RESEARCH ARTICLES

Efforts and rewards with regard to work of resident nurses in specialized units

Elias Barbosa de Oliveira^I; Natalia Victor Madeira de Souza^II; Suellen Costa dos Santos Chagas^III; Luana dos Santos Vasconcelos Lima^IV; Renata dos Anjos Correa^V
INurse. Post-Doctorate on Alcohol and Drugs. Doctor of Nursing Practice. Adjunct Professor, Postgraduate (Master) and Graduate School of Nursing, State University of Rio de Janeiro. Rio de Janeiro, Brasil. E-mail: eliasbo@oi.com.br
^IINurse. Specialist in Nursing in Occupational Health. Intensivist Nurse Practitioner (Residency). Nurse, Military Police Hospital of Rio de Janeiro. Rio de Janeiro, Brazil. E-mail: nattyvictor@yahoo.com.br.
^IIINurse. Specialist in Prevention and Control of Hospital Infection. Azevedo Lima State Hospital. Rio de Janeiro, Brazil. E-mail: suellenchagas@gmail.com
^IVNurse. Post-Graduate, School of Nursing, State University of Rio de Janeiro. Specialist in Public Health Nursing. Federal University of the State of Rio de Janeiro. Specialist in Occupational Health Nursing. Nurse, Military Police Hospital of Rio de Janeiro. Rio de Janeiro, Brazil. E-mail: lulusvl@gmail.com.
^VNurse. Graduate, School of Nursing at the State University of Rio de Janeiro. Specialist in Nephrology Nursing (Residency). Nurse practioner, Kidney Disease Clinic. Rio de Janeiro, Brazil. E-mail: enfaredacorrea@gmail.com

SUMMARY: The purpose of this study is to identify efforts and rewards associated with the work of resident nurses in specialized units, verifying a possible association with the risk of occupational stress. This is a quantitated, exploratory, descriptive piece of research, from which data was collected by means of a self-administered questionnaire containing questions regarding work effort and rewards associated with work. Participating in this study were a sample of 16 resident nurses from a public hospital in the municipality of Rio de Janeiro. Data collection took place in 2008.The work effort, pointed out by the study group, caused occuptional stress, some of this being due to time pressure, interruptions and disturbances, excessive responsibility at work, heavy workloads and physical exertion. The main rewards were the respect of management and colleagues, support during difficult times, fair treatment and chance of future employment. Thus it was concluded that there was a need to diagnose and monitor the work effort and strengthen the rewards in order to minimize stress and promote the physical and mental health of the group.

Keywords: Nursing; Effort; Reward; Students.

INTRODUCTION

This study stemmed from the reflections of a team in a continuing education service concerning the absenteeism and tardiness of the program’s resident nurses, their excuses being exhaustion caused by long workshifts, extensive work hours and tiredness resulting from the care of critical patients who, relying entirely on nurses, demand a high level of psychophysical efforts. To further add to the situation, the resident nurses resented not always being able to count on the support and guidance of more experienced professionals, having, in some circumstances to engage in activities for which they felt unprepared. As the resident nurse is an integral part of the team, unjustified absences and sick leave, tend to lead to problems in terms of labor dynamics and conflicts among team members, becoming a source of concern for tutors. In addition, those remaining on the job expended further effort in order to maintain the quality of service.

Absenteeism in nursing practice¹, mainly in hospitals, has been the source of study and concern for many administrators, being that it leads to problems of an organizational and financial nature. It is estimated that at least 35% of working days lost annually are due to psychological problems, in that work can be pervaded by the sense of a lack of achievement and personal satisfaction. Nursing staff in crowded critical units such as emergency and intensive care, show a higher rate of health problems, leading to absenteeism² for medical reasons. In such units, interpersonal relationships are difficult, caused mainly by the physical and mental strain placed on the entire team, since patients may show high dependency on nursing care, and pain, suffering and death being always imminent.

Thus, difficulties in intra- and interprofessional³ relationships can generate conflict and disputes involving issues concerning the power and autonomy of agents, in that nursing practice is complex, continuous and unpredictable. Consequently, by its nature, it can lead to distress and strain on the part of employees, especially when they are subjected to conflicting situations, or when there is an absence of an appropriate environment for accomplishing their work. As for emotional work overload⁴, it should be noted that resident nurses take direct nursing care of more than one patient per shift or duty, separate from unit nurses who, for the most part, perform management activities. The fact is that resident nurses are not fully familiar with and instrumentalized to take on the high level of demand generated by patients, and therefore feel overloaded. Often to avoid uncomfortable situations, they end up caring for the more severely ill patients, and even perform unit management activities. Thus, a lack of familiarity with labor dynamics⁵, especially among first-year residents, entails occupational stress. This is due to the constant tension of having to face new situations, which makes the forseeing of action development difficult. There is also the problem of dealing with problems inherent in the work process and dealing with unpredictable situations.

The interest in productivity, efficiency and the introduction of new technologies in organizations, particularly in hospitals, has not been followed by the introduction of with adequate work conditions⁶, and of sufficient human and material resources for workers to develop tasks. Such work contexts can produce experiences that may be harmful to the health and psychological well-being of workers. These aspects should be identified and analyzed properly, allowing the provision of effective intervention to minimize their negative effects on workers and organizations.

Considering the importance of institutional programs geared towards the management of occupational stress in nurses and resident nurses and the need to contribute to knowledge in the field, this study aimed to identify the efforts and rewards present in the work of resident nurses in specialized units, and to verify a possible association with the risk of occupational stress.

THEORETICAL FRAMEWORK

A study conducted throughout the country with regard to resident nurses7 confirms that these individuals need to be further studied, heard and valued, as nursing residency is undoubtedly an excellent form of professional qualification. Thus, the improvement in terms of training in this type of program will reflect the quality of life of trainees as well as the service offered to the population.

Residency programs⁸ should provide nurses with the opportunity to broaden their experience, and conduct practical activities associated with research, assistance, extension and learning of nursery practice with the ultimate purpose of inserting a qualified professional into the labor market and in accordance with the guidelines expressed in Federal Law No. 8.080/90, which regulates the Unified Health System (SUS).

With the extinction of qualifications since the promulgation of the Law of Guidelines and Foundations of Education (LDB/96), undergraduates on nursing programs, by having a general education, do not always find themselves capable in increasingly complex areas. In nurse education, generally, nursing schools find difficulty in incorporating proposals to increment changes in the training of professionals, as established by the national curriculum guidelines with regard to nursing practice.
These difficulties are mainly related to acquisition / development / assessment of skills and abilities, essential content, practice / internships and complementary activities. It is observed that there is still no clear definition of competencies for nurse training and the reaching of a consensus on these competencies. In other words, the ability to act effectively, based on knowledge, but not limited to this alone.

Thus, the resident nurse in being inserted into critical units, faces numerous demands concerning prescribed work¹⁰ characterized by the imposition of schedule, pace, training, information, learning, experience, and the speed of theoretical and practical knowledge acquisition. Additionally there is the need to adapt to organizational ideology, market requirements and relations with users. There are also expectations in terms of productivity and quality from management¹¹, where the potential and intrinsic needs of the worker are neglected due to the need for immediate results. Therefore, the unmeasured consumption of the professional’s physical and emotional energy contributes to work strain or wear, especially when taking the workload into consideration.

Workload¹² represents the set of efforts expended by the employee to meet the demands of the task, this consists of physical, cognitive and psychoaffective (emotional) effort acting in an integrated manner. The quantitative workload (excessive work, focused attention and continuous time pressure) denotes the amount of mental and physical work required within a given unit of time. The qualitative workload is related to the level of complexity of the task and the possibility of application, significant interests, experience, capability and potential of the employee.

Workload has negative consequences for individual health, such as stress¹³, and may cause illness when dealing with prolonged, intense or frequent situations, or when the individual does not have adequate resources for adaptation and resistance. For organizations, there is a significant increase in direct costs caused by absenteeism due to the increase in turnover rates, decline of worker efficiency and the increasing number of work-related accidents, to mention a few. Likewise, there is a considerable rise in indirect costs related to decreased motivation, the disruption of interpersonal relationships, dissatisfaction and decreased quality of life at work.

One of the theoretical frameworks used to understand occupational stress is the effort-reward imbalance at work model, as proposed by Siegrist¹⁴. This model postulates that occupational stress is a response to an imbalance resulting from certain characteristics of the work environment that require high effort (work demands and motivation of individual workers in demanding situations) and low reward (monetary reward, self-esteem and social control). The lack of reciprocity between effort and reward can lead to long-term physiological activation and consequent physical and psychological responses to stress. Such responses can be extremely varied, depending on situational factors such as social support and individual factors such as genetic predisposition, lifestyle and coping strategies. Thus, when a high degree of effort is not combined with a high degree of reward, emotional tensions arise increasing the risk of illness.

Studies on the relationship between occupational stress and mental health affecting workers among us and in other countries¹⁵, reveal alarming rates of temporary or permanent incapacitation for work, absenteeism, early retirement and health risks resulting from such a relationship. Among the factors clearly contributing to occupational stress are work overload, factors inherent in the job, unsatisfactory ergonomic characteristics, lack of professional career development, lack of perspectives and conflicting relationships at work.

METHODOLOGY

A quantitative rsearch method was chosen due to the problems with regard to the health of the employee which, by its nature, requires an exploratory and descriptive study for na initial diagnosis of the situation, with the prospect of conducting further studies. Data were collected in a major university hospital located in the municipality of Rio de Janeiro, one which is considered to be a center of excellence. In addition, it is noted for excellence in the areas of undergraduate education and improvement in knowledge through residency programs and expertise in various fields. From a population of 23 resident nurses enrolled on intensive care programs, cardiac surgery, nephrology and ambulatory care, the sample consisted of 16 students. Adopted as inclusion criteria were the following: first and second year residents, regular attendance at their respective programs, and placed in overcrowded and complex units at the time data was collected.

In terms of data collection, this was performed in the second half of 2008. For this we used a structured instrument, translated and adapted to Portuguese14 comprising 23 items and consisting of three dimensions: effort (6 items - 1-6), reward (11 items - 7-17) and excessive work commitment (6 items - 18-23). In this study, we worked only on the effort and reward dimensions. The options in terms of answers are dichotomous, with Likert-type questions (depending on the response) evaluating the subject's perception with regard to their situation experienced at work. The used expressions consisting of "agree" and "disagree" and - in the case of a response indicating stress - there is a gradation of four options ranging from "very stressed" to "not at all stressed."

Once the invitation was extended, and explanations about the research and scheduling of interviews was provided, data were collected individually at the unit in which residents performed their activities. In compliance with Resolution No. 196/96 of the National Health Council / Brazil, the respondent​​ certified the authorization of the study by the Ethics in Research protocol (No. 2183/08) and signed the consent form.

Subjects were guaranteed anonymity and could withdraw from the study at any stage. I explained that the results would be presented at events and journals published in the scientific field.

After collection, the data were treated using simple statistics (absolute and relative frequency) techniques using the sum of scores obtained from the Likert scale composed of items that made it possible to measure the group attitude with regard to questions raised.

RESULTS AND DISCUSSION

Efforts at work in specialized units

Work in crítical units 17 is characterized by intense pace and pressure for increased productivity, and the accomplishment of numerous activities of a technical nature by nursing and medical teams. It is a situation where the clinical instability of patients requires advanced technological resources, observation and ongoing interventions due to the risk of complications. In addition to routine care, which requires time and dedication, one should take into account the unpredictable situations that demand knowledge, experience and organizational support for necessary interventions.

Of residents participating in the study, all 16 (100%) agreed with the fact that they feel constantly pressed for time due to the heavy workload, a feature which made the group highly stressed. When analyzing the relationship between workshifts and workloads one should consider the psycho-sensorial and physical effort expended by the resident nurse, who, being inexperienced, has not yet developed the necessary skills to cope with new and unpredictable situations. Under these circumstances, occupational stress can be aggravated as a result of pressure in the work environment (the pressure associated with having to complete many tasks in a given ammount of time), a low sense of personal control combined with high levels of demand caused by insecurities (the possibility of suffering physical or psychological injury), the sense of responsibility in regard to others, and by changes inthe resident’s social environment (transfers or layoffs).

It is noted that the ability to withstand pressure¹⁹ is an individual characteristic, as people do not react in the same way to the same stimuli. This reaction will depend on their life history, beliefs and values​​. It should be noted that there is no formula that can guarantee life without stress, but there are methods or techniques to reduce it. It is important that the individual develops the ability to manage ambiguity, creating the conditions to modify the context or learning to live under pressure.

Work in critical care units implies a great deal of responsibility, according to 15 residents (93.75%). After all, critical patients are unstable and dependent on the expertise of professionals in terms of interventions, including use of equipment, which contribute to a high workload¹², in terms of which physical, cognitive and psychoaffective efforts are mobilized in its execution. Therefore, an activity in high demand, and the need for strenuous controll begins to demand increasingly more of the student (n = 10, 62.5%) in recent months, being a job that is characterized by intense physical exertion (n = 12, 75 %).

In a hospital environment, nurses are exposed to heavy workloads²⁰  by virtue of work organizational demands and pressure for increased productivity, efforts being accentuated by the fast pace of work, performing repetitive movements and long working hours. Additionally, professionals routinely perform numerous activities that require physical effort, since they work most of the time standing or ambulating, factors which together contribute to occupational diseases caused by repetitive movements. Under such circumstances, there is physical and emotional strain, in other words, a gradual loss off energy²¹, with a greater incidence in situations where there is an imbalance between the demands of work and the rewards. Thus, depending on how the work is designed and conducted, a breakdown of the individual’s values ​​of dignity, spirit and willpower can occur. The fatigue limit is reached when, no longer able to withstand the pressure, the worker chooses to abandon his or her profession.

Other causes of work fatigue in residents (n = 9, 56.25%) were interruptions and annoyances, which by their nature, are quite disturbing. Time is lost, attention is diverted, causing risk of errors and iatrogenesis, especially with regard to workers who have not yet mastered the work process.  It is noted that, depending on the personality characteristics of some workers, well-being¹² is established in a calm environment where there are few audible or visual stimuli and there is the possibility of concentrated mental activity. Other people feel the need to make gestures, moving frequently, hearing sounds, capturing visual impressions and communicating intensively with others.

Work rewards in specialized units

Work²² must ensure material support and enable the formation of personal identity and relationships towards organizations, teams and groups. At work, satisfaction has a strong influence on the performance of the individual and the greater the satisfaction factors, the greater the commitment to provide professional quality service. It is up to the institution to provide opportunities for learning and professional growth, in which interpersonal relationships promote well-being and a sense of belonging. Accordingly, we found that residents felt respected by management (n = 16, 100%) and colleagues (n = 15, 97.75%), could count on the support of people in difficult times (n = 10; 75%) and were treated fairly (n = 13, 81.25%).

Thus, the social environment of work contributes to worker satisfaction, providing that those occupying positions of leadership, in this case supervisors, are attentive, fair, ethical, competent, recognize and reward the positive development of workers and allow their participation in decision making²³. Job satisfaction influences the physical and mental health of each individual, their attitudes, professional and social behavior, repercussions on their personal life, family and organizations. Primarily, when considering that the transition from the academic to the field of work, this can generate moments of personal insecurity when facing the unknown and a need for familiarization with the new role which may represent a stressful  situation²⁴. Ultimately, resident nurses are differentiated from other workers, considering they are mostly college graduates, non-specialized, with little or no experience in the profession and lacking employment guarantees from the institution in which they work²⁵. Therefore, in order for the student to develop skills and maintain their health, there is need for special attention from the institution, especially in regard to the prevention of accidents and exposure to occupational hazards.

On the other hand, in view of the efforts and achievements, 12 (75%) residents said they did not receive the respect and recognition they deserved. It is a dialectic matter for, in taking that position, it denotes that, despite the support and respect received from superiors and colleagues, residents feel the need of approval for the work performed, probably by other professionals, patients and family. With regard to future prospects, 13 (81.25%) residents believed their chances are in accordance with their personal effort, since residency⁵ is able to provide the development of practical skills, contribute to greater safety in practice, besides being an active instrument for personal and professional growth by opening doors to the labor market.

The residents (n = 9, 56.25%) agreed that they have passed or may yet pass through undesired changes at work. This position reflects the limited autonomy that the group has in relation to the choices of what to do at work and how to do it. Under these circumstances, stress tends to intensify due to pressure resulting from the required workload, workshifts on weekends and holidays, the changing industry, and precarious working conditions. Thus, the deficiencies in hospitals and health centers, in which are observed among other factors, poor equipment and facilities, and shortage of professionals in quantitative and qualitative terms, entail significant limitations to educational training⁹. Furthermore there is the development of inadequate techniques or the observing of misconduct on the part of medical professionals, who in many situations resort to improvisation.

CONCLUSION

Studies show that there is an association between the effort expended in the work of nurse residents employed in overcrowded in critical units, and occupational stress. It was, in fact, possible to prove this to the extent that all agreed that they felt pressed for time, as a consequence of heavy workloads. Efforts relate to the physical and mental fatigue brought on by care of critical patients requiring observation and strenuous control, including the technological apparatus in use, which accordingly calls for increased responsibility and physical and mental effort in practice. Interruptions and annoyances undergone at work only intensify the workload, in that the nurse resident strives to attend to the requests of the team and the patients, the loss of time, overwork and losses in terms of the expended concentration required to complete the task along with the risk of accidents, errors and iatrogenesis.

As to the rewards resulting from work, most residents agreed they received the deserved amount of respect from superiors and colleagues, that they could count on support in difficult times, that they were treated fairly, that the position they occupied was in accordance with their training, and that future chances were compatible to future efforts and achievements. The rewards, of both a material and symbolic order, act as protective factors contributing to job satisfaction, motivation, a sense of belonging and the exchange of experience and should be reinforced by the teaching institution. Taking into consideration the study limitations due to a relatively small sample siza, which preclude generalization, one ratifies the importance of strengthening the rewards, and of diagnosing and monitoring efforts, in order to intervene in stressors that, by their nature, are likely to contribute to the loss of the health of residents, training and quality of the services offered.

REFERENCES

1. Faria AC, Barboza DB, Domingos NAM. Absenteeism due to mental disorders in nursing 1995-2004. Arq Science Health [serial on Internet] 2005 [cited 13 January 2013] 12:14-20. Available at: http://www.cienciasdasaude.famerp.br/Vol-12-1/03%20-%20id%20100.pdf

2. Silva DMPP, Marziale MHP. Health problems responsible for the absenteeism of nursing staff in a public hospital. Acta Scientiarum. Health Sciences Maringá. [serial on Internet] 2003 [cited on 07 Feb 2009] 25:191-97. Available at: http://periodicos.uem.br/ojs/index.php/ActaSciHealthSci/article/view/2232/1459

3. Coimbra VCC, Silva ENF, Kantorski LP, Oliveira MM. Mental health and nursing work. Rev Gaucha Enferm. [serial on the Internet] 2005 [cited on 10 Dec 2010] 26:42-9. Available at: http://seer.ufrgs.br/RevistaGauchadeEnfermagem/article/view/4539/2469

4. Franco GP, Barros ALBL, Martins LAN. Burnout in nursing home residents. Rev esc Nurse USP. 2011 [cited on 4 October, 2011] 45 (1): 12-8. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342011000100002&lng=e&nrm=iso&tlng=en

5. Sato LA. Social representation of hard labor. In: Mary Jane Spink, organizer. Knowledge of everyday life: social representations in social psychology perspective. Sao Paulo: Brasiliense, 1995. 188-11.

6. Martins MCA. Psychosocial risk factors in mental health. Millenium - Magazine ISPV. 2004 [cited 26 January 2013]. Available at: http://www.ipv.pt/millenium/Millenium29/default.htm

7. Franco GP, bl Barros, Martins LAN. Quality of life and depressive symptoms in nurse residents. Rev Latino-am nursing. [serial on Internet] 2005 [cited 6 January, 2013] 13:139-44. Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692005000200002&lng=pt&nrm=iso&tlng=pt

8. Aguiar BGC. What is nurse residency. In: Ministry of Health (Br).  Guidelines for nurse residents. Brasília (DF) 2005. [cited 10 January 2013] Available at: http://biblioteca.claretiano.edu.br/phl8/pdf/05_0004_M.pdf

9. Colenci R, Berti HW. Vocational training and insertion into the labor market: perceptions of nurse pratice undergraduates. Rev esc Nurse USP. [serial on Internet] 2012 [cited 12 March 2013] 46:158-66. Available athttp://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342012000100022&lng=e&nrm=iso&tlng=en:

10. Dejours C. The psychodynamics of work: Dejourian school Dejourian on analysis of the relation between, pleasure, suffering and work. Sao Paulo: Atlas, 2010.

11. Barboza DB, Soler ZASG. Absence from work in nurse practice: occurrences among staff of a teaching hospital. Rev Latino-Am Nursing. Ribeirão [serial on Internet] 2003 [cited 10 April 2012] 11:177-83. Available at:  http://www.scielo.br/pdf/rlae/v11n2/v11n2a06.pdf

12. Selligmann-Silva E. Mental health and work. In: Benilton Bezerra Junior organizer. Citizenship and madness: mental health policies in Brazil. Petrópolis (RJ): Cortez, 1987. 188-11.

13. Bicho LMD, SR Pereira. Occupational Stress. Polytechnic Institute of Coimbra, Department of Civil Engineering, Portugal [serial on internet] 2007 [cited 14 March 2013]. Available at: http://prof.santana-e-silva.pt/gestao_de_empresas/trabalhos_06_07/word/Stress%20Ocupacional.pdf

14. Guimarães LAM, Siegrist J, Martins DA. Model of occupational stress ERI (effort-reward-imbalance). In: Guimarães LAM, S. Grubits Series Mental health and work. Sao Paulo: Casa do Psicólogo; 2004. p. 69-94.

15. Vasconcelos EF, Guimaraes LAM. Effort- reward work on a sample nursing professionals. Information [serial on internet] 2009 [cited 28 March 2013] 13:11-36. Available at: https://www.metodista.br/revistas/revistas-metodista/index.php/PINFOR/article/viewFile/2075/2040

16. Cabral IE, Tyrrell. The object of study and qualitative research approach in nursing. In: Gauthier JHM Cabral IE, Santos I, Tavares CMM. Nursing Research: new applied methodologies. Guanabara Koogam; 1998.  18-29.

17. Oliveira EB, Souza NVM. Stress and technological innovation in cardiac intensive care units. Rev Nurse UERJ. 2012; 20:457-62.

18. Helman CG. Culture, health and illness. Translation Eliane Mussmich. Porto Alegre (RS): Medical Arts, 1994.  247-62.

19. Murofuse NT, SS Abranches, Napoleon AA. Reflections on stress and burnout in relation to nursing. Rev Latino-Am Nursing. [serial on internet] 2005 [cited 10 January 2013] 13 (2):177-83. Available at: http://www.scielo.br/pdf/rlae/v13n2/v13n2a19.pdf

20. Moreira AMR, R. Mendes Risk factors of musculoskeletal disorders related to work in nurse practice. Rev Nurse UERJ. [serial on internet] 2005 [cited 17 January 2013] 13: 19-6. Available at: http://www.facenf.uerj.br/v13n1/v13n1a03.pdf

21. Lima DL, Buunk Ap, Araujo MBJ, Keys JGM, Muniz DLO, Queiroz LB. Burnout syndrome in Federal University of Uberlândia residents -2004. Rev bras educ med. [serial on internet] 2007 [cited 3 January 2013] 31: (2). Available at: http://www.scielo.br/pdf/rbem/v31n2/03.pdf

22. Nunes CM, Tronchin DMR, Meleiro MM, P. Kurcgant Job satisfaction and dissatisfaction in the perception of university hospital nurses. Rev Elect Nurse. [serial on internet] 2010 [cited 9 April, 2012] 12: 252-7. Available at: http://www.fen.ufg.br/revista/v12/n2/v12n2a04.htm

23. Martinez MC, Paraguay AIBB. Satisfaction and occupational health - conceptual and methodological aspects. Cad Jobs soc psychol. [serial on internet] 2003 [cited 15 January 2013] 6:59-78. Available at: http://pepsic.bvsalud.org/pdf/cpst/v6/v6a05.pdf

24. Mattosinho MMs, MS Coelho, Meirelles BHS, Souza SS Argenta EC. World of work: some aspects experienced by nursing graduates. Acta Paul Enferm. [serial on internet] 2010 [cited 4 September, 2012]. 23:466-71 Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-21002010000400004

25. Pinheiro J, Zeitoune RCG. The work of resident nurses in perspective of occupational hazards. HU Magazine, Juiz de Fora [serial on internet] 2011 [cited 7 Jan 2013] 37: 225-32. Available at: http://www.seer.ufjf.br/index.php/hurevista/article/viewFile/1430/547.