v11n3a10

ORIGINAL ARTICLES

 

Experiences of mothers of children living with cardiopathies: a care research study

 

 

Ana Cleide Silva Rabelo1, Lúcia de Fátima da Silva1, Maria Vilaní Cavalcante Guedes1,Keila Maria de Azevedo Pon1, Fabíola Vládia Freire da Silva1
1 State University of Ceará, CE, Brazil

 


ABSTRACT
Objective: Analyze the life experience of mothers of children living with cardiopathies based on the Theory of Transpersonal Care. Methodology: This is a care research, with a qualitative approach, performed between May and June 2011. The sample was with 21 mothers that accompanied their children during treatment in a specialized hospital of cardiopulmonary treatment, in the municipality of Fortaleza, Northeast Brazil. Results: The mother lives changing processes in her social life, because of the necessity to dedicate her life to the child, as well as feelings, such as anxiety, fear, sadness and frustration by the imminent risk of child’s death. To build some strength, the mother usually looks for her own beliefs. Discussion: The use of elements from the Clinical Caritas Process aids the development of humanized caring nursing. Conclusion: The application of this theory helps to understand the mother’s experience as a caretaker and as a person that needs caring.
Keywords: Theory of Nursing; Research; Caring; Cardiopathies; Child.


 

 

INTRODUCTION

This article is focused to analyze the experiences of mothers whose children are hospitalized with cardiopathies, referring these experiences to the elements described in the Clinical Caritas Process, proposed by Jean Watson and understood as a model of transpersonal care that considers the cared being as part of the process of caring(1).

Hospitalization is a difficult moment which the child requires even more caring, love, dedication and attention, from both parents and health professionals. Therefore, the interactions among the caretakers enable better adaptation of the child to the experience of illness.

Regarding the experience of the mother, the child hospitalization is a potentially stressing situation, as it happens in an environment that frequently challenges her sense of safety and competence(2).

In this process, the mother reveals the suffering from the responsibility that she assumes towards her family and society to take care of the sick child, and also from the working dynamics of the hospital environment(3).
Even with the present mother, the illness of the child generates a constant tension, not only because of the sickness, but also because usually the mother tries to assume some caretaking tasks without proper direction for such tasks. Thus, she gets worried with any movement of the child and, most of the times, she does not have an available professional do help and minimize her anguish(4).

Based on that, it is essential to provide the nursing caretaking treatment also to the necessities of the family, which requires the mastery of the nurse in specific theoretical information and sensibility to deal with this clientele.

It is fundamental that these professionals understand the mother as a mediator between the child and the hospital, and as such she is the one who transmits to the team the signals and messages sent by the child. These signals can help the professionals and reveal their conduct, and promote changes in caretaking, adapting the hospital world to the conditions of the child/mother(5).

The use of theoretical references in the professional practice of nursing is a facilitator to establish actions of caretaking that privilege the human being inserted in an environment, with the intention to reestablish a healthy state through nursing caretaking treatments. In nursing, many studies are dedicated to the caring topic. This study is based on the Theory of Transpersonal Caring of Jean Watson.

This theory presents the human being as a point of convergence in all nursing steps; the integrality of the body, mind and spirit in a transpersonal process(6). Among the elements of the Clinical Caritas Process, it is included the sacredness of the cared being, a connection with the human being to a level that extrapolates the concrete and visual and the proposal of the healing process as the reconstruction of the being(7).

The Clinical Caritas Process is an emerging model of transpersonal caring that modifies the caring factors, which provide a form and structure to the theory of human caring and help nurses to solve problems with creativity. Such process approaches the other with courtesy, sensibility and caring attention(1).

Yet, based on this theory, we highlight the importance to recompose and reconstruct the involved subjects, from the caring provided by the nurse, aiding to demonstrate the acceptance of life based on the establishment of a relation of help, trust, caring and love, infused with an ethic commitment(8).

In this study we focus to analyze the Clinical Caritas Process mentioned by Jean Watson with mothers of children with cardiopathy, understanding the relationship between love and caring, both for themselves (self/mother) and the other (child/professional), with an objective to develop nursing practices, promoting changes in these relationships. To reveal, elucidate and give support to the question of this study, we use the theoretical references of Watson, based on the Theory of Transpersonal Caring(1).

Consequently, this study aims to analyze the experience of mothers of children diagnosed with cardiopathies in light of the Theory of Transpersonal Caring.

 

METODOLOGY

This is a care research, with a qualitative approach. The care research is equipped with particularities to the area of nursing, which has a reciprocity and which results subsidize the practices(9).

To perform such care research, five steps must occur successively: approximation with the object of study; the encounter between the researcher-caretaker with the researched-cared being; establishment of the connections between research, theory and caring practices; distance of the researcher-caretaker and the researched-cared being; analysis of the learned experience(10).

Approximation with the object of study
In this first step, there was a definition of the object of study, which is: to reveal the experience of the mothers of children diagnosed with cardiopathies in the process of hospitalization of the infant. The methodological reference answers the propositions of this study, as it allows to, besides the research, the caretaking actions can be developed.

In a literature review, it was discussed about the congenital cardiopathies; the nursing caretaking procedures to the mother and her child with congenital cardiopathy; the relationship between mother and child in this situation; the Transpersonal Theory of Jean Watson and; the nursing caretaking procedures to the children with congenital cardiopathies and their mothers. Such discussions contributed to approximate to the object, delimitate and analyze the understanding necessary to certify the study propositions.

Encounter between the researcher-caretaker with the researched-cared being
On the second step of the method, there was a meeting with the nursing team on a first moment, when there was an explanation about the objectives of this study, establishing a partnership, clarifying the preoccupation of the researcher-caretaker to collaborate with the activities od caring without compromising the working routines.

This step was set as the first moment if interaction between the researched-cared being, when the real necessities are identified.

This study was performed with 21 mothers of children diagnosed with cardiopathies, hospitalized in a pediatrics unit of a large hospital, specialized in cardiopulmonary complications, in the municipality of Fortaleza, between May and June 2011. This hospitalization unit has 24 beds, distributed among eight collective wards, which all present a high turnover rate.

The nursing staff of the studied unit is composed by two nurses and six high-schooled professionals (technicians or nursing assistants), who work in 12-hours shifts. The studied place was selected because it is a tertiary unit, specialized in diagnose and treatment of cardiac and pulmonary diseases, equipped with all proceedings of high complexity in these areas and is a reference in cardiac transplant in both adults and children.

The participants of the study were selected by intentional sampling, which is when all mothers that were accompanying their children during the process of hospitalization were asked to participate in the study, in the first moment with the researcher-caretaker. There was no preoccupation with the quantity of participants, as the saturation of the reports regarding the studied phenomena was interesting for this research.

As including criteria, there was: having a child hospitalized due to a congenital cardiopathy and demonstrate to be accessible to participate in this study. As excluding criterion, it was: for mothers who were not present during the whole hospitalization process of the child.

To collect the information, a semi-structured interview was used, which used the following guiding question: how it is for you to experience the process of illness of your son with cardiopathy, and being treated with him by the nursing team? We also applied an instrument to identify the subjects involved. The interviews were recorded in a digital device, with the authorization of the participants, and the observation data of the interviewer were also recorded in a field journal.

According to the regulations, we followed the ethic-legal precepts of the Resolution 196/1996, from the Brazilian National Health Council, and there was the approval from the Ethics in Research Committee of Ceara State University, under protocol number 10725967-2. The names of the researchers-caretakers were substituted by fictional names of flowers to preserve their privacy and anonymity. The mothers gave their opinion to choose their nicknames.

Establishment the connection between research, theory and caring practices
This third step was vital to observe the success of the application of this care research method, as it is related to the articulation between the research (the method of care research per se), the theoretical reference (Jean Watson’s Transpersonal Theory) and the practice (caretaking treatment in the encounter moment). Therefore, it movement allowed the approximation of the researcher-caretaker with the researched-cared being, to perform the interviews.

Continuing the procedures, the priorities in the treatment were established, which were decided in-group between the subjects involved in this study. The caretaking was performed in many formats: listening, stimulating, explaining, guiding, praising and touching.

Distance of the researcher-caretaker and the researched-cared being
This corresponds to the fourth step of the method and demanded a large sensibility from both sides (researcher and researched) to indicate the end of the meetings, considering the end of the study. Such moment was prepared during the whole methodological path. Then, at the end of the meetings, the researched-cared being was ready for the detachment of the researcher-caretaker.
 
Analysis of the learned experience
In the last step, we focused to learn the meaning of the speeches from the mothers. For this moment, we based on Jean Watson’s Transpersonal Theory using the content analysis as the strategy to observe the information(11).

 

RESULTS

From this moment we started to analyze the results obtained through the interpretation of the collected data from the interviews through a free observation. After the transcription of the speeches, similarities of meanings, which they revealed, and the implicit aspects of the research grouped them.

Characterization of the researched-cared beings
The interviewees were between 18 and 45 years old, and the majority declared to be in a stable relationship. Only seven were single mothers, without any support from the father of the child. Regarding their school education, one was illiterate, ten had completed the Middle school, nine finished the High school and one had a College degree.

About their professional activities, seven worked out of home, however, after the birth of the child, they started to spend more time at home, especially taking care of their children. Twelve were housewives, one was a rural worker and another one was a teacher.

In terms of family income, 17 lived with less than one minimum wage, and four with an income between two to four minimum wages. Regarding their origin, 11 were from cities away from the capital, nine from the capital and one from the neighbor state, Piaui. About their faith, the majority declared themselves as Roman Catholics. Moreover, eighteen affirmed they do not have any hobby. Nineteen had between one and three children, and two had more than five children.

Unfamiliarity of the mothers about the illness of their children and the confrontation
When discovering the illness of her child, the mother tries to understand the reason for the sickness, the factors that led to the impairment of the child’s clinic situation and the child’s real prognostic, aiming to better prepare herself. She makes a constant and observant evaluation of any possible alterations.

In a necessity to comprehend the reason for the child’s sickness, the mothers “memorize” the discourse of the doctor, without understanding it. In other cases, they demonstrate, in their simple words, the assimilation of the meaning of the illness, as we observe in their speeches, such as:

He has hypertrophic cardiomyopathy. One side of his heart has more muscles and beats too fast, then he also has arrhythmia too, and because of the arrhythmia he is going to be in observation and cannot do anything” (Jasmine);

I know he has a murmur and switched veins. He had a palliative surgery so he could breath better and later, when he reaches five years old, he will go through another surgery” (Acacia)

The lack of information was observed and pointed out as a reason for anguish, fear and anger, especially because the mothers try to be part of the health-illness process of their sons, but are excluded from it. For those mothers, “a heart problem” is something very serious, and that they cannot interfere:

I can say that I don’t know anything about it, but to say that it is a murmur, and it is unsettling to not know what it really is. How can I help?” (Gillyflower).

The mothers also exchange information among themselves, aiming to prevent what is about to happen with their children, and also to better understand the disease. Some of them, however, transmit erroneous information.

Therefore, an environment of unbiased hope is developed, and the anguish rises among them:

The mother of another child told me that all heart diseases are the same. The cure will depend on the age when the sickness was found” (Hydrangea).

Staying with the child during the illness
Having a child with congenic cardiopathy brings, to the mother, moments of anguish and preoccupation. The uncertainty feeling develops into suffering, because the imminent life-threatening situation is real in her thoughts. On the other hand, the mothers are optimistic and believe in a full and near recovery, and that these moments of pain will go away, and soon they will be at home, starting a new life:

We feel a little bit sad, because we don’t know how it will be tomorrow, but always believing everything will be alright” (Fleur-de-Lis);

“Surely, I am very sad, because we want to see your children feeling good. I would like they did not have those things. But I want him to survive, grow b and healthy” (Acacia).

Self-care: body, mind and spirit
When dedicating fully to take care of the child, the mother forgets about herself and her own necessities. She is afraid to leave the child and something bad happens when she is away. Then, she stays by the child’s side, even if it ends up harming some of her basic needs, such as nutrition:

I am not hungry anymore, I feel dizzy eventually, I do not want to dress up, and if I could, I would be by his side all the time [...]” (Orchid).

Sleeping is another compromised aspect that impedes them to have a good quality of life during the child’s hospitalization episode, as it was observed in the speeches the mothers affirmed they have trouble to sleep. This difficulty is connected to the anxiety and the sadness towards the child’s sickness:

It has been days since I could get some sleep. I am afraid of sleeping, then something happens” (Violet).
Based on the situation, the mother abdicates her world to aid the sicken son. Her personal life is placed on the side, as well as her pride and personal objectives. What before was considered an essential factor, is now a superficial necessity based on the importance to take care of the child. According to the speeches, the mothers affirm they do not have time to take care of their personal appearance, and that their time is used exclusively to help with the necessities of their most valuable asset.

When they are asked about their leisure activities, the mothers revealed individual and particular strategies, such as going to the church, watch TV and fraternize with other mothers, which are all activities they can do inside the hospital.

I relax having a conversation with the other girls. Everybody here is very united. We help each other very much” (Tulip);

 “While she is there, sleeping, I watch TV. Sometimes I attend the Mass, right here, at the chapel downstairs” (Fleur-de-Lis).

Search of spiritual comfort
As mentioned, the mother searches for God the support to hold on to this troubled path, and to face the unpredictable reality of having a child with a cardiac difficulty. As seen, the spirituality gives meaning and support to the mothers that see themselves facing the disease, the changes and the very frequent losses. Thus, to bear the pain to live with their sons’ cardiopathies, they hold to their faith in God:

I am worried, so anxious with everything, but I trust God that everything will be alright, and my daughter will be healthy again” (Orchid);

“Today I feel very well, thanks to God, because my daughter is felling better. Now I am praying she comes to the room, if God permits” (Violet).

Hospital: a new home
It is undeniable that the family and the child diagnosed with cardiopathy face problems, such as: long periods of hospitalization, frequent readmissions and aggressive therapies with some serious undesirable effects. According to the mothers/caretakers, the hospital is a hostile place they cannot adapt themselves and do their normal activities.

They report difficulties found in the infrastructure, with inadequate accommodations for both mother and child, lack of a leisure square, presence of elevated noise pollution, no privacy or comfort. Such factors contribute to the elevation of the motherly suffering during the hospitalization period:

And if it is crowded, you have to call many times. Here is terrible. Every hospital is like this. It has an atmosphere of death, sickness, of people suffering, no privacy” (Sunflower);

“Here is good, but there is too much fuss [noise], and I cannot sleep well” (Lavender); “It is not so clean. Here is dark. We do not have anything to do. The day goes by like that, and you did not do anything” (Gillyflower).

In some speeches, however, it was observed the feeling of security because they were in a hospital, as this is a place that transmits confidence, physical and emotional well-being:

“I prefer to stay here than at home. There [at home] everything is much more difficult. I am very afraid. Here I feel safer” (Petunia);

“Here is really good. We have food for our kids and for ourselves. People take care of him. It is really good” (Lily).

Maternal impressions about the nursing caretaking towards the cardiac child
Based on what was observed, the quality of healthcare service was evaluated by the mothers as a link of confidence and sympathy transmitted by the nurse; the nurse’s professional experience, knowledge and ability to deal with children; offering information about the disease and the therapy, especially in the beginning of the treatment, as seen on parts of the speeches exposed below:

“They [the nurses] always come here. They are very attentive and worried [with us]. Sometimes, she comes here just to seen how is he [the child] is doing. The assistants medicate him well, and the nurse comes form time to time to know from us” (Heartsease);

“They [the nurses] are very attentive, anything that happens with us, they are already here, checking what is going on” (Jasmine);

They take a very good care of her [the child]. They explain me the things [the procedures]” (Arum).

Besides the difficulties, throughout the hospitalization of her child, the mothers/caretakers are satisfied. They base this satisfaction on the treatment provided by the nurse and the nursing team during the child’s hospitalization.

On the other hand, there were reports of unsatisfactory conducts regarding the treatment done by the nursing team, when there were episodes that the mothers pointed out some lack of compromise of the professionals involved with aseptic techniques, or when the child was handled without preoccupation, or even the lack of communication between the nursing team and the mothers.

“There are some nurses that come to change the diapers and raise the feet of the child all the way up, but they don’t wash their hands before the procedure, and this she cannot do” (Lily);

“There is a nurse that she does not even talk to us. We ask anything and the only thing she says is that she doesn’t know” (Hydrangea).

The caretaking practice between the nurses and the mothers of cardiac children
According to the evidences, it was confirmed the necessity of a special attention to the mothers, looking to bring together the singularities of the involved subjects towards an alleviation of the suffering generated by the process of illness and hospitalization.

For such necessity, there is no established model in how to promote the approximation between nurses and mothers, but it is necessary to be sensible and available, as the speeches of the mothers tell us:

“When I was sick, they were worried about me. I have done all medical exams and followed the prescriptions” (Rose);

“Everybody here is really good. They are worried about me and him [the child]” (Azalea);~

“They are very good, they do everything to make you feel better. The service here is very good” (Iris).

As a whole, mother and child experience the disease in a similar intensity. Thus, to have a complete an authentic caretaking treatment, it must be offered to both.

In the mothers’ speeches, it is noted the lack of interaction between mothers and nursing team, as the mother does not see herself someone who needs caring, as well as she is not noted as a weakened emotionally and physically person by the nursing team:

“They take care of my child, and this is enough for me. They don’t need to take care of me” (Acacia);

“They don’t have to do anything for me, I don’t care. I just want them to take care of my son” (Sunflower).

It is important to highlight that the nurse can promote the reconstitution of the involved people in the moment of caretaking, as when it happens in a lovely and gentle manner, it also allows getting into the space of the treated person, establishing a connection between the treated subject and the universe.

DISCUSSION

Based on the uncertainty of the disease, there is an expectation that amplifies itself because of the lack of information; especially there is no clear information of what can happen after. Consequently, the mothers stay alert, motivated by the preoccupation and anxiety.

The impact of the news, the confirmation of the cardiac situation of the child, who was considered normal up to this moment, is one of the most difficult stages to be faced by the mothers as it is an unexpected event that demands an adaptive behavior, which are sometimes not available and not possible. And the mothers are normally unprepared for these situations. But, after the diagnose of congenic cardiac disease, the mother starts to experience a process of transition of the child’s health-illness state(12).

As the mother confronts the new situation, fear and insecurity are observed in the speeches, and they usually come from insufficient or inefficient information given during the hospitalization periods the child is forced to have.

According to the seventh element of the Clinical Caritas Process, regarding the importance to treat the unity of the being and the meanings, observing the otherness referential, a real connection is established with the treated being. It must be observed the teaching information and alternatives so the person treated can auto-digest the caretaking procedures, so to recognize his own necessities and then, understand his own capacities(1).

The nurse searches, from the experience of the mother, the offered information, adding it to the treatment as an educational process developed in a trusting relationship.

Knowing this fact, it is also considerably important to have as many meetings with mothers that have similar experiences, in order to strength their families with positive reflexes in the conduction of the child’s treatment. Hence, it is possible to reduce the anxiety of the parents by allowing them to understand the illness, empowering them to perform adequate healthcare treatment, and transforming them in multipliers of experiences and of the improvement in the desired quality of life for their child.

It is also important to emphasize hat learning is more than just acquiring some information; it is a meaningful correlation. And the design and context of learning affect the whole process, with the content adequate to the intellectual, symbolic and cultural level of the patient(1).

Then, to the nurse, it is important the development of activities capable of combining the experiences from the mothers to the information the nurse wants to transmit, because from that transpersonal relationship the challenges are easily overcame.

When the child falls ill, the meaning and perspective of the future are threaten, taking the mother to think about the possibility of a loss, suffering and pain, as well with the frustration to not see her dreams fulfilled. With that, the nurse can start a interpersonal relationship allowing the mother to express her feelings, but always respecting her difficulties and limitations.

When correlating the fifth element of the Theory of Transpersonal Care, the importance of a connection between who takes care and who receives the caring treatment is highlighted, to the point the emotions and feelings can be observed, either positive or negative ones(1).

When permitting the mother to show her feelings, the nurse enables and helps the cared being to reconstruct herself, when dealing with that feeling by herself from her own history, considering and authorizing a caretaking relationship.

A nurse with Caritas Conscience can be the only one to hear, see and accept the person behind the b emotions frequently present with the illness, thus stimulating the patient to liberate those feelings provoked by fear, anger and confusion. It is exactly this moments that the fairness of the nurse (uniformity of the mind, even under stress) can help them to control and stability(1).

Then, while considering and understanding the feelings of the mothers of children diagnosed with cardiopathies, it is possible to promote and maintain optimal health.

According to the observed, the search for improvements in the state of health is based on the ninth element of the theory, as from the intentional conscience of caring the basic needs can aid the alignment of body, mind and spirit, the totality and unity of the being in all aspects of caring(1).

The nurse looks for what is essential to the human care, exploring its potential in all aspects. In this sense, the caring mother tends to guide herself to a better preservation of her mind and body, to demonstrate the responsibility and respect to herself.

Based on that, she uses her faith and hope to alleviate the anguishes that come from the process of illness. Moreover, it is highlighted that the pray has a scientific and spiritual meaning, providing hope and faith to the people in many aspects in life(1).

While searching for the religion, the mother tries to find the support to handle the problems generated by the sickening of the child and then, reducing the suffering of both. This reinforces the second element mentioned in the Clinical Caritas Process, which stimulates the presence of faith and hope as essential elements to connect to the other(1).

To understand the child and the companion in the process of sickening, it is significant to proportionate, in the physical area, adequate accommodations for both, because they seen the hospital as a not pleasant environment, and the staying in this place represents an inconvenient situation, especially when there is a long hospitalization period.

This aspect is discussed on the eight element of the theory to present the necessity to generate an environment of healing, amplifying the comfort and dignity in all levels, either physical or non-physical(1).
During the caretaking procedures, some abilities are essential, as well as an ontological competence in human care, and not only the technique itself. Therefore, the professional must be reflexive, skillful when connecting to the other, building trust and security(1).

Evidently, in the organization of work, there are pressuring moments, difficulties and challenges likely to provoke suffering to the mother and her son. In this sense, there are strategies to optimize the caretaking service provided. An impatient nurse generates intolerance from who this professional is expected to have a comforting attitude.

This is the proposal of the fourth element of the Clinical Caritas Process, which aims to develop and preserve the trusting relationship in the authentic caretaking through attitudes that have a real interesting that have a real interesting meaning, becoming important things like smiles, body posture, caring touch and capacity to listen(1).

Based on the exposed information, we reinforce that the nurse uses in the caretaking procedures the verbal and non-verbal communication in a way to establish harmony between the caretaker and the cared being. And, while demonstrating respect by the feelings of the mothers, the nurse nourishes a relationship of caretaking that is based on respect and honesty. The nurse, therefore, promotes a positive acceptance of the other.
This situation complements what was discussed on the first element of the theory, which is: to practice humanitarian values, such as kindness and fairness among the caring context, using love as a possible feeling to the nurse to open himself to the other, and then, establishing coexistence and communion(1).

In a transpersonal care in nursing, both the professional and the cared being are subjects of this relationship. They transform and are transformed during the caretaking procedure. Then, it is necessary from the professional adequate strategies to every situation(13).

Implication to nursing

This study has positive implications for the nursing caretaking, because it enables the implementation of a theoretical-methodological model proposed by Jean Watson regarding the mother of children diagnosed with congenic cardiopathies, together with an innovative approach, the care research study. Then, to understand the experiences o mothers diagnosed with cardiopathies became a challenge, which was overcame with effort and dedication.

As it was observed, activities based on the scientific knowledge were promoted as well as those based on transpersonal caretaking in a relationship involving the researched subject and the researcher.

 

CONCLUSION

According to the evidences, taking care of a son with a cardiac diagnose involves emotional, social, spiritual and economical aspects. For the mother, living with a cardiopathy means to experience a process of transformation and suffering, which comes mainly from the changes that happen in the family.

Moreover, the Transpersonal Theory of Jean Watson demonstrated a connection with the objective of this study, which became more than just a nursing theory, as it deals with a design that generates proximity, empathy, interaction and compromise with the other. It always aims the independence and valorization of the involved subject.

Regarding the limitations of this study, we highlight the difficulty to interact the concepts of Watson’s Theory with the nursing practices, as the lack of this theory’s proposals in the College curricula of the nurses results in a blockage from the nurses to the ideas raised in the theory.

We must say that, despite the applicability of the Transpersonal Care Theory enables the nurse who is providing the healthcare service in child cardiology units, it is better to understand the experience of the mother as a caretaker and as a person that also needs care. At the same time, it helps to change the sight to a more humanistic caretaking.

As a proposal for humanization of the caretaking aimed to the mother of cardiac children, the nurses can apply the elements of the Clinical Caritas Process, observing the humanized caretaking capable to alleviate the suffering of these mothers, reducing their anxiety and worries.

We also propose that the institutions responsible to educate future nurses include, in their curricula, the transpersonal caretaking, which helps the professionals to expand their visions of the world and their ability to think critically.

 

REFERÊNCIAS

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Contribution from the authors : Ana Cleide Silva Rabelo: development and review; Lúcia de Fátima da Silva:tutoring, discussion and review; Maria Vilaní Cavalcante Guedes: discussion and review; Keila Maria de Azevedo Ponte: discussion and review; Fabíola Vládia Freire da Silva: discussion and review.

 

 

Received: 02/04/2012
Approved: 12/11/2012