable between categories of hospital personnel. Results. The response rate was 77%. The key results were that overall job satisfaction was moderately high (3.86 on a scale of 5); however there are differences in satisfaction models between categories of personnel. In addition, there are significant differences in the correlations between job satisfaction and the independent variables among the groups of personnel. Conclusions. The findings of this study suggest that executives of a health care institution that are informed about the expectations and daily work-related problems of their employees are better able to understand the needs of their employees. Executives should: 1) build up effective relationships between managers and staff; 2) identifynegative working conditionswhich affect staff; 3) appropriately delegate authority to personnel, and hold them accountable for the work done in their organizational units; 4) keep staff informed about changes that will affect them; and 5) express appreciation and recognition for the efforts of staff members in accomplishing the work of the health care organization. In doing this, executives will create a favorable working environment for the hospital staff. The value of the study is that the results can be used as a set of reference levels and indicators for the human resources development component of the quality management system of Pärnu County Hospital / <p>ISBN 978-91-58721-04-7</p>

Syfte: Syftet med studien var att ta del av hur vårdpersonal på Hospice beskriver sina olika känslor som uppstår i vården av patienter i livets slutskede, vilka copingstrategier de använder sig av för att bearbeta dessa känslor samt vilka faktorer som de upplever påverkar valet av copingstrategier. Metod: En kvalitativ metod med semistrukturerade intervjuer användes. Åtta kvinnliga deltagare ur vårdpersonalen på Hospice (lika fördelade mellan sjuksköterskor och undersköterskor med varierande ålder och erfarenhet) blev intervjuade. Resultat: Känslor av skuld, frustration, maktlöshet, stress och otillräcklighet upplevdes betungande. För att bearbeta dessa användes främst aktiv och problemfokuserad coping, framförallt samtal och stöd. Vårdpersonalen lägger stor vikt vid att kunna separera privatlivet från arbetslivet. Även känslofokuserad coping i form av distraktion eller avskärmning användes ibland. Detta för att uthärda i stunden och vid senare tillfälle bearbeta dessa upplevelser. Faktorer som påverkade bearbetningen var samarbetet i arbetsgruppen, tidsbrist, samt individuella egenskaper. Slutsats: Klimatet på arbetsplatsen, det vill säga organisation, attityder samt tid för gemensam reflektion är viktigt för bearbetningen. Det är också viktigt att blivande vårdpersonal får kunskap om palliativ vård och olika copingstrategier för att hantera sina känslor. Vårdutbildningar behöver ses över inom detta område. Hur coping används påverkar personalhälsan och även i förlängningen patientvården. Kunskap om copingstrategier måste finnas även på avdelningar där inte specifik palliativ vård bedrivs. / Objective: The aim of this study was to learn how the healthcare personnel at Hospice describes their emotions during work with patients in palliative care, which coping strategies they use to deal with these emotions as well as factors they experience affects the choice of strategies. Methods: A qualitative approach with semi-structured interviews was used to collect data. Eight female participants with varying age and work experience from the Hospice nursing staff were interviewed. Results: Feelings of guilt, frustration, powerlessness, stress and inadequacy were perceived as difficult. To cope with these emotions active and problem-focused coping was used mainly for ventilation and social support seeking. They find it important to separate their private life from work. Emotion-focused coping was used at times for distraction or to distance themselves, to endure in the moment and later on process these emotions. Factors affecting the coping strategies were cooperation in the work group, time constraints and individual qualities. Conclusion: The workplace climate regarding organization, attitudes and times for group reflection, is significant for coping. It is important that aspiring health professionals learn about palliative care and coping strategies to manage their emotions. Nursing programs need to be reviewed in this area. How coping is used affect health among the staff and ultimately also the patient care. Knowledge of coping strategies is important in all areas of healthcare.

no / Aims and objectives; We report findings from a qualitative study to identify patient views of community hospital care. We consider how far these were in accord with the hospital staffs' views. This constituted part of a wider randomized controlled trial (RCT). The methodological challenges in seeking to identify patient satisfaction and in linking qualitative findings with trial results are explored. Design A sample of 13 patients randomized to the community hospital arm of the RCT joined the qualitative study. Official documentation from the hospital were accessed and six staff interviewed to identify assumptions underlying practice. Results Analysis of interviews identified a complex picture concerning expectations These could be classified as ideal, realistic, normative and unformed. The hospital philosophy and staff views about service delivery were closely in harmony, they delivered rehabilitation in a home-based atmosphere. The formal, or 'hard', process of rehabilitation was not well understood by patients. They were primarily concerned with 'soft' or process issues ¿ where and how care was delivered. Conclusions We identify a model of community hospital care that incorporates technical aspects of rehabilitation within a human approach that is welcomed by patients. If patients are to be able to participate in making informed decisions about care, the rationale for the activities of staff need to be more clearly explained. Recommendations are made about the appropriate scope of qualitative findings in the context of trials and about techniques to access patient views in areas where they have difficulty in expressing critical impressions.

The work presented in this dissertation has been focused on exploiting the branch-and-price (BNP) method for the solution of various stochastic mixed integer programming problems (MIPs). In particular, we address the stochastic generalized assignment problem (SGAP), a hospital staff scheduling problem (HSSP), a stochastic hospital staff scheduling problem (SHSSP), and a stochastic short-term personnel planning problem (SSTPP). The BNP method has been developed in concert with the dual stabilization technique and other enhancements of this method for each of these problems. In view of an excessive number of scenarios that arise for these problems, we also implement the Monte Carlo method within the BNP scheme. The superiority of the BNP-based method over the branch-and-cut (BNC) method is demonstrated for all of these problems. The first problem that we address is the SGAP for which the processing time of a job on a machine is assumed to be stochastic. Even though the generalized assignment problem (GAP) has been solved using the BNP method, yet no study has been reported in the literature on the use of the BNP method for the solution of the SGAP. Our work has been motivated by the desire to fill this gap. We begin by showing that it is better to solve the SGAP as a stochastic program in contrast to solving it by using the expected values of the times required to process the jobs on the machines. Then, we show that the stochastic model of the SGAP is a complete recourse model — a useful property which permits the first stage decisions to produce feasible solutions for the recourse problems. We develop three BNP-based methods for the solution of the SGAP. The first of these is BNP-SGAP, which is a combination of branch-and-bound and column generation methods. The pricing problem of BNP-SGAP is separable with regard to each machine, and it is a multiple-constraint knapsack problem. The second method is BNP-SGAP implemented in concert with the dual stabilization technique (DST), and it is designated as BNPDST-SGAP. We have introduced a new DST by modifying the Boxstep method of Pigatti et al. [76]. We have shown that our method performs better than the method of Pigatti et al. [76] resulting in over two-fold savings in cpu times on average. The third method that we develop for the solution of the SGAP is BNPDST-SGAP implemented with an advanced start to obtain an initial feasible solution. We use a greedy heuristic to obtain this solution, and this heuristic is a modification of a similar method used for the knapsack problem. It relies on the information available at a node of the underlying branch-and-bound tree. We have shown that this procedure obtains an initial feasible solution, if it exists at that node. We designate this method as BNPDSTKP-SGAP. We have also developed a BNC method to solve the SGAP using CPLEX 9.0. We have compared the performances of the BNP and BNC methods on various problem instances obtained by varying the number of machines, the ratio of the number of machines to the number of jobs, the machine capacity, and the penalty cost per unit of extra resource required at each machine. Our results show that all BNP-based methods perform better than the BNC method, with the best performance obtained for BNPDSTKP-SGAP. An issue with the use of the scenario-based methods that we have employed for the solution of the SGAP is that the number of scenarios generally grows exponentially in problem parameters, which gives rise to a large-size problem. To overcome the complexity caused by the presence of a large number of scenarios for the solution of the SGAP, we introduce the use of the Monte Carlo method (MCM) within the BNP scheme. We designate this method as BNPDSTKP-SGAP with MCM. It affords the use of a small subset of scenarios at a time to estimate the "true" optimal objective function value. Replications of the subsets of scenarios are carried out until the objective function value satisfies a stopping criterion. We have established theoretical results for the use of the MCM. These pertain to determining unbiased estimates of: (i) lower and upper bounds of the "true" optimal objective function value, (ii) the "true" optimal solution, and (iii) the optimality gap. We have also provided the 100(1-ï ¡) confidence interval on the optimality gap. Our experimental investigation has shown the efficacy of using this method. It obtains almost optimal solutions, with the objective function value lying within 5% of the "true" optimal objective function value, while giving almost ten-fold savings in cpu time. Our experimentation has also revealed that an increment in the number of scenarios in each replication makes a greater impact on the quality of the solution obtained than an increment in the number of replications. We have also observed the impact of a change in the variance of a processing time distribution on cpu time. As expected, the optimal objective function value increases with increment in processing time variability. Also, by comparing the results with the expected value solution, it is observed that the greater the variability in the data, the better it is to use the stochastic program. The second problem that we study is the hospital staff scheduling problem. We address the following three versions of this problem: HSSP (General): Implementation of schedule incorporating the four principal elements, namely, surgeons, operations, operating rooms, and operation times; HSSP (Priority): Inclusion of priority for some surgeons over the other surgeons regarding the use of the facility in HSSP (General); HSSP (Pre-arranged): Implementation of a completely pre-fixed schedule for some surgeons. The consideration of priority among the surgeons mimics the reality. Our BNP method for the solution of these problems is similar to that for the SGAP except for the following: (i) a feasible solution at a node is obtained with no additional assignment, i.e., it consists of the assignments made in the preceding nodes of that node in the branch-and-bound tree; (ii) the columns with positive reduced cost are candidates for augmentation in the CGM; and (iii) a new branching variable selection strategy is introduced, which selects a fractional variable as a branching variable by fixing a value of which we enforce the largest number of variables to either 0 or 1. The priority problem is separable in surgeons. The results of our experimentation have shown the efficacy of using the BNP-based method for the solution of each HSSP as it takes advantage of the inherent structure of each of these problems. We have also compared their performances with that of the BNC method developed using CPLEX. For the formulations HSSP (General), HSSP (Priority), and HSSP (Pre-arranged), the BNP method gives better results for 22 out of 30, 29 out of 34, and 20 out 32 experiments over the BNC method, respectively. Furthermore, while the BNC method fails to obtain an optimal solution for 15 experiments, the BNP method obtains optimal solutions for all 96 experiments conducted. Thus, the BNP method consistently outperforms the BNC method for all of these problems. The third problem that we have investigated in this study is the stochastic version of the HSSP, designated as the Stochastic HSSP (SHSSP), in which the operation times are assumed to be stochastic. We have introduced a formulation for this formulation, designated as SHSSP2 (General), which allows for overlapping of schedules for surgeons and operating rooms, and also, allows for an assignment of a surgeon to perform an operation that takes less than a pre-arranged operation time, but all incurring appropriate penalty costs. A comparison of the solution of SHSSP2 (General) and its value with those obtained by using expected values (the corresponding problem is designated as Expected-SHSSP2 (General)) reveals that Expected-SHSSP2 (General) may end up with inferior and infeasible schedules. We show that the recourse model for SHSSP2 (General) is a relatively complete recourse model. Consequently, we use the Monte Carlo method (MCM) to reduce the complexity of solving SHSSP2 (General) by considering fewer scenarios. We employ the branch-and-cut (BNC) method in concert with the MCM for solving SHSSP2 (General). The solution obtained is evaluated using tolerance ratio, closeness to optimality, length of confidence interval, and cpu time. The MCM substantially reduces computational effort while producing almost optimal solutions and small confidence intervals. We have also considered a special case of SHSSP2 (General), which considers no overlapping schedules for surgeons and operating rooms and assigns exactly the same operation time for each assignment under each scenario, and designate it as SHSSP2 (Special). With this, we consider another formulation that relies on the longest operation time among all scenarios for each assignment of a surgeon to an operation in order to avoid scheduling conflicts, and we designate this problem as SHSSP (Longest). We show SHSSP (Longest) to be equivalent to deterministic HSSP, designated as HSSP (Equivalent), and we further prove it to be equivalent to SHSSP (General) in terms of the optimal objective function value and the optimal assignments of operations to surgeons. The schedule produced by HSSP (Equivalent) does not allow any overlap among the operations performed in an operating room. That is, a new operation cannot be performed if a previous operation scheduled in that room takes longer than expected. However, the schedule generated by HSSP (Equivalent) may turn out to be a conservative one, and may end up with voids due to unused resources in case an operation in an operating room is completed earlier than the longest time allowed. Nevertheless, the schedule is still a feasible one. In such a case, the schedule can be left-shifted, if possible, because the scenarios are now revealed. Moreover, such voids could be used to perform other procedures (e.g., emergency operations) that have not been considered within the scope of the SHSSP addressed here. Besides, such a schedule can provide useful guidelines to plan for resources ahead of time. The fourth problem that we have addressed in this dissertation is the stochastic short-term personnel planning problem, designated as Stochastic STPP (SSTPP). This problem arises due to the need for finding appropriate temporary contractors (workers) to perform requisite jobs. We incorporate uncertainty in processing time or amount of resource required by a contractor to perform a job. Contrary to the SGAP, the recourse model for this problem is not a relatively complete recourse model. As a result, we cannot employ a MCM method for the solution of this problem as it may give rise to an infeasible solution. The BNP method for the SSTPP employs the DST and the advanced start procedure developed for the SGAP, and due to extra constraints and presence of binary decision variables, we use the branching variable selection strategy developed for the HSSP models. Because of the distinctive properties of the SSTPP, we have introduced a new node selection strategy. We have compared the performances of the BNC-based and BNP-based methods based on the cpu time required. The BNP method outperforms the BNC method in 75% of the experiments conducted, and the BNP method is found to be quite stable with smaller variance in cpu times than those for the BNC method. It affords solution of difficult problems in smaller cpu times than those required for the BNC method. / Ph. D.

The subject of this diploma thesis is to characterize the requirements on legal stay of foreign employees in the Czech Republic, their employment and recognition of their qualification. Topics found in the literature and associated to international migration of employees in medical facilities, topics associated to their legal stay in the Czech Republic, rules of employing them and rules of recognition of their qualification are described in theoretical part of my diploma thesis. The main goal of the practical part is to find out what is the state in 2 medical facilities which took part in my research. And to compare them from the perspective of their quality, according to the structure of all professions and work adjustment of foreign employees. Also to find out if and eventually why the legal regulations are contravened. Keywords: stay of foreigners, employment of foreigners, recognition of qualification, medical facilities, hospital staff.

This is a Minor Field Study (MFS) which is a scholarship financed by the Swedish International Development Cooperation Agency (Sida). The study was held in 2007 in Yogyakarta, Indonesia and is based upon retrospective qualitative interviews with five Bachelor nurses who experienced the disaster work during the earthquake 27th of May, 2006. The aim of the study is to explore the experiences, feelings and thoughts of Bachelor nurses who were involved in this natural disaster. The interview, transcription and analyse work were made one year after the earthquake were a qualitative content analysis method was used. Two group interviews were held at the University of Gadjah Mada. The result is based upon the respondents’ stories from these group interviews. In the result are the respondents’ experience, feelings and thoughts presented in themes which are put in three phases: before, during and after the earthquake. Previous studies are based on western disaster work and they are of a quantitative aspect. Finding qualitative studies from a helper’s view and especially from developing countries are difficult. This Minor Field Study increases the understanding for helpers’ feelings and thoughts during a natural disaster. It can easily be used by rescue personnel and hospital staff as a preparing literature of what they might experience before, during and after the work of a natural disaster. / <p>Program: Sjuksköterskeutbildning</p><p>Uppsatsnivå: C</p>

Made available in DSpace on 2016-04-28T20:39:09Z (GMT). No. of bitstreams: 1 Ana Paula Marson.pdf: 673352 bytes, checksum: 9c50a1e9a8526b3c7e6ee5ad0a0cfb26 (MD5) Previous issue date: 2015-09-18 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / This study investigates the Kangaroo Care intervention possibilities concerning the mother's approach to her premature baby, surrounded by a technological barrier that permeates treatment. The survival and development of the baby depend on technology, medicines and health professionals, as they represent, in his early life, safety for him and his mother. In the face of the adversities of this situation, the aim of the study is to analyze the challenges of the implementation of the 1st phase of the Kangaroo Care in a neonatal unit. Kangaroo Care not only provides early skin-to-skin contact between the infant and the mother and father, allowing greater participation in caring, but also enables the organization of the neonatal environment as to noise and lighting, and pain control, in order to decrease the negative effects on the infant s development. The basis of Winnicott's thought shows that the consistency of maternal care ensures continuity of being or continuing baby's existence. Thus, the baby depends emotionally on the mother for his survival and, in the neonatal unit, depends on the professionals present there. Thus, the concern of this research is to look closer at the medical professionals who work in the neonatal unit, because the physical and mental health of the premature baby depends on them. The research was conducted at the Neonatal Unit of the University Hospital of the State University of Londrina. We used a qualitative research method, participant observation and interviews, contextualizing the first stage of the Kangaroo Care implementation through evaluation of benefits and difficulties / O presente estudo investiga as possibilidades de intervenção do Método Canguru no que diz respeito à aproximação da mãe com seu bebê prematuro, envolto em toda barreira tecnológica que permeia o tratamento. A sobrevivência e desenvolvimento do bebê dependem do maquinário, de medicamentos e de profissionais atuantes nesse contexto, visto que se tornam, no início da sua vida, a segurança para ele e para a sua mãe. Diante das adversidades que essa situação coloca, o interesse deste estudo consiste em analisar os desafios da implantação da 1ª etapa do Método Canguru em uma unidade neonatal. O Método Canguru proporciona o contato pele a pele precoce entre a mãe-bebê e o pai, permitindo uma maior participação desses no cuidado com seu bebê, como também permite toda a organização do ambiente neonatal no sentido de diminuição de ruídos, de luminosidade, controle de dor, a fim de minimizar os efeitos negativos no desenvolvimento do prematuro. A base de todo pensamento winnicottiano evidencia que a constância do cuidado materno assegura a continuidade do ser ou existência continuada do bebê. Sendo assim, o bebê depende emocionalmente da mãe para sua sobrevivência e, na unidade neonatal depende dos profissionais lá presentes. Desse modo, a preocupação desta pesquisa consiste em voltar um olhar mais atento aos personagens que participam da neonatal, pois deles dependem o seguimento da saúde física e mental do bebê prematuro. A pesquisa foi desenvolvida na Unidade Neonatal do Hospital Universitário da Universidade Estadual de Londrina. Para isso, utilizou-se do método qualitativo de pesquisa, com uso da observação participante e de entrevistas, contextualizando a primeira etapa da implantação do Método Canguru mediante avaliação de benefícios e dificuldades