Ethical education of nurses: indicators of change on the perception of professors

Abstracts

OBJETIVO: Discutir os indicativos de mudança identificados por professores no cenário da formação do enfermeiro em relação à sua dimensão ética. MÉTODOS: Pesquisa do tipo estudo de caso, com abordagem pós-estruturalista, com seleção de seis cursos de graduação em Enfermagem do Estado de Santa Catarina, em que foram desenvolvidos grupos focais com 50 professores. RESULTADOS: Os professores indicaram mudanças em três diferentes cenários: no cenário da sociedade, da ciência e da academia; no cenário do trabalho da enfermagem e no cenário local, na forma como os alunos se apresentam nesse contexto. CONCLUSÕES: As mudanças perpassam dimensões locais, nacionais e globalizadas, fomentadas por transformações na estrutura social e política com evidências implicadas no pensar e fazer ético do profissional.

Educação em enfermagem; Ética em enfermagem; Ética

ORIGINAL ARTICLE

Formación ética del enfermero - indicativos de cambios en la percepción de profesores

Flávia Regina Souza Ramos^I; Laurete Medeiros Borges^II; Laura Cavalcanti de Farias Brehmer^III; Luciana Ramos Silveira^IV

^IPost-Doctoral degree in Education (University of Lisboa). Associate Professor, Nursing Department and Graduate Program PEN/UFSC - Florianópolis (SC), Brazil

^IIPh.D. student, Graduate Nursing Program at Universidade Federal de Santa Catarina/PEN/UFSC- Florianópolis (SC), Brazil. Faculty at IF/SC

^IIIPh.D. student, Graduate Nursing Program at Universidade Federal de Santa Catarina/PEN/UFSC - Florianópolis (SC), Brazil. CNPq grantee

^IVMaster's student, Graduate Nursing Program at Universidade Federal de Santa Catarina/PEN/UFSC- Florianópolis (SC), Brazil. CNPq grantee

Correspondence

ABSTRACT

OBJECTIVE: To discuss the indicators of change identified by professors in the nursing education setting, in relation to its ethical dimension.

METHODS: The research was a type of case study, with a post-structuralist approach, with a selection of six undergraduate courses in nursing in the State of Santa Catarina, which were developed in focus groups with 50 professors.

RESULTS: Professors indicated changes in three different scenarios: the scenario of society, science and academia; the scenario of nursing work and the local scenario; the way students present themselves within this context.

CONCLUSIONS: The changes permeate local, national and global dimensions, fueled by transformations in social and political structure with evidence involved in thinking about and applying professional ethics.

Keywords: Education nursing; Ethics nursing; Ethics.

RESUMEN

OBJETIVO: Discutir los indicativos de cambios identificados por profesores en el escenario de la formación del enfermero en relación a su dimensión ética.

MÉTODOS: Se trata de una investigación de tipo estudio de caso, con abordaje post-estructuralista, con selección de seis cursos de pregrado en Enfermería del Estado de Santa Catarina, en el que fueron desarrollados grupos focales con 50 profesores.

RESULTADOS: Los profesores indicaron cambios en tres escenarios diferentes:en el escenario de la sociedad, de la ciencia y de la academia; en el escenario del trabajo de la enfermería y en el escenario local, en la forma cómo los alumnos se presentan en ese contexto.

CONCLUSIONES: Los cambios perpasan dimensiones locais, nacionales y globalizadas, fomentadas por transformaciones en la estructura social y política con evidencias implicadas en el pensar y hacer ético del profesional.

Descriptores: Educación en enfermería; Ética en enfermería; Ética.

INTRODUCTION

In Brazil, professional health education has confronted different actors with new and complex challenges, regarding the historical context of education policies, health and the configurations of the labor world. The permanently debated relation between work and education displays responsibilities that originate in universities. At the national level, the influence health policies exerted on the planning process of higher education in the area is noteworthy. Along the 20 years that have passed since the 1988 Federal Constitution, which guaranteed the universal right to health and created the Unified Health System, there are countless examples of health sector policies, programs and initiatives that were mainly formulated to invert the logic of the healthcare model. These actions represent a strong influence on the new curricular guidelines for health courses, in response to the need to prepare professionals fine-tuned with the new practices a transforming sanitary context demands.

This study is part of a research that elected two of these responsibilities, that is, the articulation between the change process of nursing courses Political Pedagogical Projects, in accordance with National Curricular Guidelines, and the challenge of nurses' ethical education. One of the goals of the research entitled "The discursive construction of ethics in nursing education at Schools in Santa Catarina" was to: analyze the discursive construction of ethics in nursing education, present in curricular change processes, regarding the elements related to the labor world, to the school's world and to the articulation modes between these elements in educative practice. Among the different analytic categories, this research focuses on the theme of the challenges perceived with regard to the insertion of ethics into nursing education, specifically aiming to discuss the signs of change teachers have identified in the context of nursing education, especially related to these professionals' ethical education.

Ethics is frequently addressed as a philosophical discipline that serves to study human conduct, that is, as rational knowledge or critical reflection on action and moral life⁽¹⁾. There is a common semantic distinction between moral and ethics, although the terms are used as synonyms, in view of their etymology, as they represent the Greek and Latin translation of the same word. According to Foucault, moral can be considered as the values and rules of conduct directed at individuals and groups, as well as at their actual behavior, in relation to the rules and values they are proposed. The distinction with ethics is that it represents the relation with oneself, the way one constitutes oneself, as a moral subject of one's own actions, with regard to the prescriptive elements that constitute moral codes. Foucault considers ethics from the perspective of subjectification processes, the constitution of an ethos or a way of being, which makes the individual a subject, through moral work performed on him/herself⁽²⁾.

METHODS

The study adopted Michel Foucault's post-structuralist approach to discourse analysis, based on the notion of language as a system of historically and socially constructed meanings. It is considered that written texts and oral expressions reveal references and outlines of certain discourses that, in turn, operate at the interior of social disciplines and practices in different ways, with different power and intervention strategies in social life. Discourse elements are constructed through particular thoughts and understandings, which produce developments that are not restricted to the textual sphere⁽³⁾. Thus, textual (oral and documentary) data are not limited to the place of simple variables or to the role of content illustration or description, but are the contents themselves of reflection and criticism.

In view of these premises, this study was defined by a case study design, as this research strategy does not limit the analytic processes characteristic of post-structuralist studies. It is considered that case studies permit exploring a unique phenomenon or a set of situations/experiences marked by a relative empirical unit ; - which is looked at in greater depth and intensity; - valuing the real and complex contents this phenomenon is situated and happens in⁽⁴⁾.

After a documentary survey of the 26 Undergraduate Nursing courses in Santa Catarina State, six courses were selected, in view of their geographical distribution across different regions of the State and a minimum existence of six years. The faculty members were invited through the course coordinators, after initial contact and detailed information on the study. At each of these six schools, a focus group was held with teachers interested in the study theme, totaling 50 participants, in groups of between five and 15 subjects. The researcher mobilized the discussion and proposed central questions on the theme, increasingly getting deeper into the interface between education, ethics and nursing.

Focus group recordings were transcribed and constituted the documentary corpus that, after organization, was treated in Atlas-Ti 5.0 software (Qualitative Research and Solutions). The program, named based on the expression Non-numeric and Unstructured Data – Index, Searching and Theorizing, permits indexing, seeking and theorizing, based on non-numeric and unstructured data, facilitating qualitative data analysis, storage, exploration and development of ideas and/or theories regarding the data⁽⁵⁾.

The Institutional Review Board at Universidade Federal de Santa Catarina approved the study (Opinion 075/07); all subjects expected their consent through the Informed Consent Term.

RESULTS

Signs of broad changes: society, science and the academy

To analyze the changes occurred in the higher Nursing education context, the faculty members identified transformations along two distinct and inter-related axes: at the macro level, globalization and the information society are appointed; at the national level, public health and education policies in Brazil.

For the teachers, the themes deriving from the social are not mere objects of discussions, but also start to act as agents of changes. Politics, the economic system or violence are examples of themes that intervene in education as they mobilize new reflections. The narrow relation between health and its social determinants, in the globalized reality, also helped to produce more critical students and faculty members, as a reflex.

According to the research subjects, higher education in Nursing went beyond the operational technical limit of adjusting the new curricula and started to manage daily requirements, deriving from health policies, different realities and experiences at each university.

One of the signs of change the faculty expressed was science, or the idea of scientific advancement, with technological advances as the main representative. Scientific research and ethical implications of knowledge and technology are a matter of current bioethical discussions and are incorporated into the education process of nursing professionals.

"... besides the uncertainties, we are facing a new sciences, a science that was restricted to few things until some time ago; today, we've got DNA readings, Human Genome, Stem Cells. All of these changes that raise discussions on the human being... not only him, but the entire means, the context he lives in." (P2)

From a slightly different perspective, a perception of change was identified that is related to the scientific paradigm transition. The faculty members acknowledge that scientific value is increasingly contested and debated on, and that there is no room anymore for absolute truth. The task of questioning science envisions teachers' further preparation in view of students' contesting and exploring profile. Existing knowledge and recent discoveries live together in the education context.

This sign also gives rise to a problemization of the relation between science and academy, as the latter is no longer the exclusive and authorized agent of knowledge production and dissemination. Faculty find themselves more determined for the search of new technologies and experiences, enhanced by another type of relation with available knowledge.

"The teacher is no longer the owner of knowledge, each person has his knowledge. We are educators [...] science itself, by evolving so much, came to offer facilities, through communications, information we didn't have." (P7)

While one understanding about the academy seems to express a more generic and shared sense, daily work in this space is realistically "retold" through students and teachers' private and concrete experiences. Despite talking about a relatively generalizable university scenario, the signs of changes gain features that lie much closer to the micro-spaces. While outlining this scenario, the faculty members reflected on nursing education, arguing about the: - influences of the job market on students' entry and their own superficial apprehension of these market's trends; - a position of private institutions as companies and higher education as a good; - a consequent trivialization of this education, which can sometimes be attributed to this market logic, as well as to students' lack of maturity; - finally, a delay in the expected valuation and understanding about the range and commitments of university education to moments "outside school", which graduates face difficulties in the work process. Thus, even the motivations to start a professional education course are questioned.

"I (student) started a course that seems to be a higher education course... but it seems as if I'm going to enroll there to take cutting and sewing, it's more something I'm adding. And when you (teacher) start to work more broadly the barrier arises... because it seems that that is not related." (P1)

The faculty members admit that competitiveness among education institutions influences behavior in the job market. The increased offer of courses and places in private education gave rise to concerns with teaching quality, capable of distinguishing courses and guaranteeing the most qualified programs' survival. In the insertion of these schools' graduates into the job market, they are somewhat discriminated against because of their origins. The teachers express discomfort with the production logic motivated by employability – as if the value of education were constantly being diluted, while only its product side remained; a side that trivializes students' conquest in their education process.

The concerns the faculty members demonstrated are also related to support for professional training, generating demotivation because it does not figure among institutional priorities. That is processed in the same set of changes that drives advancements in universities, curricula and assessment forms, as well as students' criticality and teachers' awareness of the need for training and new competency development. Part of this polemic is connected with financial support, but nevertheless considers the importance of planning and collective discussions.

"This new structure requires so many concerns and incentives, which the institution has not funded, and teachers have lost motivation. Why? Because at the least, we'd need, for example, much more planning, discussion." (P1)

Signs of changes in nursing work

According to the interviewees, a distinguished look on health professionals' education exists, not only based on technical competency, but also challenging institutions to prepare professionals who are educators, scientists, researchers. They reinforce the idea that this demand derives not only from the job market, but from the world we live in.

"The job world has required a different subject [...] according to me, it is a moment to ethically consider the relation with the other at work." (P2)

In the work process, the faculty members see ethical and bioethical issues as "something apart", disarticulated from classroom themes, as if the teacher's whole understanding were dissolved or annulled when (s)he is in practice. On the other hand, despite this assessment, the teachers clearly reveal the perception that important ethical issues exist at work, which demand preparation for reflection, at risk of graduated nurses being but "improved technicians".

In the nursing work context, the teachers appoint the need for professionals to assume greater responsibilities, in view of the category's struggles and the change processes. A critical tone appears with regard to nursing professionals' disinterest in actions in the political context. The argument that nursing is a "profession of women" was raised with a double meaning, that of acknowledging emancipation and the advances conquered, side by side with a reproduced image that still links the female with the private domain and with the precariousness of political action in the public domain.

"We acknowledge that. There is always the issue of the profession. And we don't have enough historical time to have changed that [...] yes, it's a gender issue [...] That is where responsibility for taking a stand comes up. I don't see any way out for the profession, unless any independent being takes a stand with a view to achieving a sum further ahead. That thing, the lack of union in the profession." (P4)

The theme about the ability to decisively influence the directions of the profession makes the faculty members return to existing, permanently unsolved themes that have always been the focus of disagreements and inquiries. Nurses' functions, between care and management, for example, are updated in new work fields and modes.

According to the teachers, today, we are challenged every day to reflect on what we are. Two currents exist – one more traditional, in which the nurse performs tasks ("have to do") and the other that attributes more value to the human issue. They underline the insufficiency of professionals who only value the individual, without a collective view of everything that involves their work or that does not articulate and value care and management in their complementariness.

"[...] and we, in this second current, we are going to be swallowed. Because that's the trend today. It depends on everything, our concept of who we are, who is man, who is woman... and the ethical issue. And that spans education." (P7) "[...] we have to prepare people to take care and manage [...] attribute value with regard to care, but it can't be just care management [...] if you don't balance these things you are no good for the market." (P4)

The changes that mobilize professionals in the development of their activities range from discussions on the Unified Health System (SUS) to health promotion, modes of working and building a relation with users; these, in turn, have also changes, are much more aware of their rights and represent more of an opposition against paternalistic, unwelcoming or non-humanized practices.

On the other hand, the teachers highlight that society may not have a distinguished look on nursing work yet, which remits to the stereotype of meekness and non-resistance to institutional pressures (employers and job market). The moral harassment issue is reminded as a model, as an alert to the form it can take in the context of nursing work, at a moment when professionals seriously problematize and make it visible.

"The person resents it but does not do anything. [...] We know that it's wrong, sometimes, we suffer, but we don't raise any opposition. I think that, with this moral harassment fashion, things are going to change." (P5)

The theme of changes at work motivates comparisons between what the faculty members experience today and at the time they graduated, reflecting on a work environment that "mistreated more", in contrast with a position of greater respect and credibility nowadays. They highlight the partnership with other professionals who contributed to better, less unequal and more solidary work relations.

In view of all of these issues, the participants believe that they are offering better-quality teaching, preparing better professionals, with greater research initiation, more politicized, sensitive to act as educators, as they believe that not a single scenario –hospital work or the Family Health Strategy, but multiple and increasing interventions and spaces in society define the professional role.

As for the changes they perceive today, the question remains how these changes occur and whether they are happening in function of the professional role/profile itself in their work field or as a mere adaptation to the context. What is reaffirmed is the way ethical issues are inalienable from the commitment to education, permeate the entire education process and are fundamental for the construction of new practices.

Signs of local changes and the student in this scenario

The confrontations the faculty members experience in the universities' daily reality are not isolated from the transformation process that affect and articulate science, education and work. In these contexts, different intents establish approaches around projects and certain ideals. The teaching staff finds itself stimulated to reflect on daily practice at universities and health services, but also feels the obstacles to consolidate planned change proposals or even to construct relatively consistent plans.

When the Curricular Guidelines establish the need for articulation with other health courses, experiences reveal different kinds of limits. Changes can arouse conflicts due to the complexity of the issue and because they require the stakeholders' commitment to the discussion, reflection and assessment movement on priority actions for each context.

The trajectory of changes joins professionals who have worked at the institution longer with "those who just got there", with a view to constituting a group that shelters and feeds common objectives, as well as the necessary flexibility and opening. At the same time as they consider these group characteristics, as conditions for collective work, the teachers find themselves committed and visionary, think about their personal qualification as a contribution to educational and institutional goals. They know that, to grow, a chain of involved events exists and bet on the success of the collective undertaking.

Some factors, though, were appointed as bottlenecks for teaching performance, including the geographical limitation (when they do not live in the region) and the contract form without exclusive dedication or stability, leading to other professional affiliations and the lack of a teaching career perspective.

In a local analysis, the faculty members acknowledge that, when they take up an administrative function, they discover challenges they have no previous experience to face, which makes them perceive the institutional context differently. It is expected, for example, that pedagogical projects proposed as a result of group participation and negotiation with the institution be properly supported and that their execution be prioritized. When these expectations are frustrated, teachers in teaching management functions can represent an ally to conquer collective advances.

"So, it is not a project for those people only, if it was approved in that form, it's because the institution accepted it and it is obliged to grant support for this model to happen. Unfortunately that's not what we experience today." (P4)

Although they perceive universities' greater attention to teachers' education, institutional incentives are not comparable to increasing personal investments in their own qualification. In the reported experiences, both the teaching staff's training and maturity, gained through contact and coping with challenges, reflect in students' development.

Constant concern with the quality of teaching work outcomes and the construction of pedagogical alternatives is perceived as a manifestation of this maturity. Confidence in the conquests and positive impacts achieved gains visibility when the community perceives and visualizes the projects. This result also appears in isolated experiences, put forward as self-assessment by the teaching staff itself, academic coordination sectors, professional forums or students.

"We are going through a maturing process. Until we are consolidated as a group [...], it is a process that does not happen overnight [...] things here have a great chance of working out [...]. If a backlash happens one day, then we'll find other ways." (P1)

Professional higher education distinguishes itself by constructing new teacher-student-world relations. According to the faculty members, empowerment is contributing to these new relations, enabling students to become more independent and claim their rights. The change context and the implantation of the curricular guidelines raise tensions and doubts about the students' participation and involvement or about the way they will respond to the new profile.

"We don't know if it's for good or worse but, this semester, they are adults, they are prepared for this, they have an established opinion." (P1)

"Nothing is hidden from the student. [...] Why do they feel safe? Because there won't be any danger of being wrong. So, the freedom they have to turn to the teacher, integrator or coordination. It's exactly because they know the system. Knowledge, for example, about the teaching plan". (P4)

One positive sign is the reference made to students as being more critical. Reports of countless negative experiences, however, rekindle a discourse of permanent tension between teachers and students. Offensive declarations are reminded, as well as contempt in the way of treating teachers and their work, comparisons between professionals, among other communication noise and inadequate relation forms in the academic environment. Situations reach extreme dimensions when conflicts become "personal" and threaten teachers' rights, who are sometimes constrained and frightened.

"It seems there is no respect anymore. On the other hand, we've got to consider that there's a positive side to this: would this be a kind of conduct adjustment? What is "ready" is no longer accepted, that's the reason for the contestation... No respect for tradition." (P5)

"Because, sometimes, you say something, and he interprets something else and already comments on it differently, to another person, distorts everything, and that causes irreversible problems, sometimes. Like, one of these days, a student came to talk to professor X with a recorder, recording their conversation." (P1)

For the faculty, the courses receive different students, including a large number of nursing technicians who are already employed at public and private institutions and experience concrete limitations in their dedication to studying. The goals sought in education are diverse, and teachers will perceive various values and behaviors in the student group.

The teachers find ways to understand the challenge of pedagogical relations, which escape from former models and formulations. They understand the period of uncertainties this student experiences, link this moment with a context of crisis in society's values and projects, but complain about the behavior of a consumer who "pays for a service" and should understand the benefits he is entitled to. They believe that the conquest of rights should be accompanied by a broader understanding about, an ability to assess the consequences of one's action and freedom of expression.

DISCUSSION

In what respect are we changing? Why do we want to change?

When the determinant potential of the macro and national axes for transformations in the social, scientific and academic contexts is acknowledged, the emergence of an awareness is observed that is directed at the ethical-social debate, mobilized by the repercussion of situations that infringe on values and rescue their discussion. "A new thinking and acting is becoming concrete in nursing education, aiming for improvement in response to social demands, entailing the construction of ethical-social competences, involving the ability to collaborate and cooperate with the other"⁽⁶⁾.

One argument of changes in society that repeatedly appears in the teachers' perception refers to globalization, in line with the speed at which information is disseminated, which demands teaching institutions' constant updating and teachers' preparation to address emerging issues in health.

The social context was also evidenced as fertile ground for the emergence of different questions students raise during education. Likewise, the application of curricular guidelines should turn towards the constant assessment and reflection movement on practices to respond to this global context's demands. This confirms that daily practice is the space where the elements of professional moral conduct are integrated, meeting with the meaning of human life and the goals of work itself, obligations and duties⁽⁷⁾.

Another dimension of change results from the field of public health policies, which link the ethical-social responsibility of the subjects involved in the education process with the challenge of preparing professionals who are capable of taking part in health service production in line with the principles and consolidation of the SUS⁽⁸⁾.

The ethical dimension of human actions is now outlined in the articulation between the global and national levels, mobilized by a minimal information base about the rights at stake in these relations and by the participation of new stakeholders.

As for the perspective of changes in the scientific scenario, the modern world of uncertainties and the overcoming of technical rationality can represent advancements in this area, demanding flexible and critical professionals with competences to take part in different professional sectors⁽⁹⁾.

The influence of enhanced scientific progress is easily identified in the changes that have occurred in the academy. Different possibilities emerge here to problematize the teachers' own position towards science, as the academy's desired role also affects themselves, as teachers who represent and play a role in this space. In this movement, one can consider one's teaching practice beyond the model of knowledge depositary, in the belief that scientific baggage and information access can mobilize the search for new knowledge and effective exchange with the subjects of the educative action. A study on nursing education presented similar findings, evidencing the traditional teaching approach as a limiting factor for the development of creativity, participation and ethics. In this perspective, teachers guide students towards external objectives, which students have not internalized⁽¹⁰⁾.

On the one hand, this information access enhances efforts towards updating/recycling, but it also entails the responsibility to question the legitimacy or quality of what is consumed, in the hasty connections and exchanges. A positive and promising view of this sign rapidly reveals risks and new responsibilities in view of much broader and renewable competences, which demand more critical attention.

Despite the acknowledgement of this need, ethics and bioethics teaching remains limited to isolated subjects and teachers or to a "minimal discourse" that is hardly put in practice⁽¹¹⁾. One promising sign, similar to what was appointed based on the analysis of Ethics, Bioethics and Nursing Practice subject programs, is the presence of bibliography addressing students' philosophical, ethical and moral foundations, as equipment to address the ethical and bioethical conflicts of nurses' daily work⁽¹²⁾.

The analysis of recent studies on ethical education in Nursing in the international context raises questions on whether nurses are better prepared in educational terms to practice their ethical decision-making skills. Thus, the danger of students' distancing or dissociation from reality is appointed, entailing problems to apply moral judgment in clinical contexts⁽¹³⁾.

In summary, the study findings were coherent with the proposition of the nursing technology concept, covering aspects of science, knowledge production, professional competency and even socioeconomic, political and ethical elements of society. Technology production and use give rise to a professional posture and decision making ruled by ethical principles⁽¹⁴⁾.

Reflection on these new times in the academy remits to the "human being" itself, as the object of health practices. Science that broadens its view on what is human, and social life is also the science that can diverge from another type of requirement and reflection – ethics. Professionals are dedicated to a cause of social and human transcendence, which is why professional practice requires involvement in this social cause, like health, teaching and information going beyond the people they serve⁽¹⁵⁾.

To permit the transformations targeted in health education and nursing work, ethics needs to be valued in all sectors of society, mainly at schools and colleges, as a paramount factor of life in society, which positively contributes to more qualified social context and humanized and competent action⁽¹⁶⁾.

"The ethical dimension of human practice, if not accomplished and experienced, can turn into the mark of the greatest of all damages to humans"⁽¹⁷⁾.

Even an adverse reality is capable of involving teachers in discussions about students' professional and social education. The ethical practice of implementing change in Nursing education implies responsibility for the construction of a citizen-subject, capable of propositional and critical action in the health system. Reality challenges professionals and society to reconsider and interfere in the construction of a care model that responds to the needs of the entire population⁽¹⁸⁾.

FINAL CONSIDERATIONS

Despite the challenges and difficulties the faculty members face, they discern the context in their perspectives of change, of new and interesting roles for nurses in collective work. These opportunities remit to political values and to the role of professional organizations in teaching institutions, in short, to how professionals take a stand and get mobilized in ongoing transformations.

The study permitted pointing towards the analysis of some of the current challenges in ethical nursing education, and the fundamental nature of acknowledge teachers' perceptions and experiences in courses that are going through changes. In summary, the teachers' discourse appoints complex elements related to the international, national and regional/local contexts, in the professional, institutional and personal dimensions. This signals a critical perspective under construction, directed not only at the context they act in, but also addressing their own situation as nurses and educators. In this discourse, the visibility of the ethics theme repeatedly appears as peculiar to this age and closely connected with daily clinical, pedagogical and political nursing practices.

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Ethical education of nurses - indicators of change on the perception of professors

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Publication Dates

• Publication in this collection
  23 Sept 2011
• Date of issue
  2011

History

• Accepted
  12 Feb 2011
• Received
  28 Apr 2010