A nursing team's approach to users of a mental health emergency room

Abstracts

Pesquisa qualitativa exploratória desenvolvida em 2008, num Centro Municipal de Urgências Médicas/Curitiba. Objetivos: conhecer a concepção da equipe de enfermagem sobre emergências em saúde mental e analisar como se desenvolve a abordagem da equipe de enfermagem ao usuário com transtorno mental em situação de emergência. Participaram 6 enfermeiros e 7 técnicos em enfermagem que atuam na emergência e internamento. Os dados foram obtidos mediante entrevista semi-estruturada e organizados em categorias temáticas. Para os participantes, emergências psiquiátricas são situações que apresentam risco de vida para a pessoa ou a terceiros. Como características de emergência citaram: comportamento agressivo e agitado, tentativa de suicídio e abuso de substâncias. A primeira impressão do comportamento do paciente e a tentativa de diálogo determinam quais condutas os profissionais adotam. Reconhecem dificuldade e despreparo na abordagem ao paciente. Conclui-se que há necessidade de educação permanente sobre novos serviços e adaptações dos existentes para o atendimento nessa área.

Equipe de enfermagem; Emergências; Pessoas mentalmente doentes; Saúde mental; Enfermagem psiquiátrica

ORIGINAL ARTICLE

A nursing team’s approach to users of a mental health emergency room

Abordaje del equipo de enfermería al usuario en la emergencia en salud mental en un centro de emergencias

Érika Hissae Kondo^I; Juliane Cardoso Vilella^II; Letícia de Oliveira Borba^III; Marcio Roberto Paes^IV; Mariluci Alves Maftum^V

^IUndergraduate Nursing Student, Universidade Federal do Paraná. Curitiba, PR, Brazil. [e-mail]

^IIRN. Master’s student, Graduate Nursing Program, Universidade Federal do Paraná. Member of the Study, Research and Community Service Group on Human Nursing Care. CAPES Grantee. Curitiba, PR, Brazil. [e-mail]

^IIIRN. Master’s student, Graduate Nursing Program, Universidade Federal do Paraná. Member of the Study, Research and Community Service Group on Human Nursing Care. CAPES Grantee. Curitiba, PR, Brazil. [e-mail]

^IVRN. Master’s student, Graduate Nursing Program, Universidade Federal do Paraná. Member of the Study, Research and Community Service Group on Human Nursing Care. Curitiba, PR, Brazil. [e-mail]

^VPh.D. in Nursing from the University of São Paulo at Ribeirão Preto College of Nursing. Adjunct Professor I, Nursing Department, Universidade Federal do Paraná. Deputy Coordinator, Study, Research and Community Service Group on Human Nursing Care. Curitiba, PR, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

This qualitative exploratory study was conducted in 2008, at a Municipal Emergency Care Center in Curitiba. Objective: to learn about the conception of the nursing team about emergencies in mental health, and analyze how the nursing team approaches users with mental disorders in cases of emergency. Participants were 6 nurses and 7 nursing technicians working in emergency and hospitalization. Data collection was performed using semi-structured interviews and organized into thematic categories. Participants considered psychiatric emergencies as situations that may threat their own lives or that of others. The emergency characteristics they mentioned were: aggressive and agitated behavior, suicide attempt and substance abuse. The first impression of the patient's behavior and an attempt to have conversation determine the conducts adopted by the professionals. They recognize their difficulty and lack of preparation to approach the patient. In conclusion, there is a need for permanent education on new services and for adjustments to existing services for care in this area.

Keywords: Nursing, team; Emergencies; Mentally ill persons; Mental health; Psychiatric nursing.

RESUMEN

Investigación cualitativa, exploratoria, desarrollada en 2008, en Centro Municipal de Emergencias Médicas/Curitiba. Objetivos: conocer la concepción del equipo de enfermería sobre emergencias psiquiátricas y analizar cómo se desarrolla el abordaje del equipo al usuario con transtorno mental en emergencia. Participaron 6 enfermeros y 7 técnicos en enfermería que actúan en emergencias e internaciones. Los datos fueron obtenidos mediante entrevista semiestructurada y organizados en categorías temáticas. Para los participantes, las emergencias psiquiátricas son situaciones que presentan riesgo vital para la persona o terceros. Como características de la emergencia, citaron: comportamiento agresivo y agitado, tentativa de suicidio y abuso de sustancias. La primera impresión del comportamiento del paciente y la tentativa de diálogo determinan las conductas a adoptarse por los profesionales. Reconocen dificultad e inexperiencia en el abordaje del paciente. Se concluye en que hay necesidad de educación permanente sobre nuevos servicios y adaptaciones de los existentes para la atención del área.

Descriptores: Grupo de enfermería; Urgencias medicas; Enfermos mentales; Salud mental; Enfermería psiquiátrica.

INTRODUCTION

The way people with mental disorders are approached in emergency situations is that important that, if done with safety, readiness and quality, it can determine these persons’ acceptance and adherence to treatment. Also, it can be conceived as the most important technology at an emergency service, as it allows professional to practice active listening, expressing respect for patients’ singularity, offering them adequate answers and problem-solving nursing care. Care actions should be articulated with other existing services in the system, permitting patients’ adequate forwarding to other competent services. This way of developing health work promotes welcoming and collaborates in the establishment of a trust relations between users, the service and the team^(1-2).

The importance of the quality of the emergency approach in mental health is highlighted. The first impression exerts significant influence, as well as the way people are received, the attention professionals pay and the demonstration of concern with patients when they arrive at the health service. These attitudes preponderate in the patients’ reaction to the theme, as well as in the acceptance of recommendations and their adherence to treatment. These influences occur even after the long period the patients have sought care⁽³⁾.

Recent changes in mental health care in the context of the psychiatric reform, regarding the conception of mental health, treatment forms and the insertion of new services, give rise to the need to reflect on the care these patients receive. These services include the emergency care units where health professionals welcome patients with mental disorders, highlighting their importance in the prevention of complications and identification of acute and life-threatening situations.

In this sense, emergency in mental health refers to any disturbance of thought, feelings or actions that demand immediate intervention to protect the patient or third parties from death risk. The most frequent emergency situations include suicidal behavior, aggressive behavior and disorders of thought and perception. Twenty percent of patients attended at emergency mental health services have suicide problems and ten percent problems with violent behavior⁽³⁾.

Patients’ violent and aggressive behavior provokes fear, anxiety and insecurity in people around them, including professionals. Some people’s fear of all psychiatric patients, however, is disproportional to the few who actually represent a risk for other people. Professionals’ excessive fear can impair clinical judgment and lead to the premature use of a large number of sedative drugs and physical restrictions, such as containment in bed⁽³⁾.

Based on the above, the study aims are presented next.

OBJECTIVES

Get to know the nursing team’s conception of emergencies in mental health and analyze the nursing team’s approach of users in emergency situations in mental health.

LITERATURE REVIEW

Emergencies in mental health are closely related with several evolutionary and accidental crises inherent in human experience. What characterizes an emergency in mental health, however, is the behavioral manifestation deriving from a situation the person is in and for which his/her general functioning is severely impaired, so that he/she becomes unable to assume personal responsibilities⁽⁴⁾.

The evolution in the development of a crisis is predictable, ranging from a precipitating stress factor to a state of acute crisis, which Caplan described in four phases: phase I, corresponds to exposure to the precipitating stress factor; in phase II, anxiety, feelings of confusion and disorganization increase in response to the lack of a solution for the precipitating stress; in phase III, possible resources are mobilized to solve the problem and relieve discomfort; and, in phase IV, the cognitive functions are disorganized, emotions show to be unstable and behavior can reflect psychotic manifestations when no solution could be reached in previous attempts⁽⁴⁾.

Emergency in mental health refers to a situation of changed thoughts (delirium) or actions (aggressive acts) that demand rapid care. These alterations are associated with death risk, like in case of suicide or patients with violent behavior, or situations of mental alterations deriving from drugs use or physical illnesses, which require intervention to decrease sequelae. Thus, emergency is a set of affective interests and contrasting practices, in which patients and their crises are merely a part but not the whole. The health team should consider all of these possibilities at the moment of the assessment⁽¹⁾.

The number of patients in emergency mental health situations is increasing, due to reasons like: growing violence incidence levels, greater appreciation of the role of organic illness in mental health alterations, and the epidemic of alcohol addiction and other substance-related disorders. This gives rise to the need for other emergency services to guarantee an expanded range, including substance abuse, child and partner violence, the violence of suicide, homicide, rape, social issues like lack of housing, ageing and acquired immunodeficiency syndrome (AIDS)⁽³⁾.

In view of the above regarding emergency situations in mental health, the perspective of a rise in the number of cases and immediate need for joint action by the health team, reflections on this intervention are needed. In this sense, authors^(3-8) focus on the importance of learning therapeutic communication to establish a therapeutic relation between patient and professional.

Therapeutic communication is considered to be

[...] the health professional’s competency to use knowledge on human communication to help the other discover and use his/her ability and potential to solve conflicts, acknowledge limitations, adjust to what cannot be changed and face challenges to self-accomplishment, in the attempt to learn how to live as healthy as possible, with a view to finding a meaning for living with autonomy⁽⁸⁾.

The relationship between team and patients influences the information offered, even in psychiatric emergency situations. In this sense, a relationship aimed at helping the patients needs to be developed in a structured way, through planned interactions, using knowledge on therapeutic communication, in which professionals provide support, comfort, information and arouse their feeling of confidence and self-esteem⁽⁸⁾.

Therapeutic relationships can be established through the use of therapeutic communication techniques, such as reflexive listening, attentive listening and interpretation of verbal and non-verbal messages, among others. For therapeutic communication to take place, professionals need to be direct, honest, calm, non-threatening and transmit the idea to patients that they are controlling the situation, act decisively to protect them from damage to themselves or third parties, using empathy to plan and assess interventions⁽⁷⁾.

In emergency mental health situations, intervention is a short and focused treatment strategy, aimed at impeding progression and damage situations for patients and other people involved, without any intent on offering in-depth therapy⁽⁵⁾. A therapeutic approach is needed, based on a humanized and singular assessment. Thus, health professionals need skills and swiftness to adopt behaviors, assess situations and support patients, listen reflexively, express interest, ask questions, arrange events in a logical sequence, approach the patients calmly, inform and transmit the desire to help them and, if necessary, ask help from other professionals. It is highlighted that cultural attitudes influence the communication and response style of professionals working with people in crisis situations, underlining the importance of permanent education in mental health^(3,8-9).

Nursing actions need to include the assessment of precipitating stress factors, physical and mental conditions, suicide and homicide potential and drugs use. Next comes intervention planning, followed by the final analysis of the crisis’ solution and previous planning. Thus, the best approach in emergency situations is reflexive listening, as people in crisis reveal the extent to which they need support and words to conceptualize the meaning of their crisis and discover routes towards the solution^(3,8).

When professionals do not manage to have the patients decrease their exacerbated behavioral manifestations and it is considered that they represent risks for themselves or others, physical containment needs to be used. During the application of the containment technique, one member of the team, which preferably comprises five or at least four persons, should calm down the patient and explain why he/she is being contained. Patients should not be left alone and contentions should be constantly verified, observing signs of cyanosis, pressure in body areas, tie-off of limbs, xerostomy, vomiting and other aspects that can cause patient damage. When the patients’ aggressiveness and agitation decreases, contentions should be removed, one at a time, every five minutes, until two contentions are tied, which should be removed jointly. It is important to highlight that this practice should be used as a last resource⁽³⁾.

METHOD

This qualitative and exploratory research was carried out at a Municipal Medical Urgency Center (CMUM) in Curitiba-PR. The CMUM serves as the intermediary level between Basic Health Units/Family Health Strategy Units and Referral Hospitals, offering outpatient care, with the necessary equipment for urgency care and medium-complexity short-term internments. Another function is the internment of patients with mental disorders who, after assessment, can be forwarded to the Health Unit of their coverage area or full-time internment.

Research participants were six nurses and seven nursing technicians working in the emergency and internment sectors of the CMUM, where care is delivered to patients in urgency and emergency situations in mental health. The number of participants was delimited during data collection, through data saturation, perceived in the thirteenth interview.

Semistructured interviews were used for data collection, with the following questions: What do you consider to be an emergency in mental health? How do you approach people in emergency situations in mental health?

Approval for the research project was obtained from the Institutional Review Board at Universidade Federal do Paraná (UFPR), registered under process No. 0017.0.091.000-08, and the Municipal Government of Curitiba gave a favorable opinion regarding its feasibility. All participants were informed about the research goals, in compliance with Resolution 196/96 on research involving human beings.

Data were analyzed in the light of Thematic Analysis, involving the following phases: pre-analysis, when documents are selected for analysis and the premises and initial aims of the study are resumed; exploration of the material, through transformation of gross data with a view to reaching the core of understanding the text and aggregating information into categories according to the theme; and result treatment and interpretation as the final phase of the analysis, when the obtained data are highlighted and interpreted⁽¹⁰⁾.

RESULTS

The data that emerged from the interviews were analyzed and grouped in four categories: conception of emergency in mental health; the nursing team’s approach in case of emergency in mental health; physical containment in case of emergency in mental health and difficulties in emergency practice in mental health.

Conception of emergency in mental health

The participants reported that emergency in mental health is a life-threatening situation for the patient and third parties and is perceived through manifestations of aggressiveness, agitation and loss of control. The term episode was repeatedly used to define an emergency situation and three of the interviewees cited suicide attempts as an occurrence that demands emergency care. Cases of substance abuse and social issues, on the other hand, are sometimes mentioned with doubts about whether they represent emergency situations but, due to the patients’ behavioral characteristics, they are treated as such. Examples are the following reports:

A person beyond his normal awareness, at quite an altered level, aggressive, agitated, confused, who in some way presents risks for himself and the people around him. I don’t see cases of alcohol and drug addiction as psychiatry, but in case of emergency they are treated as such (A.3).

A patient going through an episode. Both aggressive with people and self-aggression. A patient who tries to commit suicide and reaches a threshold of despair, depression, of madness really. I see these two situations as psychiatric emergency (E.9).

The nursing team’s approach in case of emergency in mental health

According to the nursing team’s reports, the approach starts with the observation of behavior, which influences the type and attempt to dialogue that will be established. The professional’s primary contact and impressions of the patient define further conducts, such as the use of physical and chemical containment, considered routine activities in this emergency care, according to all interviewees. Physical containment was appointed as a way to approach patients who represent risks for themselves or others, and is therefore considered a means to protect the patient in crisis, companions and employees involved, followed by talking, administering medication and checking vital signs. All participants mention requesting colleagues’ help and acting in group as a need in case of approach for containment purposes, according to the following reports:

You have to see whether he’s not having an episode, his attitude, if he’s aggressive or calm, to be able to approach him. First I try to talk. If that doesn’t work, I talk to the physician to see if he’s gonna be medicated. Before I approach him, I call the team, prepared them and the containment material. First, physical containment is done. Then, vital data are collected, when the patient is calm, contained (A.1).

The primary intent is try and talk, to see if he’s collaborating or not. If not, then I call help and we go for containment, to avoid that the person ends up attacking other people or himself (A.3).

I try to approach, talk, say that everything’s fine, that we’re gonna help him and ask him to collaborate. And if he doesn’t and we feel at risk of being attacked or of attacking himself or ending up hurting himself, we use contentions, drugs according to the prescription of the physician at work. As his level is getting better, the contentions are removed, it protects the team and him too (E.9).

Physical containment in case of emergency in mental health

According to the participants, physical containment is a nursing team practice in case of emergency situation in mental health at the study institution. They explained, however, that no routine exists for how to apply the technique, for the care that should be performed before, during and after the containment, as well as who’s responsible for deciding and applying it. Hence, the facts develop and the group decides on how to act during the event. The participants discuss the lack of specific materials and sometimes have to improvise, using diapers, sheets, cotton padding, materials for use in physical containment:

There are the containment strips we use. They’re bandages. There were some strips padded with foam so as not to hurt the patient. In principle, upper and lower limbs and, if that doesn’t do it, the chest (A.2).

We use bandages, of 15, 10 centimeters. There are four. One for each arm and leg and the sheet to contain the chest. Sometimes we manage to get a cloth they have at the emergency medical service, specific for containment, but generally we contain with a sheet” (A.7).

When those padded strips from the emergency medical service are available, we use those. When not, we put a baby diaper around the wrists, around the ankles, get the bandage and do the containment, taking care not to hurt, not to make it too tight, see peripheral perfusion [...] (A.8).

Difficulties in emergency practice in mental health

When discussing how to approach emergency care users in mental health, the participants appointed several difficulties, including the professionals’ lack of understanding about the suffering of agitated patients in acute situations, and that patients do not want this behavior, but that it emerges as the way for them to express the suffering. They mentioned lack of preparation to deal with specific situations in the mental health area and that this causes feelings ranging from fear to mistrust, guilt, anger, pity and insecurity. They acknowledge that, when confronted with emergency situations in mental health, fast and collaborative action is needed, and that they ask the municipal guards’ help. Some subjects also reported on dissatisfaction with the negligent and careless way in which some colleagues treat mental patients. They also appointed lack of sufficient and adequate material for physical containment.

There’s lack of care, like leaving the patient with evacuation and urination for several hours, not untieing due to fear of aggression [...] in short, seeing the patient as a being who also needs care, just like others. Employees who don’t see patients with mental disorders as sick, in fact (A.2).

One thing I think that doesn’t work, is that we don’t have training for this type of approach. We’ve already heard a lot of theory, but have never trained in practice, we don’t know how to adequately perform the group of eight, and don’t have material for containment [...], improvise with a sheet, bandage, and sometimes end up hurting the patient, because the material is not adequate [...] (A. 3).

I think it’s one of the patients who’s most difficult to deal with [...]. In the approach, we’re often scared, afraid of being attacked [...] we know histories from other colleagues and are suspicious. I prefer two cardiac arrests at the same time than a patient like that [...] (A. 4).

All participants mentioned lack of preparation and training for care delivery to patients with mental disorders. It is perceived however that, on the one hand, less experienced professionals related the lack of training with difficulty and fear they feel, entailing insecurity when delivering emergency care in mental health. On the other hand, more experienced and better-trained professionals discuss the separation of care in reserved places and with specialized staff, as a way to improve care delivery, according to the following report.

I think that, here [...] psychiatric patients should not stay together with clinical patients, for the sake of the patients’ own safety [...]. Because there are many elderly here and, with this kind of patient inside the room, there’s no way [...] (A.2).

DISCUSSION

In this study, some nursing technicians did not acknowledge the mention of suicide attempts and behavioral alterations caused by psychoactive substance use as emergency situations. These facts are noteworthy, as they reflect professionals’ lack of understanding for people who, due to suffering, try to end their lives, as well as for people with problems related to the consumption of alcohol and other psychoactive substances. These situations, however, correspond to a considerable number of emergency situations, sometimes due to intentional (self and hetero-inflicted injuries) or non-intentional external causes (traffic and other types of accidents), or also to other psychic clinical events (depression, anxiety, violence and suicide). This lack of understanding can lead to contempt for emotional needs and the importance of suicide attempts in professional care delivery to psychoactive substance users^(11-12).

A study⁽¹¹⁾ revealed that health professionals consider that a suicide attempt occurs at a moment of great despair, also mentioning it as a way to attract attention. Consequently, it arouses different feelings among professionals, such as guilt, impotence, frustration, weakness and despair when they perceive their difficulties to work with suicide. This underlines the need for trained professionals to work in mental health, permitting care delivery to people whom at some time in their lives do not find meaning in their own lives.

It is important to consider that psychoactive substance consumption causes sensory-perceptive alterations, which can result in emergency situations, such as aggressive and agitated behavior. Also, substance abuse increases the chances of developing other mental disorders, just like behavioral characteristics and psychiatric disorders predispose to risks for substance use⁽¹³⁾.

Physical containment is used in situations when patients are intensely agitated and manifest aggressive behaviors, but should only be applied when initial attempts for verbal intervention are not sufficient, and are mainly indicated for patients at risk of physically attacking themselves or other people^(3,5,9).

The indication of physical containment is mentioned in Federal Council of Medicine Resolution No 1.598, issued on August 9^th 2000. According to Art. 11, it should be indicated and prescribed by medical professionals, and patients should be directly accompanied by a nursing professional whenever contained. Until date, the Federal Nursing Council has not issued any standard on physical containment of patients, representing a gap in care delivery to patients with mental disorders, as containment is constant practice in the daily work of nursing professionals at mental health services⁽¹⁴⁾.

The interviewees reported that, during the nursing team’s approach, vital data are verified. This nursing care is important as its analysis, together with physical examination of the patient and laboratory tests, distinguishes between psychiatric behaviors of psychogenic and organic origins, such as: hypoglycemia, psychomotor epilepsy, brain tumors. Another reason for the importance of monitoring vital data is the risk of respiratory depression, hypotension and others resulting from central nervous system depressants, which are normally used for people with agitated and aggressive behavior, including barbiturates and benzodiazepines⁽³⁾.

Among materials used to restrict patients’ movements, the participants mentioned the cushioned strips the emergency medical team uses. The use of these strips aims to provide containment with lesser risks of physically injuring patients. Participants mentioned the absence or lack of this material, however, as a difficulty in emergency care practice, entailing the need to improvise with other materials on different occasions.

Professionals who, at the heart of their profession, are responsible for welcoming and delivering care, in view of the singularity of human beings and the understanding of their suffering, sometimes express themselves by reinforcing the stigma that accompanies mental patients. Among the reports, some participants directly and indirectly admit difficulties to accept mental disorder as a natural event in the illness context.

Feelings regarding emergency mental health care are validated by the conclusions from a study⁽¹⁵⁾ at a General Emergency Care service, which describes nursing professionals’ feelings towards mental patients and their care. Agreement is highlighted about the common sense involving the dynamics between thinking, feeling and acting, resulting in feelings of pity, fear and anger. Fear, anger and revolt can entail distancing from people in psychic suffering, function as a factor of demotivation or disinterest in care delivery, assuming a defensive and even negligent attitude in care, mainly to aggressive patients, while pity shows the clear will to help.

The lack of care mental patients have historically been submitted to is highlighted, as well as the perpetuation of the way of thinking disseminated in society about the need for mad people to remain distant, far from everyone. The reality presented her indicates the need to rethink mental health nursing teaching and practice, as teaching mostly involves very small hour loads and is restricted to psychiatric hospitals⁽¹⁵⁾.

The approach is highlighted as the first step to take care of a patient with mental disorder in an acute phase, and this first impression is capable of interfering in treatment acceptance. Thus, the urgent need to qualify professionals active in this area is highlighted. In this sense, permanent education in mental health should include knowledge on the transition from hospital care practice, aimed at containing behavior, to the incorporation of interdisciplinary practice principles, with a view to raising both new and more experienced professionals’ awareness and qualifying them in terms of professionals’ role as agents of transformation.

Hence, permanent education in mental health faces the challenge of consolidating the psychiatric reform. Therefore, it should be based on the premises of significant learning, structured based on the problemization of the work process, and understood as a continuous process of revitalization and personal and professional overcoming, all of this with a view to mental patients’ rehabilitation and social reinsertion^(16-18).

CONCLUSION

This research provided knowledge on nursing care and the nursing team’s conceptions in emergency situations in mental health at an emergency care services and the search for knowledge on this theme, enhancing reflections on this practice.

It is highlighted that substitutive mental health care services are realities that result from the psychiatric reform movement, with social, political and economic characteristics, fighting for the deconstruction of asylums and their supportive paradigm. This reorientation of mental health care requires assessments, reassessments and constant reflections on the created and adapted services, so that their dynamics achieve the goal of social inclusion and do not perpetuate the image rooted in the social imaginary, seeing mental patients as dirty, ignorant, unable, aggressive and violent, who should therefore be kept far from contact with people in society.

Emergency care delivery in mental health takes different forms in Brazilian cities. In Curitiba, CMUM’s are responsible for welcoming in emergency situations and are connected with the integrated mental health care network, screening users for existing services. The importance of the approach at this moment of users’ intense suffering affects their acceptance of treatment. This demands that professionals at these services, recently destined for this type of emergency, find new forms of care delivery.

Among care forms, the use of therapeutic communication and relationship techniques is highlighted with a view to a more effective approach, including emergency situations, with manifestations of intense suffering. Thus, restrictive techniques can be avoided and higher quality care can be provided, going beyond care that is directed at the body only and incorporating care that considers the existential, relational, historical, cultural and situational dimension, as desiring human subjects. This study evidences the need to establish permanent education processes for the nursing team, with a view to care delivery in mental health. The interviewees acknowledge the need for greater knowledge in their professional practice and for a more adequate structure. Reflections reveal permanent education as a strategy to consolidate the Unified Health System. A permanent education project in mental health is recommended for the place of study and, even if redundant, the researchers add the need that this be done based on the problemization of the work process, with a view to transforming professional practices, so that theory and practice are not a dichotomy.

In view of the lack of scientific production in Brazilian journals on this theme, further research is needed.

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Correspondência:

Mariluci Alves Maftum

Rua Padre Camargo, 120 - Alto da Glória

CEP 80060-240 - Curitiba, PR, Brasil

Publication Dates

• Publication in this collection
  26 May 2011
• Date of issue
  Apr 2011

History

• Accepted
  16 Aug 2010
• Received
  27 Nov 2008