ORIGINAL RESEARCH

Satisfaction of teachers of the integrated nursing curriculum of a state university

Dayane Aparecida Scaramal^I; Mara Solange Gomes Dellaroza ^II; Marli Terezinha Oliveira Vannuchi^III; Maria do Carmo Fernandez Lourenço Haddad^IV

^I Nurse. Master. Professor of Nursing and Technology in Hospital Management at the Pitágoras University Unopar - EaD. Londrina, Paraná, Brazil. E-mail: dayanescaramal@yahoo.com.br
^II Nurse. PhD. Assistant Professor of the Nursing Department of the UEL. Londrina, Paraná, Brazil. E-mail: maradellaroza@sercomtel.com.br
^III Nurse. PhD in Public Health. Associate Professor, Health Sciences Center, Department of Nursing, UEL. Londrina, Paraná, Brazil. E-mail: marlivannuchi@gmail.com
^IV Nurse. PhD in Nursing. Associate Professor, Health Sciences Center, Department of Nursing, UEL. Londrina, Paraná, Brazil. E-mail: carmohaddad@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.11630

ABSTRACT

Objective: to identify the level of satisfaction and feelings involved in teaching activities of the integrated curriculum of a nursing undergraduate course. Method: this is a quantitative, transversal and descriptive study, carried out at the State University of Londrina – Brazil, with data collected from 51 teachers, using the Jobs Satisfaction Questionnaire for Teachers, after approval by the Research Ethics Committee (CEP) of the University, (Evaluation Report No. 095/2012 - CAAE No. 05691612.0.0000.5231). The statistical analysis was performed by the SPSS software version 20.0. Results: the results referring to the level of satisfaction showed an average of 3.3 in a variation of one (lower satisfaction) and four (greater satisfaction). The most quoted feelings were achievement, concern, and satisfaction. Conclusion: it is fundamental that the Institutions of Higher Education understand the real needs and feelings involved in the teaching activity in order to preserve maintain professional satisfaction.

Keywords: Job Satisfaction; faculty; curriculum; nursing.

INTRODUCTION

Because of the globalization process, the relationship between worker and work has undergone transformations. Nowadays, there is an increasingly intense search for productivity - evident in the capitalist scenario - related to fast working rhythms and heavy workloads¹ with possible consequences to the quality of life of professionals and exposure to distress and sometimes illness.

Job satisfaction is a relevant theme in any area of ​​activity because it is directly related to professional performance and sense of well-being. Derived from the interaction of several occupational aspects, such satisfaction can be stimulated by the relation between worker and employer, clients and family. The great challenge of the Institutions is therefore to identify not only the level of satisfaction, but also the factors that motivate each of its workers in the attempt to motivate them to perform well their work and with quality of life².

In this sense, it is important to emphasize that the work of teachers is intense and requires constant exchange with students. Teachers must be instigated to renew strategies to reach the diversity of people present in the classroom and, through this, produce an innovative teaching-learning process. This and other aspects can be considered determinants of satisfaction in the teaching practice, unless they are instigated in the work environment³.

However, there are few studies on levels of satisfaction, factors associated with it and feelings nourished by higher education teachers⁴.

Thus, the goal of this study was to identify the level of satisfaction and feelings involved in teaching activities of the integrated nursing curriculum of a state university.

THEORETICAL BACKGROUND

Satisfaction in teaching work

Job satisfaction is a topic of interest in several areas, including health and education, and has been studied by Organizational and Social Psychology since the 1970s. This research theme arose from the insistence of that observation that satisfaction was related to several factors, including productivity, mental well-being and occupational health⁵. The first study on the theme was published in the United States of America, highlighting working conditions as factors that influence professional satisfaction⁶.

Since then, several theories have emerged in the theme, with emphasis to the Theory of Basic Human Needs⁷ and the Two-Factor Theory ⁸.

Elaborated by Abraham H. Maslow, the Theory of Basic Human Needs associates satisfaction and dissatisfaction with positive and negative feelings generated from met or unmet expectations⁹. The Two-Factor Theory, proposed by Herzberg in 1987, shows that there are two categories of distinct needs that influence the level of satisfaction, establishing to a certain extent the behavior and the differences between hygienic (extrinsic) and motivational (intrinsic) factors. Dissatisfaction concerns the extrinsic aspects, usually related to the work environment and the company itself: organization, supervision, organizational policies, salary, status, security, physical conditions of the work environment, and interpersonal relations. In turn, the feeling of satisfaction relates to intrinsic aspects: professional achievement, personal progress, professional growth, participation, responsibility, recognition and work itself⁹.

In this study, based on the Theory of Basic Human Needs, basic needs were used to explain the feelings of satisfaction and dissatisfaction involved in the work process. And the Two-Factor Theory was used to understand the extrinsic and intrinsic factors related to professional satisfaction of teachers of the integrated curriculum of the Nursing Course.

Integrated curriculum in the training of nurses

The demands related to the quality of higher education are almost directly related to the reforms that marked the economic development of several countries during the 1990s, resulting in changes in the world of work in different areas. These changes encompassed a number of reforms, including flexibilization of labor legislation and change of inadequate working conditions⁵.

Thus, the continuous changes of contemporary society demanded a new teaching profile, culminating in the urgent need to prepare these teachers for a new educational scenario, starting with critical reflection and a more active role of the student. From this point of view it is not enough for the teacher to know all the contents of the subjects; it is necessary that he articulates the professional reality and instigates the student in the movement of construction of different sets of knowledge¹⁰.

In nursing undergraduate education, educational structures and pedagogical tools that involve the nursing training process are allied to critical-reflexive pedagogy - undoing the role of teachers as transmitters of information - that began to articulate knowledge with professional practice¹¹.

Curricular changes have been proposed in the quest to meet the demands of professional training in the health area. One of these changes was the creation of an integrated curriculum incorporating caregiving practices as structuring elements and making teachers and students articulate teaching and learning and the health care practice¹¹.

In the integrated curriculum, the subjects became related to each other and their barriers became less perceptible to the students; knowledge has become the main goal, and the subjects are no longer isolated. However, this integrated curricular approach does not limit the contents of the curriculum subjects; it rather proposes the articulation with the professional practice and with the other contents, giving way to interdisciplinarity¹².

Finding factors related to satisfaction and dissatisfaction in the work of these educators can broaden their own understanding and the training institution on to which extent the level of satisfaction in teaching can affect the personal and professional life of those involved.

That the act of detaching from the traditional teaching model is, thus, not considered a simple task, since it requires that the teacher be qualified for such a pedagogical proposal, have affinity with the methodology and be creative in his actions. Only by doing so will the proposal of the integrated curriculum for a teacher be met, which is to be a learning facilitator and not mere reproducer¹¹.

METHODOLOGY

Quantitative, cross-sectional and descriptive study. The research was carried out in the Nursing Course of the State University of Londrina-UEL. The process of implementation of the pedagogic project of the Integrated Curriculum of the Nursing Course took place in the year 2000 with the financial support of the UNI Project/Kellogg Foundation. This project was built collectively, aiming at the integration of contents and their organization in modules to facilitate interdisciplinarity¹³.

The instrument used to collect the data was the questionnaire on satisfaction in the work of teachers, called Teacher Job Satisfaction Questionnaire, tested and validated in Portuguese by two researchers ¹⁴ in 2006, and structured in a Likert-type format, in the following five parts:

Part A: composed of four sentences, each with four possible answers, the first two positive and the last two negative answers on the profession (I like my profession; I would change jobs if I could);

Part B: composed of 25 items, with five possible answers each, with values ​​from 1 to 5, composing a Likert-type scale where 1 corresponds toIt does not satisfy me, 2a It satisfies me little,3a It satisfies me; 4a It satisfies me a lot and 5 It satisfies me completely. It is possible to identify the activities carried out by teachers regarding feelings of satisfaction and dissatisfaction (direct work with students, degree of personal fulfillment).

Part C and D: the teacher is asked to mention three factors responsible for the highest satisfaction (part C), and three for the lowest satisfaction (part D);

Part E: the teacher chooses three of the 12 listed feelings that he/she experiences most frequently in teaching.

With the approval of the Research Ethics Committee of UEL, teachers were contacted randomly via e-mail or direct contact at the educational institution. The inclusion criteria for the selection of the participants were: to be an active nursing teacher and work for more than one year in the institution. Workers who were away from work and on probation at the time of data collection were excluded. At the first contact, each participant was clarified about the purpose of the study, and they were asked to participate voluntarily by completing the questionnaire. Three contacts were made via e-mail and/or personally seeking to obtain the completion of the form. A total of 51 nursing teachers from the 90 who were eligible participated in the study.

The data collected were inserted into an Excel datasheet, version 2010. The analyses were performed using the statistical package Statistical Package for Social Sciences (SPSS) 20.0. The characteristics of the population are presented in absolute and relative frequency. In the analysis of the satisfaction score, the results are shown in tables and graphs, with determination of means per factor (MF) and frequency.

The project was submitted to the Ethics Committee of the State University of Londrina, obtaining approval through Opinion n° 095/2012. The Free and Informed Consent Term used in this study was prepared according to the norms of Resolution 466/2012.

RESULTS AND DISCUSSION

During the study period, 51 teachers, predominantly female (94%), were interviewed. The majority of participants were doctors 33 (65%), and the others had the title of master 18 (35%), studied or in preparing for doctorate. Ages ranged from 25 to over 60 years, with predominance of teachers (19) aged between 41 and 50 years (37%). Regarding the age profile of teachers, the educational workforce was predominantly composed of professionals over 40 years old - 76% of the participants. In Brazil, this percentage is 44%⁵.

As for the analysis of the level of satisfaction, the teachers said they were satisfied, as shown in Table 1, considering that the average was 3.3, within a variation from 1 (lower satisfaction) to 4 (higher satisfaction). Regarding the age group of teachers, it can be observed in this table that there was a discrete difference in the levels of general satisfaction of teachers aged over 60 years (SD: 3.5) when compared to the age group from 25 to 30 years (MF: 3.3).

TABLE 1: Level of job satisfaction of teachers of the integrated curriculum of the nursing course of the UEL. Londrina, Brazil, 2012 (N = 51).

In general, teachers were satisfied with the factors studied, but these values ​​reached average levels considering that satisfaction was associated with values ​​of 3 (it satisfies me) and 5 (it satisfies me completely). In turn, dissatisfaction was associated with values ​​of 1 (it does not satisfy me) and 2.9 (it satisfies me little).

The factors related to stability and personal accomplishment obtained greater satisfaction (MF: 3.6). The sociopolitical factor (salary and processes for career progression) was responsible for the lowest level of satisfaction (MF: 2.9).

Dissatisfaction with salary was also present in a research with a qualitative approach in which 17 out of 40 professors investigated, even understanding how pleasant the teaching work was, reported dissatisfaction toward their salary, considering it necessary to find other strategies to increase their remuneration: to seek a heavier workload (double or triple daily work hours), or find another source of income to supplement the salary¹⁵.

Regarding the activities of the teachers, Table 2 shows the results of the analysis of factors: professional stability and personal fulfillment; students; sociopolitical factors; interpersonal and institutional relations.

TABLE 2: Factors related to satisfaction of teachers of the integrated curriculum of the nursing course of the UEL. Londrina, Brazil, 2012.

Concerning the feelings present in the activities of the teachers, professional fulfillment was mentioned by 33 (65%) of the teachers, followed by concern 25 (49%) and satisfaction 18 (35%), as shown in Figure 1.

FIGURE 1: Feelings most frequently experienced by teachers in the integrated curriculum of the undergraduate nursing course at the State University of Londrina, Brazil, 2012 (N = 51).

It is possible to see that the proportion of positive feelings (achievement and satisfaction) is noticeably greater than that of negative ones, although the feeling of "concern" stood out among the negative feelings. A study⁹ with teachers of the course of Accounting confirmed the findings of the present research, highlighting the feelings of frustration, anxiety and discouragement as relevant, although in smaller proportions.

It is noteworthy that regarding the profile of the teachers studied here, most of them were women between the ages of 41 and 50. There was no difference in level of satisfaction between the age groups evaluated.

The result is consistent with another finding that showed a relationship between the time of service and job satisfaction among teachers ¹⁶. Teachers newly hired are pleased to be embarking on a professional path into an innovative curriculum. On the other hand, the satisfaction of older teachers may be related to the commitment to putting this curriculum into practice. Regarding the level of satisfaction of the teachers, the mean was 3.3 on a scale of 5 points, confirming similar findings of another study carried out in Brazil on this theme⁹.

With regard to the factors involved in this analysis, we highlight the intrinsic ones, which obtained the highest levels of satisfaction. In turn, the extrinsic ones were responsible for the lower levels of satisfaction. Studies with teachers also revealed that satisfaction was related to teaching itself, and that dissatisfaction was the result of socio-political work conditions^9,17.

The factor "sociopolitical conditions" refers to the variables "teacher salary" and "processes for career progression". Anchored in Herzberg's theory (1987), researchers¹⁴ also conducted a study using the Teacher Job Satisfaction Questionnaire with the objective of analyzing the level of professional satisfaction of teachers in Portugal and found a mean level of job satisfaction of 2.34 on a scale of 5 points, lower than that found in the present study (2,9).

In the Two-Factor Theory, hygienic factors are extrinsic and almost always related to professional dissatisfaction, but workers do not exercise control over them⁹. However, few teachers choose their profession because of salaries, prestige or other types of external rewards (hygienic factors)¹⁸. The real motives that drive the choice are afection for the profession and social contribution, which are related to intrinsic factors¹⁹.

In this study, direct contact with students was one of the factors with the highest level of satisfaction in the performance of teaching work. This result was confirmed by another research ²⁰ with intensivist physicians, which identified that those working in an academic environment and who kept in contact with students and residents had greater personal satisfaction. Given this context it is possible to infer that, being close to the reality of the students help teachers to begin to better understand their yearnings. Thus, the teacher clearly shares the knowledge, contributes to the learning in an interactive way and this becomes professional and personal satisfaction for the teacher.

In the nursing area, teachers are very close to the students and always need to integrate theory and practice. Besides motivating students to think, it is necessary that teachers instigate the students to act, reflect and, mainly, to feel, considering that humanized care is the essence of nursing.

The attributions to nursing teachers are therefore many, and they involve the responsibility to train competent nurses, able to work in different scenarios, knowing how to manage and develop nursing care. This requires several adaptations before the numerous changes in the sociopolitical context of the country.

An adaptation to these requirements is the methodological proposal of an integrated curriculum, which may be the reason why good levels of satisfaction were found among the teachers studied. Active methodologies used in this curricular proposal favor the teacher/student relationship from the moment they propose activities in small groups and evaluative strategies²¹. These actions favor a close relationship and provide an educational action that involves not only cognitive learning, but the integral development of the student. The practice of the integrated curriculum allows the teacher to go beyond teaching the know-how, because it gives him the conditions to teach the students to learn to be and learn to live, with exchanges and mutual knowledge.

If, on the one hand, the relationship with students contributed to a good level of satisfaction due to direct contact, on the other hand, because this is an integrated curriculum that guides the use of active methodologies, the factors lack of student preparation, lack of interest and passive behavior in the classroom were responsible for the lowest level of satisfaction. According to some authors²², these factors hinder the application of active methodologies of integrated curricula, making teachers to adopt attitudes incompatible with the curricular proposal. This is because, in certain situations, some teachers choose the traditional methodology and a position of transmitter of knowledge, not upholding to the central role of the student in their own learning.

Globalization has been one of the processes responsible for bringing about changes in higher education, including the role of teachers in the classroom. Teachers are no longer merelly transmitters of knowledge but facilitators of the teaching-learning process. This change required that teachers sought not only constant updating but also innovations to achieve the training of professionals properly prepared to meet the complexity of the health problems of the population²².

This stance also requires a change in the behavior of the students, making them responsible for their training, giving them a more active role. These challenges are found in the Integrated Curriculum of the Nursing Course of the UEL, guiding the teaching/learning process so that students may be active. The teacher needs to organize his teaching method, to plan and promote situations that allow the student to be critical and reflexive and that the learning be contextualized within the real needs of the student ¹³.

In this sense, the integrated curriculum based on an active methodology predicts and demands that the students develop and value learning to learn in a way that they may reflect on their learning process, because the construction of content is carried out by the students themselves ¹³.

Other factors that influence teacher dissatisfaction are overtime and pressure for being productive. In this perspective, teachers eventually need to use the time that should be spent with family and friends to dedicate to work motivated by the desire for professional success, and as a strategy of personal satisfaction. This work overload does not always achieve the productivity index required by the university, and this often generates dissatisfaction^23,24. Thus, it is possible to infer that there is an overload in the teaching work that interferes with the conciliation between family and professional activities, generating dissatisfaction and discouragement.

It is important to emphasize that the activities of the teachers are closely linked to professional growth and achievement and conquer of space within the profession. This journey produce many feelings. Most of them, as the teachers state, are related to satisfaction, although the feeling of concern is present because of the commitment to teach.

In summary, the analysis performed regarding the level of job satisfaction among teachers and the analysis of the positive and negative feelings reported by them indicated the satisfaction of Nursing teachers.

CONCLUSION

The study indicated that, despite the level of professional satisfaction confirmed by the category, there are critical points to reflect on, contextualizing them in the teaching action.

The feelings experienced by teachers regarding professional practice are, for the most part, satisfaction, achievement and enthusiasm, highlighting the value of the work performed by teachers and the importance of feeling satisfied with their profession.

Among the limitations of the study, we cite two: the analysis of only one institution and the expected number of responses to the questionnaire was not obtained. On the other hand, the research was carried out in one of the few universities that have the Integrated Curriculum in the Nursing Course. Therefore, it is suggested that more studies evaluate the level of job satisfaction among teachers in other curricular proposals.

It is recommended that Higher Education Institutions carefully observe and understand the real needs of their teachers so that job satisfaction be maintained, considering it one of the means of promoting the quality of teaching and professional and personal fulfillment.

REFERENCES

1. Rüdiger DS. Globalization and melancholia: depression as an occupational disease. Cadernos de derecho, Piracicaba [online] 2014 [cited in Nov 11, 2017]; 14 (27): 139-50. Available from: https://www.metodista.br/revistas/revistas-unimep/index.php/cd/article/viewFile/2224/1360

2. Ribeiro LA, Santana LC. Quality of life at work: a decisive factor for organizational success. RIC Cairu [online] 2015 [cited in Nov 11, 2017]; 2 (2): 75-96. Available from: http://www.cairu.br/riccairu/pdf/artigos/2/06_QUALIDADE_VIDA_TRABALHO.pdf

3. Davoglio TR, Spagnolo C, Santos BS. Motivation for the permanence in the profession: the perception of university professors. Psicologia Escolar e Educacional, SP [online] 2017 [cited in June 12, 2018]; 21 (2): 175-182. Available from: http://www.scielo.br/pdf/pee/v21n2/2175-3539-pee-21-02-00175.pdf

4. Martins JT, Ribeiro RP, Ribeiro BGA, Robazzi MLCC, Veiga EV. Faculty well-being: integrative literature review. Varia Scientia Journal - Health Sciences [online] 2016 [cited in Nov 11, 2017]; 2 (2): 156-64. Available from: file:///C:/Users/Pc/Downloads/14885-57999-1-PB.pdf

5. Capistrano D, Cirotto AC. What makes Brazilian teachers to be satisfied with their profession? Analytical Archives of Educational Policies [online] 2014 [cited in Nov 13, 2017]; 22 (123): 1-16. Available from: file:///C:/Users/Pc/Downloads/1516-6632-1-PB.pdf

6. Hoppock R. Job satisfaction. New York: Harper; 1935.

7. Maslow AH. A theory of human motivation. Psychologica Magazine, 1943; 50: 370-96.

8. Herzberg F. One more time: how do you motivate employees? Harvard Business Review, Watertown, USA. 1987.

9. Araújo TS, Miranda GJ, Pereira JM. Satisfaction of accounting professors in Brazil. R. Cont. End. - USP [online] 2017 [cited in Nov 11, 2017]; 28 (74): 264-81. Available from: http://www.scielo.br/pdf/rcf/v28n74/en_1808-057X-rcf-28-74-00264.pdf

10. Diesel A, Baldez ALS, Martins SN. The principles of active teaching methodologies: a theoretical approach [online] 2017 [cited in Nov 11, 2017]; 14 (1): 268-88. Available from: https://edisciplinas.usp.br/pluginfile.php/4117719/mod_resource/content/1/Os%20princ%C3%ADpios%20das%20metodologias%20ativas%20de%20ensino%20abordagem%20te%C3%B3rica.pdf

11. Franco ECD, Soares AN, Bethony MFG. Integrated curriculum in higher nursing education: what the teaching nurses say. Enferm. Foco [online] 2016 [cited in Nov 11, 2017]; 7 (1): 33-6. Available from: file:///C:/Users/Pc/Downloads/662-1664-1-SM%20(2).pdf

12. Franco EK, Tavares CZ. Alternative curricular proposals: perspectives for engineering education. Journal of Applied Education Studies [online] 2016 [cited in Nov 13, 2017]; 1 (2): 82-99. Available from: file:///C:/Users/Pc/Downloads/4362-13604-1-PB.pdf

13. Garanhani ML, Baduy RS, Kemmer LF, Martins JT, Martins EA, Takashahi OC. The process of building the integrated curriculum of the UEL. In: Dellaroza MSG, Vanichi MTO, organizers. O Integrated curriculum of the nursing course of the State University of Londrina: from dream to reality. São Paulo: Hucitec; 2010. p. 19-34.

14. Pedro N, Peixoto F. Professional satisfaction and self-esteem in teachers in the 2nd and 3rd cycles of primary education. Aná Psicológica. 2006, 2 (24): 247-62.

15. Ramos MFH, Fernandez APO, Furtado KCN, Ramos EMLS, Silva SSC, Pontes FAR. Job satisfaction in teaching: An analysis based on the social cognitive model of job satisfaction and collective teaching effectiveness. Estudos de Psicologia [online] 2016 [cited in Nov 13 2017]; 21 (2): 179-91. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-294X2016000200179&lng=en&nrm=iso&tlng=en#B5

16. Pauli J, Tomasi M, Gallon S, Coelho E. Satisfaction, conflict and engagement at work for high school teachers. Revista Pensamento Contemporâneo em Administração [online] 2017 [cited in Nov 21, 2017]; 11(4):72-85. Available from: file:///C:/Users/Pc/Downloads/1004-3068-2-PB%20(1).pdf

17. Gonçalves ASR, Pires DEP. The work of university teachers in the health area: situations that generate pleasure and suffering. Rev. enferm. UERJ [online] 2015 [cited in Nov 11, 2017]; 23 (2): 266-71.

18. Tartuce GLBP, Nunes MMR, Almeida PCA. High school students and attractiveness of the teaching career in Brazil. Cadernos de Pesquisa [online] 2010 [cited in Nov 11, 2017]; 40 (140): 445-77. Available from: http://www.scielo.br/pdf/cp/v40n140/a0840140.pdf

19. Almeida PA, Tartuce GLBP, Nunes MMR. What are the reasons for the low attractiveness of teaching among high school students? Psicol. Ensino & Form., [online] 2014 [cited in Nov 11, 2017]; 5(2):103-21. Available from: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S2177-20612014000200007&lng=en&nrm=iso

20. Nassar Junior AP, Azevedo LCP. Factors associated with professional and personal satisfaction in Brazilian adult intensivists. Rev Bras Ter Intensiva [Internet]. 2016; 28(2):107-13. Available from: http://www.scielo.br/pdf/rbti/v28n2/0103-507X-rbti-28-02-0107.pdf

21. Kikuchi EM, Rosseto EG, Lopes DFM. Tomeleri K. Ferrari RAP. Hirazawa SA. Sodré TM. Assessment of learning in the integrated curriculum. In: Kikuchi EM, Guariente MHDM, organizers. Integrated curriculum: The experience of the nursing course of the State University of Londrina. 2012. p. 129-46.

22.Tacla MTGM, Zani AV, Rosseto EG. Pieri FM. Cestari MEW. Good teaching practices in the integrated nursing curriculum In: Kikuchi EM, Guariente MHDM, organizers. Integrated curriculum: The experience of the nursing course of the State University of Londrina; 2012. p. 75-92.

23.Lemos MC, Passos JP. Satisfaction and frustration in the nursing teaching work. REME rev. min. enferm. [online]. 2012 [cited in Nov 11, 2017]; 16 (1): 48-55. Available from: http://www.enf.ufmg.br/site_novo/modules/mastop_publish/files/files_4fccf66a17245.pdf

24. Borsoi ICF. Work and productivism: health and way of life of teachers of public institutions of Higher Education. Cad. psicol. soc. trab. [online]. 2012 [cited in Nov 11, 2017]; 15 (1): 81-100. Available from: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=S1516-37172012000100007&lng=en&nrm=iso