artigo originaL / research report / artícuLo Caring as the essence and science of Nursing and health care O cuidar como essência e ciência da enfermaria e dos cuidados médicos El cuidar como la esencia y la ciencia de la enfermería y de los cuidados médicos Jean Watson* AbStrACt: Human Caring is part of the human condition and a way of Being Human. Caring is found throughout time. Moreover, the notion of ‘caring’ in nursing has been a given throughout its history. In the past 3 decades or so, professional human caring has been increasingly acknowledged as the essence and core of professional nursing. This focus is evident in nursing practice, nursing theories, nursing curricula, and nursing’s philosophical and ethical perspective toward humanity and patient caring relationships. In this paper, I present the main tenets of works by means of which I have posited Caring as the disciplinary foundation for nursing and have put forward Caring Science as an evolved view of nursing and human sciences (WATSON,1979, 1985, 1999, 2005, 2008). KEywOrdS: Human Caring. Nursing. Health care. rESumO: O cuidar humano é parte da condição humana e uma maneira de Ser Humano. Cuidar é algo que se faz presente ao longo do tempo. Além disso, a noção de “cuidar” em enfermagem tem sido tida por certa durante toda a sua história. Nas três últimas décadas, o cuidar humano profissional foi reconhecido cada vez mais como a essência e o núcleo da enfermagem profissional. O foco no cuidar é evidente na prática da enfermagem, nas teorias da enfermagem, nos currículos da enfermagem e na perspectiva filosófica e ética da enfermagem como relação à humanidade e aos relacionamentos de cuidado com os pacientes. Neste artigo, apresento os princípios dos trabalhos mais importantes nos quais postulei o Cuidar como o fundamento disciplinar da enfermagem e para propor a ciência do Cuidar como uma concepção avançada da enfermagem e das ciências humanas (WATSON, 1979, 1985, 1999, 2005, 2008). PAlAvrAS-ChAvE: Cuidar Humano. Enfermagem. Cuidados médicos. rESumEN: El cuidar humano es parte de la condición humana y una manera de Ser Humano. El cuidar se presenta a través de la historia humana. Por otra parte, la noción de “cuidar” en el oficio de enfermería ha sido considerada su esencia a través de su historia. En las últimas 3 décadas, se ha reconocido cada vez más el cuidar humano profesional como la esencia y la base de la enfermería profesional. Este foco es evidente en la práctica de enfermería, las teorías de la enfermería, currículos de enfermería y la perspectiva filosófica y ética de la enfermería hacia la humanidad y las relaciones de cuidados con los pacientes. En este artículo, presento las principales bases de los trabajos por medio de los cuales he postulado el cuidar como la fundación disciplinaria para la enfermería y he propuesto la ciencia del cuidar como una concepción más avanzada del cuidado y de las ciencias humanas (WATSON, 1979, 1985, 1999, 2005, 2008). PAlAbrAS llAvE: Cuidar humano. Enfermería. Cuidados médicos. Human Caring is part of the hu- tive toward humanity and patient an Honoring of the following: infinityman condition and a way of Being caring relationships. Watson has of the human spirit and the evolv-Human. Caring is found through- posited Caring as the disciplinary ing universe; ancient and emergingout time. Moreover, the notion of foundation for nursing and put for- cosmology of a unity consciousness‘caring’ in nursing has been a given ward Caring Science as an evolved of related of All; the world viewthroughout its history. view of nursing and human sciences (ontology) as ethic related to an In the past 3 decades or so, pro- (1979, 1985, 1999, 2005, 2008). Ethic of Belonging (acknowledg-fessional human caring has been ing our connectedness with infinityincreasingly acknowledged as the Caring Science field of spirit, before our separateessence and core of professional physical being1; the moral positionnursing. This focus is evident in Within a framework of Caring of sustaining the infinity and mys-nursing practice, nursing theories, Science there are basic assump- tery of the human condition andnursing curricula, and nursing’s tions that differ from medical sci- keeping alive the evolving humanphilosophical and ethical perspec- ence1. These assumptions include spirit across time, in order to face * PhD, RN, AHN-bc, FAAN. Distinguished Professor Nursing. University of Colorado Denver. College of Nursing. Founder/Director Watson Caring Science Institute. www.nursing.ucdenver.edu/caring. www.watsoncaringscience.orgO MundO da Saúde São Paulo: 2009;33(2):143-149. 143
caring as the essence and science of nursing and heaLth careand deepen our humanity; an ethical related ness, and unitary conscious- cal observable level, and alsoawareness that we hold another per- ness. It involves an intentionality at non-physical, subtle energyson’s life in our hands; this sovereign and caring consciousness, which level; whereby energetic con-expression of life is given to us, be- has to be cultivated and lived out sciousness of Caritas radiatesfore and beyond our control with in daily personal/professional life. the field, wholeness, beauty,expressions of trust, love, caring, These 10 processes include the fol- comfort, dignity, peace, calmhonesty, forgiveness, gratitude and lowing: are communicated.so on; transpersonal perspective 1. Practice of Loving-kindness and 9. Administrating human carethat goes beyond ego fixations and equanimity within the context essentials, helping another withobsessive feelings that are negative of caring consciousness (a car- basic human needs, with an in-expressions of life; the relationship ing consciousness carries high- tentional caring consciousnessbetween our consciousness, words, er energy vibrations from our that honors unity of mindbody-and thoughts and how they posi- heart-center, the Source of our spirit and wholeness in all as-tively or negatively affect our ener- humanity, connecting human- pects of care.getic –transpersonal field of Being/ to- human; heart- to- heart; spirit –to- spirit from one to an- 10. Opening and attending to theBecoming and Belonging; thus our other). spiritual mysterious and exis-consciousness affects our ability to tential unknowns in life/death,connect, to ‘be-in-right-relation’ 2. Being authentically present in the moment, acknowledging health, illness - ‘allowing forwith Source; the infinite universal and allowing for the deep belief miracles’.Cosmic field of Love. In this evolved view of science system and subjective life-world These Caritas Processesand a starting point of Caring and of self and other (instilling faith acknowledge the unitary energeticHumanity as ethic, we can appre- and hope). nature of all of life and life journey.ciate, honor and face the reality 3. Cultivating one’s own spiritual These processes can be consideredthat life is given to us as a gift. We practices with comprehension holographically in that the wholeare invited to sustain and deepen of interconnectedness that is in any part and any part is in theour own and other’s humanity as goes beyond the individual and whole.our moral and ethical starting point opens one to Source and evol-for professional caring-healing. ving consciousness. Caritas Nurse: Caritas These views of Caring Science 4. Developing and sustaining Nursingare not unlike Nightingale’s no- authentic heart-centered,tion of natural healing processes, authentic caring relationship What is emerging throughoutwhich draw upon spiritual dimen- with self and other. the shift to Caritas process is ansions that are the greatest source of acknowledgement of a deeper 5. Being present to and supporti-healing (1969). During the last 3 ve of the expression of positive more evolved form of nursing:decades there is an increasing at- and negative feelings, arising in Caritas Nursing and the Caritas Nurse.tention to Caring in nursing as the self and other (with an under- As each nurse evolves and nursingethical core and stable essence of standing that all of these feel- evolves we learn that the moreprofessional nursing, in contrast to ings come and go and need to evolved practitioner works fromchanging dimensions Watson re- be recognized and honored). the higher/deeper dimensionsferred to as trim. of humanity and one’s evolving 6. Creatively using all ways of consciousness. An evolved nurse knowing, Being and doing as10 Caritas Processes as core cultivates the practices of Caritas integral to caring process in Nursing. Another view of a Caritasof Caring solving problems/ seeking so- nurse is one who is working from lutions for patients/families/ The most recent work on an open, intelligent heart-center, community.Caring by Watson (2008)2 builds rather than from a less conscious-upon the original 10 Carative fac- 7. Engaging in genuine teaching- ness, head-center. The heart-cen-tors and extends them as 10 Caritas learning experiences that arise tered evolved Caritas Nursing opensProcesses (bringing together caring from an understanding of inter- to transpersonal experiences in theand Love) as the fully mature prac- connectedness. caring moment. The Caritas Nurse istices of caring. These processes are 8. Creating and sustaining a working more and more in awake-based upon worldview and ethic of healing environment at physi- ning the heart-center to bring one’s144 O MundO da Saúde São Paulo: 2009;33(2):143-149.
caring as the essence and science of nursing and heaLth carefull and open spirit-filled self to any 2. Heart-centered Authentic Pres- three decades. This has occurredcaring occasion. ence largely in the academic world of This model of Caritas thinking 3. Compassionate Forgiveness nursing science, which often hasinvites a total transformation of self disconnected nursing theory from 4. Gratitude- Appreciationand systems from within, the deep nursing practices. However, dur-inner place within the creativity of 5. Energetic Caritas Consciousness ing the past decade there has beenthe human heart, which connects evolution –personal spiritual special attention to theory-guidedus with Source to sustaining the practice practice models and caring andhuman spirit. It is here in this form 6. Opening - Giving –Receiving healing relationships as the core ofof evolved nursing that nurses find 7. Being Still- Silence – Holding professional nursing. Concurrently,heart-centered caring as the source the Still Point practitioners are seeking morefor compassion, wisdom, truth and authentic practices, giving mean- 8. Connecting with infinite cosmicauthentic transpersonal caring. ing and purpose to their profes- field of Universal Love sional lives and work. Much of thistranspersonal Caring 9. Manifesting Caritas Field (to changing consciousness has been sustain caring and our huma-relationship nity) triggered by the nursing short- age, nursing despair over system Transpersonal Caring embodies 10. Other - infinite demands, as well as an awarenessa spirit to spirit, heart-to-heart con- It is in understanding and con- of a lack of human caring in ournection through the full presence necting with the deeply human personal/professional lives, and inof the nurse with Caritas Loving dimensions of life/death that we both systems and society.consciousness and intentional- open our hearts to human experi- Nurses are torn between theity in the moment. Transpersonal human caring values and the ences of suffering, loss, search forcaring radiates a field of caring be- ‘calling’ that attracted them to the meaning, which nurses face andyond the two people, but a process profession, and the technologically, witness daily, if not moment- by-that becomes part of the life jour- high paced, task-oriented biomedi- moment. These deeply humanney and greater complexity of life. cal practices and institutional de- conditions and experiences cannotA transpersonal caring transcends be dealt with by technical compe- mands, heavy patient load, alongtime, space and physicality and af- tent and conventional evidence- with outdated industrial practicefects both nurse and patient which based practice models of Western patterns4. It has been reported inboth carry into their life processes medical-nursing science. Thus, some comprehensive summaryas long as they live. a model of Caring Science allows research that nurses who are not It is this human caring mo- for the emergence of an evolved able to practice caring can becomement which informs the next mo- Caritas Nurse, it invites nurses into hardened, brittle, worn down, andment and potentiates healing and a deeper appreciation of the com- robot-like5.wholeness. In this model of caring/ plexity of the human experiences, Both practitioners and healthCaritas nursing is not just doing, butinvolves informed, consciousness inner life journey and meaning of systems now realize radical changeintentional way of Being. inter-subjective responses to car- from within is an essential and nec- ing, healing, illness, despair, dis- essary requirement to reverse the ease, and death. It is this model non-caring trend many experienceCaritas ways of being- which truly honors and opens to or witness in hospitals and healthbecoming the unity of mindbodyspirit and care today. In other words all the The following Caritas Ways our human –to-human connection change approaches to date, at-of Being have been identified as with Source which unites All. tempt to solve the health care crisisanother dimension of cultivating in the USA and other WesternizedCaritas Processes in Professional Current focus in human countries by focusing on externalNursing Practices: Caringa issues and forces. These include such system solutions as econom-Caritas –Ways of Being- Philosophies, ethics, and theo- ics, technology, management -Becoming: ries of nursing science have contin- organization, access control, and 1. Loving Kindness ued to evolve over the past two or environmental hospitality models.a. This section draws upon previous manuscript (Watson, 2009)3O MundO da Saúde São Paulo: 2009;33(2):143-149. 145
caring as the essence and science of nursing and heaLth careOther proposed solutions focus on national crises in hospitals today. ing Magnet criteria through trans-nursing recruitment and retention, Increase demand for efficiency forming nursing, but also havebetter compensation packages, and quantity, for production and sought to realize deeper levels ofsigning bonuses, relocation fees, outcomes, set within an outdated caring and helping practices forand hiring increased numbers of industrial mindset, has led to more their nursing staff. Watson’s Theoryminimally-educated laypersons or and more distancing between of Human Caring is one prominentassistants. These tactics comprise patients and practitioners, and theoretical, ethical, philosophicalsuperficial and short-term ap- between and among practitioners. framework in which nurses andproaches, when what is needed is a The result is a culture which has administrators are engaged todeeper, philosophical, value-based lost its way, void of humanity and inspire and transform nursing andapproach relevant to sustaining the authentic human caring relation- health care for this work.integrity and dignity of the profes- ships, important communication, Some shifts of consciousnesssion of nursing, which has the larg- and connections, paving the way which underpins this movementest number of practitioners in the for even more increase in medical and system attempts to resolve thehealthcare system and in society. errors, safety violations and numb- moral/professional conflicts for The contrast is attending to the ness among the practitioners. nursing, include acknowledging6:most fundamental resource and the Ultimately, the ability to resolve • human caring is not a commod-most precious and powerful source conflicts between what nursing is ity to be bought and sold;for authentic reform/transforma- (viz., the theories, philosophies, • caring and economics are not tion of hospitals and clinical agen- ethics and knowledge that guide mutuality exclusive, and cancies: competent, compassionate, their professional/disciplinary prac- co-exist to achieve cost-benefit/knowledgeable, and caring nurses tices) and what nurses supposedly do, cost-effectiveness ;and health practitioners. Nurses may be the most critical challenge • caring is a professional ethical and practitioners who are literate for the discipline and for the pro- covenant that nursing has withwith caring relationships are capa- fession’s survival into this millen- the public to sustain humanble of having loving, caring, kind, nium, and thus may well impact all caring in instances where itand sensitively meaningful, per- of health care, both nationally and may be threatened; it necessari-sonal connections with an increas- internationally4. A values-based, ly involves something deeperingly enlightened public: a public theory guided approach to human and more substantial than aseeking wholeness and spiritual caring and health care change helps ‘customer’ model orientation;connections for their wellbeing, not to make visible a major shift thatjust sterile, depersonalized medical is required for authentic changes, • practitioners and patients alike technological interventions, void of in order for nursing and human require caring relationshipshuman-to-human caring relation- caring to survive into this era. and healing environments, ifships. Recently a number of hospitals caring-healing practices are to The underlying dissatisfaction in the United States have shifted be sustained within any healthwith healthcare continues to in- toward explicit implementation of care setting.clude system cultures and routines Human Caring theory as a guide • true transformation of health which inhibit the ability of nurses toward professional nursing prac- care ultimately has to cometo practice their own profession; tice changes, as well as culture in- from a shift in consciousnessthe dominance of medical –insti- stitutional changes. Some of this and intentional actions oftutional foci, and the quantity of momentum is triggered by the the practitioners themselves,time demands over the quality of American Nurses Credentialing changing health care from thedirect-care person-centered re- Center, Magnet Hospital Program. inside out.lationships, and also caring and Magnet hospitals must demons- The evolving caring-healinghealing processes and practices. trate criteria that recognize quality practice environments are in-This tension continues in spite of patient care, nursing excellence, creasingly dependent on relation-marketing logos and slogans about and innovations in professional ships, partnerships, negotiation,“caring institutions”6. practice and also assure quality of coordination, new forms of com- Recent crises related to safety care to consumers. munication patterns and authen-concerns have brought renewed In recent years, many nursing tic connections. This awakeningattention to nursing and physician leaders and administrators have includes a shift toward a spiritual-practices and how to address the been committed not only to meet- izing of health, in contrast to the146 O MundO da Saúde São Paulo: 2009;33(2):143-149.
caring as the essence and science of nursing and heaLth caremore conventional medical-clin- Caring and Nursing patient satisfaction outcomesical, techno-cure orientation to Administrative leadership related to the introduction ofhealth and illness. These shifts in a theory-guided professionalhow health and healthcare is per- Nursing administrators as well practice model.ceived, have arisen from the public, as hospital managers and Chief Ad- • Resurrection Health, Chicago, Il-and demand of nursing and health ministrative Officers have a signifi- linois. Providing leadership incare administrators to develop cant role to play in transforming the system wide implementationcreative solutions, that transcend dominant medical system, which of caring theory. Also exploringthe ubiquitous and ineffective fix-it has been framed in some classic re- computerized documentationmodels. search as being biocidic (unhealthy, system, which incorporates toxic) in contrast to biogenic (life language and nursing interven- giving and life receiving for patient tions based upon caring theoryEmerging models of Caring and practitioners alike). in contrast to conventional– healing medical-nursing tasks and pro- In the past decade or so, in- watson Caring Science cedures7.creasing number of hospitals and Institute: International • Inova Fairfax Hospital, Fairfax,academic programs in the United Caritas Consortium Virginia. A comprehensive sys-States and other parts of the world, tem formally researching car-have begun to use Watson’s Theory Because of these national ing theory through a federallyof Human Caring in very specific and international developments funded project whereby out-ways, as a guide to changing nurs- and sincere desire for authentic comes of caring theory practic-ing practice – and ultimately chang- change, new projects using Caring es are examined in relation toing the culture of hospital nursing Science Theory and Philosophy of patient and nurse satisfaction,and academic nursing. (For more Human Caring are now underway retention rates and other varia-information, see websites: www. in many systems. The Watson Car- bles.watsoncaringscience.org; www. ing Science Institute and The In- • Central Baptist Health, Lexing-nursing.ucdenver.edu/caring ternational Caritas Consortium2 ton, Kentucky. Magnet hospital are one example where individu- “This theory/philosophy involves using caring theory as profes- als and representatives of systems sional practice model. making explicit human caring convene twice a year to deepen and relationship-centered car- • Scripps HealthCare, La Jolla, and sustain what is referred to as ing is a foundational ethic for California. This organization is Caritas Nursing – that is, bringing healing practices; it honors the exploring caring theory in rela- caring and love and heart-centered unity of the whole human being, tion to complementary, holistic human to human practices back while also attending to creating medical programs. into our personal life and work a healing environment. Caring – • Bon Secours St. Mary’s Hospi- world2. These gatherings are hosted healing modalities and nursing tal, Richmond, Virginia. Saint by different clinical – educational arts are reintegrated as essentials to Mary’s Hospital is providing systems using Caring Theory as ensure attention to quality of life, exemplary programs in caring forum for transforming education inner healing experiences, subjec- and practice from the inside out. theory-guided practice models, tive meaning, and caring practices, For example, the following health and exploring pilot program which affect patient outcomes and care systems have sponsored the with CaritasHeartMath™, a system successes alike. International Caritas Consortium program that integrates Caritas This work places human-to – and the Watson Caring Science Ins- nursing and Science of Human human – caring as central to pro- titute in recent past and into the Caring with the Science of the fessional nursing responsibilities, near future as this work expands Heart, as researched and de- the role and moral foundation for and radiates outward: veloped by HeartMath. (www. the profession. Preserving human • Baptist Hospital of Miami, Florida HeartMath.com). dignity, relationships and inte- – three times National Magnet • Scottsdale Health Care, Scottsdale, grity through human caring are designation recognition (Ame- Arizona. This Magnet hospital ultimately the measures by which rican Nurses Credentia ling demonstrating caring theory- patient’s evaluate their often ‘cure Center, ANCC); This organi- guided practices and research. dominated experiences1.” zation has analyzed health and The host for the April, 2008 ICCO MundO da Saúde São Paulo: 2009;33(2):143-149. 147
caring as the essence and science of nursing and heaLth care and host of the inauguration of systems guided by Caring Science • centering exercises and mind- the Watson Caring Science Ins- and caring theory as a guide. The fulness practices, individually titute. following are examples of such and collectively; • Baptist Health Jacksonville of caring-in-action indicators: • placing magnets on patient’s Northeast Florida, Jacksonville, • making human caring integral door with positive affirmations, Florida. Baptist Health achieved to the organizational vision and and reminders of caring prac- Magnet recognition for the culture – through new language tices; healthcare system, using caring and documentation of caring, • exploring documentation of theory as professional practice such as posters; caring language and integration model throughout their insti- • introducing and naming new in computerized documenta- tutions. Participants in a multi- professional caring practice tion systems; site research project assessing models, leading to new pat- • participation in multi-site re- caring across their system. The terns of delivery of caring/care. search assessing caring among sponsor for the October, 2008 Some examples are: ‘Attending staff and patients; International Caritas Consor- Caring Nursing Project’, ‘Pa- tium. • creating healing environments tient Care Facilitator Role’, the – attending to the subtle environ- • Wyoming Medical Center, Casper, ’12-Bed Hospital’; ment or Caritas field; Wyoming. This hospital is the • conscious intentional meaning- projected host in October, 2009 • displaying healing objects, ful rituals, .For example, hand for the Caritas Consortium and stones, blessing basket; washing is for infection control, is incorporating caring theory, but also may be a meaningful • creating Caritas Circles to share including indigenous, Native ritual of self-caring- energeti- caring moments; American population, cultural cally cleansing, blessing, and • caring Rounds at bedside with dimensions for the local people; releasing last situation or en- patients; also exploring research out- counter, and being open to the • interviewing and selecting staff comes through identified assess- next situation; on basis of ‘caring” orientation. ment measures8. Asking candidates to describe • selected use of caring-healing • Bon Secours St. Francis Hospital, modalities for self and patients, “Caring Moment”; Charleston, South Carolina. e.g. massage, therapeutic touch, • development of ‘caring com- Sponsor of spring, 2009 gather- reflexology, aromatherapy, petencies’ – ‘ caritas literacy as ing of the International Caritas calmative oil of essences; sound, guide to assess and promote Consortium and introducing music, arts, variety of energetic staff development and assure innovative caring practices, modalities; caring. guided by theory, philosophy • diming the unit lights and hav- These and other practices are and ethics of Caring Science. ing designated ‘quiet time’ for occurring in a variety of hospitals patients/families/staff alike, to across the United States, often inCaring Indicators and soften, slow down, and calm Magnet hospitals or those seekingPrograms the environment; Magnet recognition, where caring • creating healing spaces for theory and models of human ca- While these above named sys- ring are used to transform nursing nurses; sanctuaries for theirtems are identified as sponsors of and health care for staff and pa- own time out; May include me-the growing International Caritas tients alike. diation or relaxation rooms forConsortium, examples of how The names of other health care quiet time;these systems are implementing inter/national clinical and educa-the theory are captured through • cultivation of own spiritual tional systems incorporating Caringidentified acts and processes depic- heart-centered practices of Theory into professional nursingting such transformative changes. loving kindness and equanimi- practice models (many hospitals Caring theory-in-action reflects ty to self and others; are Magnet hospitals or preparingtransformative processes which • intentionally pausing and to become Magnet hospitals) can beare representative of actions taking breathing, preparing self to be found on following websites: www.place in many of the systems in present before entering patients watsoncaringscience.org; www.the Caritas Consortium and other room; nursing.ucdenver.edu/caring148 O MundO da Saúde São Paulo: 2009;33(2):143-149.
caring as the essence and science of nursing and heaLth care These identified system exam- human caring and healing and inside out. The dedicated leadersples are exemplars of the changing health in a system that has gone who are ushering in these changesmomentum today, and are guided astray – educationally, economi- serve as an inspiration for sustain-by a shift toward an evolved con- cally, clinically, and socially. This ing nursing and human caring forsciousness. They rely on moral, shift is in a hopeful direction, and is practitioners and patients alike.ethical, philosophical, and theo- based on a grass roots transforma-retical foundations to restore tion of nursing, one that is from the references1. Watson J. Caring Science as Sacred Science. Philadelphia: FA Davis; 2005.2. Watson J. Nursing. The Philosophy and Science of Caring. Boulder: University Press of Colorado; 2008.3. Watson J. Caring Science and Human Caring Theory: Transforming personal/professional practices in nursing and healthcare. JHealth Human Servic. 2009; Symposium issue. [in press]4. Watson J, Foster R. The Attending Nurse Caring Model: Integrating theory, evidence and advanced caring-healing therapeuticsfor transforming professional practice. Journal of Clinical Nursing. 2003;12:360-5.5. Swanson KM. The effects of caring, measurement, and time on miscarriage impact and women’s well-being in the first yearsubsequent to loss. Nursing Research. 1999;48(6):288-98.6. Watson J. Caring theory as ethical guide to administrative and clinical practices. Nursing Administrative Quarterly. 2006;30(1):48-55.7. Rosenberg S. CIN: Computers, Informatics. Nursing. 2006;24(1):53-6. B Lippincott Williams & Wilkins, Inc.8. Persky G, Nelson JW, Watson J, Bent K. Profile of a nurse effective in caring. Nursing Administration Quarterly. 2008;32(1):15-20. Recebido em 21 de janeiro de 2009 Aprovado em 6 de março de 2009O MundO da Saúde São Paulo: 2009;33(2):143-149. 149