Discovering the healthcare beliefs and practices of rural mestizo Ecuadorians. An ethnonursing study/Creencias y practicas del cuidado de salud de mestizos que habitan en zona rural de Ecuador: Un estudio de etnoenfermeria/ Crencas e praticas do cuidado de saude de mesticos que habitam em zona rural do Equador: Um estudo de etno-enfermagem.
The rural population of Ecuador has a disprortionate burden of poverty, lack of access to education, and basic healthcare. Healthcare provided by the government is free but inadequate to meet the health needs of the people living in the rural areas of Ecuador. A report on Ecuador's health care system released in 2010 in conjunction with the national census, observed that 33% of Ecuador's population lives in the rural areas of Ecuador and the supply and quality of care in Ministry of Public Health facilities is generally agreed to be inefficient and poor. (1)
The mestizo people of Ecuador are a mixed race between the indigenous people of Ecuador (Inca) and the Spaniards who ruled Ecuador between 1534 and 1822. Mestizos comprise 71.9% of the population. The term mestizo has no negative cultural or ethnic connotations. (2) Other races within Ecuador are Montubio 7.4%, Afroecuadorian 7.2%, Amerindian 7%, white 6.1%, other 0.4%. (1)
The available research regarding the health care beliefs and practices of rural mestizo Ecuadorians is very limited. Research in Ecuador has focused primarily on indigenous Indian groups, indigenous women and have been conducted in the field of anthropology. (3-5) The anthropology researchers have studied highland indigenous groups and described the naturally occurring diseases including tuberculosis, intestinal parasites, diarrheal diseases, whopping cough and measles. Additionally, the culture-specific ailments included witchcraft (brujeria), evil eye (mal de ojo), envy sickness (envidia), evil airs (mal aire), nerves or depression disorder (nervios), magical fright (susto), soul loss (espanto), water fright illness (bao de agua), alcohol abuse, empacho (bowel blockage) and hot and cold syndrome. (3-5)
Price (4) and Finerman (3) reported a common practice for treatment of disease is home remedies and herbal treatments with medicinal plants. Women were identified as the care providers in the family using these modalities. The practice of self-medication is common in Ecuador. The self-medication practice is more prominent in the rural settings due to lack of access to healthcare providers, poor economic resources, and the practice of home gardening of medicinal plants. Published nursing research related to rural mestizo Ecuadorians is limited to one qualitative study of 19 rural mestizo women and their perceived health needs. (6) The ethnographic study was conducted in the highlands of southern Ecuador and used a feminist approach to describe the health needs and resources available to women. The researchers reported issues related to domestic violence, lack of financial resources and political instability as causes of poor health.
A global initiative of Healthy People 2020 addresses the need for culturally competent healthcare in multicultural societies that may not embrace traditional Western medicine for care of health and illness. (7) Health beliefs and practices are directly influenced by social, economic, educational, and cultural factors. Emic knowledge or the insider's view regarding health and health behaviors are learned within the realm of culture and many are passed from generation to generation. (8) In Ecuador, traditional or folk remedies such as drinking te de manzanilla (chamomile tea) for stomach upset, pasando un huevo (passing an egg) over the body is a culturally acceptable way to cure febrile illness, and petitioning God for good health are examples of health practices that are accepted within a culture and may be passed from one generation to another. (9) Each culture has its own specific beliefs and health practices. Within these beliefs regarding health are also intertwined beliefs about spirituality, illness, death, and healing. (8)
Research utilizing Leininger's Culture Care Diversity and Universality theory uses qualitative methods to answer research questions and discover information about the people from the people being studied. The theory assists the researcher to predict the kinds of nursing care important and culturally acceptable to the people, their healthcare decisions, or actions. (8) The predictions of the theory are in the areas of culture care preservation or maintenance, culture care accommodation or negotiation, and culture care repatterning or restructuring. Leininger's theory helps provide a framework for incorporating a culture's belief system into health care and health promotion. (8) The ethnonursing research method was utilized to guide this study. Using this method (10) enables the researcher to document, describe, and explain the phenomena of healthcare beliefs and practices of rural mestizo Ecuadorians in their natural setting. Ethnonursing research is a qualitative method using naturalistic, open discovery, and largely inductively derived emic modes and processes with diverse strategies, techniques, and enabling guides to document, describe, understand, and interpret the people's meanings, experiences, symbols, and other related aspects bearing on actual or potential nursing phenomena. (9) Emic data refers to the people's interpretation of the world around them, rules of behavior, and what is of importance to them.
In qualitative research, the researcher seeks to understand what is known by the informants regarding the phenomena being studied. (10) Much is unknown about the healthcare beliefs and practices of rural mestizo Ecuadorians. After living and working in Ecuador for seven years, the researcher had assumptions that were explored during this ethnonursing study. The understanding of the health and well-being of groups is achieved through understanding two types of care, professional and generic. Professional care is the care given by health care providers and generic care, the care given by the people, usually family members. The generic care is often in the form of folk-remedies and treatments that have been passed down from generation to generation. (10)
The purpose of this qualitative ethnonursing study was to discover and understand the healthcare beliefs and practices of mestizo Ecuadorians within rural Ecuador. The phenomena of interest are the health beliefs and practices of rural mestizo Ecuadorians in the context of their own culture. Exploring these beliefs and practices will enable nurses and other healthcare workers to provide care that is acceptable, culturally congruent and promotes health. Nurses caring for Ecuadorians within and outside of Ecuador can utilize the findings of this study as a basis for guiding their nursing care and actions.
After institutional review board approval participants were recruited through purposive sampling and word of mouth to participate in this study. The sample consisted of 28 informants. Ten were deemed key informants because of their in-depth knowledge of the domain of inquiry (DOI) meaning the factors that affect the healthcare beliefs and practices of rural mestizo Ecuadorians and the informants ability to give rich description. Eighteen informants were deemed general informants for their verification of information from the key informants. (8) Four people were excluded from the study due to being less than 18 years old. There were no refusals known to the researcher. Inclusion criteria consisted of being at least 18 years old, a self-reported identification with the culture of rural Ecuador, mestizo race, willingness to share information and knowledge about their health care beliefs and practices, and willingness to be interviewed by the researcher.
Setting and informants. Tosagua, Ecuador, is a small rural community named for its annual flooding. The small village has a population of 15 000 that includes many small outlying communities (barrios), Tosagua is the agricultural center of the Manabi province. Most residents work in corn agriculture, granaries, or in fruit and vegetable farming as day workers. Other residents work within the community as business owners, teachers, secretaries, and religious leaders. The province has a climate that is hot and varies from dry to sub-tropically humid depending on the season of the year. The village of Tosagua has three local physicians, many pharmacies, and multiple curanderos (folk-healers). Tosagua lacks an acute care or urgent care facility. If emergency care is needed, the patient must be transported over one hour away to a larger town for acute care services such as X-ray, surgery, or in-patient care.
The researcher has an ongoing relationship in the province of Manabi. The choice of Manabi province and the town of Tosagua was guided by past experiences in these areas and a desire by the researcher to listen to the voices of this community with the hope of improving their health in the future with the outcomes of this research study. Tosagua has been visited by the researcher twice yearly during the seven years the researcher lived in Ecuador. While never living in the village, the researcher often visited to attend a faith-based service and visited twice professionally with medical mission groups. The relationships established during the researcher's visits over seven years were invaluable in allowing the informants to speak freely because the researcher is seen as the Cultural Enabler. Leininger (10) describes the Cultural Enabler as being a trusted friend of the culture. An additional cultural facilitator is the researcher's fluency in Spanish allowing for the interviews to be conducted in private without use of a translator. A local pastor assisted the researcher with access to the community and recruitment of informants. The pastor or gatekeeper was invaluable for facilitation of second interviews to allow member checks for ensuring trustworthiness of the data.
Data collection. Data collection was obtained using digital audio recordings of the informant interviews, observation, and field notes. Observation data was kept in the researcher's journal and included observation of the daily activities and interactions of the community. After verbally explaining the study in Spanish, each informant was given a written consent in Spanish to read and sign. The signed consents were kept by the researcher in a locked drawer to maintain confidentiality. The recorded interviews were stored on the researcher's password protected computer. All informants reported being able to read and write. The consent also included permission for the researcher to use de-identified quotes or paraphrases to present the data in the dissertation, publications, and presentations.
The majority of the interviews were conducted in the homes of the informants. Other interviews were conducted in the office of the gatekeeper. Most interviews lasted one to one and one half hours. Second interviews usually were 30 minutes to one hour. The interviews were conducted in Spanish by the researcher and recorded. The transcripts were translated and back checked by the researcher and a professional transcription service specializing in Spanish language. The transcripts of the translated interviews were then entered into the qualitative data analysis software system NVIVO8.
Data analysis. The collected data was analyzed using Leininger's Four Phases of Ethnonursing Qualitative Data Analysis. The qualitative data software package NVIVO8 was used to facilitate data coding, processing, and analysis of data obtained from the transcribed informant interviews. Leininger (10) described the activities of phase one as the collecting, describing, and documenting of raw data from the general and key informants. During Phase One, categories began to emerge as the researcher would listen to the recorded interview and record in the reflective journal key phrases and similar experiences of the informants. In second interviews, the information related to the categories was clarified and the researcher verified the collected data with member checks. The member checks are used validate data collected from previous and subsequent interviews and ensure trustworthiness. (8) The concurrent data collection and analysis, attention to the detail of the interviews, confirmation of the findings with each informant and faithful representation of the data obtained were used to support the credibility of this research. (8) In phase two the collected data was transcribed, translated from Spanish to English by a professional transcription company, and checked for consistency and accuracy by the researcher who has a level 3 fluency in Spanish. Verbal data, participant observation, and reflections of the researcher from the observations in the community were documented in a reflective journal. The researcher used these notes to record any identified personal bias or preconceived ideas from past experiences living in Ecuador. The NVIVO8 software enabled the researcher to view categories across coded interviews to enhance the identification of recurrent patterning. Nodes from the semi-structured interview guide were used in this phase.
During phase three, the data were analyzed until saturation of ideas was reached and recurrent patterns related to the research questions regarding the healthcare beliefs and practices were identified. Data examination during this phase also showed patterns related to meanings in-context from the informants. The patterns were coded and cross files made within NVIVO 8 linking the patterns with the informants and exemplars. The fourth and final phase of data analysis was the synthesis of data from the previous three phases. Inter-phase checks were performed to verify the emic data, coming from the view of the informant in context of their culture, (10) and findings during each phase and to validate their presence during all phases of data collection and analysis. (8) The researcher rechecked the final themes against the collected data to ensure that the themes were supported by the raw data. The final themes, NVIVO8 coding data, and review of the researcher's reflective journal were reviewed by an expert panel in qualitative research to achieve consensual validation.
The final step was to summarize the data. Results of the data were shared with informants verbally and in writing. The results were presented as part of completion of the researcher's dissertation process, used for publication submission, and public presentations.
This study was carried out with 28 individuals between 22 and 78 years of age; 67.8% were females; regarding marital status, 71.4% were married; regarding educational level, 7.1% had primary education, 64.3% secondary, and 28.5% beyond secondary. As per religious affiliation, 53.6% were protestant, 39.2% catholic, and 7.1% had no religious affiliation.
The research questions and a semi-structured interview guide were used to uncover data related to healthcare beliefs and practices. Eighteen categories were extracted from the raw data of interviews, observation of the everyday lives of the informants and field notes. The discovery of patterns of data inherent in the categories extrapolated from the informant interviews. Six patterns of data inherent in the categories emerged from this phase are: a) pattern of belief In God and the power of prayer b) valuing self-care and preservation practices, c) pattern of external factors negatively effecting health, d) pattern of identified barriers to healthcare, e) pattern of hope being essential to well-being and health, and f) pattern of valuing family caring.
In the final phase of data analysis, Phase Four, the researcher had confirmed four major themes from the categories and patterns. The four themes are reflective of the informant's perception of the meanings in-context, or perception of the world as they view it. The four themes are new knowledge for nurses related to the needs of the rural mestizo Ecuadorians. This knowledge is needed to guide nursing decisions and actions related to the provision of culturally congruent care. The four major themes that emerged from this study were (a) spirituality and prayer necessary for health and well-being: (b) living in community with people positively affects health and well-being: (c) incorporation of traditional medicine with modern medicine is essential to health: and (d) environmental context beyond the control of the people greatly affect health and well-being.
Spirituality and prayer necessary for health and well-being
The belief in God and the power of prayer were supported by all informants. All 28 informants regardless of religious preference reported using prayer on a daily basis. The prayers reported were petitions to God for sustained health and for provision of the needs of the family regarding protection from illness. Prayer is an act that may be individual, within the family, within friendship circles, or corporately with the church. Prayer and its relation to health and well-being as a theme is supported in the literature and supported by the Culture Care Theory. (11) Prayer is an integral part of the rural mestizo lifeway and is desirable between healthcare provider and patient.
In observation, the researcher attended several church services and home Bible studies with the informants. Each service begins and ends with prayer. During the home Bible studies the informants share with one another their needs and petitions for prayer. Many times a health concern was among the petitions either for oneself or for a friend or family member. At a particular prayer service in a home, a young man was obviously in the last days of his life and he was dying of AIDS. The pastor and several male leaders from the church came to the home, held a time of Bible reading and prayer with the man and his family. At the end of the prayer, the pastor anointed the dying man with oil and prayed that God would bring peace in the man's last days. Tears were shed by all present as well as embraces for the man and his family. The pastor emailed the researcher about 2 weeks later with the news that the man died surrounded by his family who sang hymns as he breathed his last. Comments regarding prayer from the informants included: I thank God daily for my health. My health enables me to work, play, and enjoy my family (Key informant).
I also pray that God will protect and keep us healthy also. Once I was sick and could not work. I prayed and prayed that God would make me well. He did but it was a long trial. The church was so valuable to me during this time. My brothers and sisters in Christ surrounded us with love, prayers, food, a little money, and lots of visits. It is good to know that your family is beside you (Key informant). But, my most important job as a Christian mother is to teach the children about God. We pray together and I teach them about faith. We all go to every church service together. I can lead them to God but they must make their own relationship with Him (Key informant).
Living in a community positively affects health and well-being
The theme of living in community and the positive affect on health is new knowledge discovered in this study. Previous studies in Ecuador have been conducted in the field of anthropology and have focused on indigenous tribes. No studies have identified the importance of community on health beliefs. Rural mestizo Ecuadorians live, work, and play together. Common examples are men working together. They can be observed walking to work together, working together at jobs sites such as construction or farm work, eating lunch together, and during lunch time playing soccer or volleyball together. They also walk home together at the end of the day. The camaraderie is shared off of the field also. Men within the local church also meet together before work to exercise together at the local park.
According to the informants having family and friends are essential to health and well-being. A neighbor may be relied upon for health advice, herbs from a patio garden, or a care of a small child if the mother needs to run an errand. Family is very important for individuals to receive care when ill. In illness, the sick rely on family to care for them. In wellness, families teach the children to care for each other through self-preservation practices such as nutritious foods, exercise, and togetherness. Additionally, the finding is not without the thread of spirituality interwoven through this theme as well. Spirituality permeates all aspects of daily life as individuals, families and community living: The men from our church have started our own walking group. We all meet at the church. We walk and share our lives with one another. We help each other through prayer and advice. It is hard to be a Godly man today. Walking helps me be healthy physically and spiritually (Key informant).
Something else I want from my doctor is to be prayed for. I would really appreciate prayer after the visit before I go home. You know God has given us the medicine. I see the doctors as an extension of God (Key informant).
Because I am in a church, I feel cared for, I feel that there are others just like me who are trying to raise families and make a better life for ourselves and others, God willing. Many years my family and I did not go to church. We were sad and nothing seemed to work in our life. This has changed and has changed us (General informant).
In Ecuador, extended families stay together. To live alone is not a common practice. Living at home until one marries is the norm. Single aunts and nieces may live together or other single relatives live in the same home or on the same property with extended family. Being alone is not desirable. This information reiterates the importance of an accompanying family member being constantly present with a hospitalized family member. In Ecuador the family member is needed to help provide care and supplies to the patient due to the hospital system requirements and being support for the patient. This may translate to care differences encountered outside of Ecuador. In hospitals in the United States, the nurse cares for the patients' physical needs and care supplies are supplied by the hospital. The supplies in Ecuador are ordered by the physician and it is the responsibility of the family to purchase the supplies and bring them to the hospital. These supplies include anything from dressing supplies to surgical instruments, medications and intravenous fluids.
Incorporation of traditional medicine with modern medicine is essential to health
All informants related that certain folk illnesses exist and may only be cured by the curandero. The curandero may be used as a primary, secondary, or tertiary healthcare resource and usually involves the use of medicinal plants in care. Twenty of the 28 informants report their parents utilizing the services of a traditional healer (curandero) and all reported visits to the curandero as adults.
Medicinal plants are also a key component to traditional medicine and self-care. The plants are prepared usually by the mother or wife for the entire family. The teas are drunk at meal times or during the day. Many informants use teas rather than colas or fruit juices in effort to obtain a balanced diet. Teas are also important to the informants for their properties to fight infection, treat diseases, and bolster the immune system. In observation in many areas of Ecuador, the practice of drinking herbal teas is common. This finding has significant implications for nursing within Ecuador and where rural mestizo Ecuadorians receive healthcare.
A repeated concern with professional healthcare is the desire to incorporate herbal preparations in conjunction with modern medicine: I was taken as a child to the curandero for mal de ojo (evil eye). Her house is just up the road. She has people who come and go all day and into the night. She treats all sorts of illnesses. Some are our illnesses, you know, mal de ojo and susto. Some people go to the curandero because the medical doctor has not helped them. Sometimes the medical doctor sends them because the problem is spiritual and not medical. The treatments vary from egg, herbs, or baths with herbs. The person usually gets better over the next few days. If the problem is a demonic problem then the person needs to go to the brujo (witchdoctor). The brujo uses witchcraft to help the person. I have never been to the brujo but what I hear is that he uses candles and incantations to saints and devils. This scares me. I would never go. There are some problems that the curanderos cannot treat but I still go to them to be sure I have my health covered. The medical doctors focus on pills too much (Key informant). The curandero can be used to treat other sicknesses too. Some people who do not want to take pills can go to the curandero, tell the curandero the diagnosis from the medical doctor and be treated with the egg and herbs (General informant).
External context beyond the control of the people greatly affect health and well-being
Living in Tosagua is difficult. Everything from obtaining safe drinking water to transportation has its own complications. Access to healthcare is very difficult. A few medical doctors work in the town and are very busy. They provide primary care, acute care, and chronic care for conditions such as diabetes and hypertension. The local physicians are partially meeting the healthcare needs of the town's people. But the informants revealed they would like more services such as urgent or emergency care directly in Tosagua that are currently only available in the larger towns which are one hour or more away.
Other factors that negatively affect health and are out of the control of the people include weather, the environment, the politics, and infrastructure of the town. In rural Ecuador the main modes of transportation are walking, bicycles, motorbikes, public or private vehicles. By far, the majority of people walk everywhere. In observation and experience in Ecuador, walking is at times very difficult due to the absence of sidewalks or poor road conditions. In the rainy season, the rutted roads are full of water puddles and the mud is thick and very slippery. Not only is falling a risk, but being splashed by passing vehicles is a common occurrence. Some roads become impassable due to standing water, deep mud, or landslides. Open sewers remain In much of the city adding to sanitation problems and potential disease: imagine being sick all of the time! Adults and children are sick year around. The rains bring colds (gripe) coughs (tos), tonsillitis (amigdalitis), and skin infections (hongos). The dry season brings allergies (alergia) and asthma (asma). The older i get, the worse the weather and rains. The rains cause so much mud that sometimes we cannot get to church because we walk everywhere. The streets are very slippery and full of mud. We stay home because it is uncomfortable to be full of mud. i miss church so much but what can we do. We get out as we can (Key informant).
The four themes identified in this study are: Spirituality and prayer necessary for health and well-being, Living in community with people positively affects health and wellbeing, incorporation of traditional and modern medicine is essential to health, and External factors beyond the control of the people greatly affect health and well-being are overlapping and not mutually exclusive. The center of all of the themes identified is health. Health has been identified by the informants as extremely important and is interwoven through all themes. In the pictorial conceptualization the overlapping themes represent the factors affecting the health of rural mestizo Ecuadorians. Just as health is the center of the pictorial model, all informants were quick to state that health means everything to them. Health is essential for work and to provide for the family. The four themes influence health and each other. An example of the overlapping nature of the themes are commonly heard in the stories of the informants. A mother related a story of how her daughter during dry season (external context) suffers with asthma (health). She prays (spirituality) and petitions her friends at church (like-minded community) for prayers that her daughter will not have asthma attacks. In addition to regular medical checkups and prescription inhalers, the mother takes her daughter to the curandero for treatment for mal de ojo due to her weak spirit from the asthma (incorporation of western medicine and folk medicine). These findings are also substantiated in the research conducted in other Latino cultures. (3,11-17)
Utilizing the underpinnings of the Culture Care Diversity and Universality theory and the ethnonursing research approach, the data gathered from this study begins to discover the healthcare beliefs and practices of rural mestizo Ecuadorians. The findings are consistent with the cultural life ways of rural mestizo Ecuadorians. In the life of rural mestizo Ecuadorians's spirituality and prayer are integral to the lifeway. The informants reported over and over how they pray and petition God for health, healing, and their daily needs of food, employment, and for others in the community to have their needs met. Not only do they pray to petition but to offer thanks to God for the blessings and good things in their lives.
The rural Ecuadorians live in community with one another. To be a part of the community means you have others, family and friends, who support and stand with you through health, illness, and life. The role of the family in illness and health is one of support and presence. Rural mestizo Ecuadorians, though they live in an area of great need and multiple barriers to healthcare are very interested in their health and desire to be enabled to care for themselves as evidenced by attention to exercise as part of a healthy lifestyle. They desire to care for themselves also with the inclusion of herbs, teas, and the care of folk healers. The expressed desire of the informants is to incorporate their traditional beliefs, prayers, and other health practices with western style healthcare.
Finally, the informants report that many times the factors that affect their health are out of their control. Tosagua has a undeveloped infrastructure and during the extremes of the weather conditions in the Manabi province, heavy rains or near drought conditions, the streets and roads become impassable due to mud and the threat of mudslides is ever present during the rainly season. (9) The open sewers and lack of potable water are of constant concern to the Informants who are aware of the health risks associated with contact with raw sewage and drinking unclean water. The informants report the ways they work very diligently to stay healthy in such adverse conditions by boiling their drinking water and participating in the political scene to elect officials who acknowledge the infrastructure needs of the community.
The informants shared with the researcher four themes they deemed culturally integral to health. This discovery aids the nurse with understanding health, wellness, illness, healing patterns and beliefs within the context of being a rural mestizo Ecuadorian. Leininger (10) defines cultural-specific care as the care that would fit the specific care needs and life ways of that culture. Culturally congruent care refers to the cognitively based assistive, supportive, facilitative, or enabling acts or decisions found in the cultural values, beliefs, and practices of an individual or group in order for the nurse to provide meaningful, beneficial, satisfying care that leads to health and well-being. (18)
Use of the Culture Care Diversity and Universality Theory is beneficial to understand "individual cultures, then to group and family, institutional, regional, and community, societal and national, and finally, global human cultures". (19) The new knowledge for nurses related to the needs of the rural mestizo Ecuadorians generated in this study can guide nursing decisions and actions related to the provision of culturally congruent care. The increase of immigration not just from Ecuador but other Latin American countries is an issue that supports the inclusion of culture care knowledge in nursing and other health education curricula. Implementation of a transcultural component to nursing education is essential to providing culturally acceptable care and one of the Core Competency of Human Diversity from the Essentials for Baccalaureate Education (20) Guiding students through identification of their own personal lifeway's, values, and norms will be assistive in learning about other cultures they may come in contact with during their nursing career.
The presented study investigated the healthcare beliefs and practices of rural mestizo Ecuadorians and the role of the nurse within rural Ecuador and the role of the nurse now and implications for future care. The phenomena of interest investigated were the health beliefs and practices of rural mestizo Ecuadorians in the context of their own culture. With this study, as in much of qualitative research, questions were answered but more questions appeared. The results of this study can be used to begin to enable nurses and other healthcare workers to provide care that is acceptable, culturally congruent and promotes health. Nurses caring for Ecuadorians within Ecuador and those nurses outside of Ecuador caring for Ecuadorians can utilize the findings of this study as a basis for guiding their nursing care and professional nursing actions.
Nursing care has not been studied within the context of rural Ecuador. A significant gap in nursing knowledge is the lack of understanding related to the rural mestizo Ecuadorians experiences with nurses. Zoucha (17) noted in his research nurses are involved in caring for patients from a variety of cultural backgrounds. He challenged nurses to gain an understanding of and appreciation for culturally relevant views of health, illness, and the experiences of care.
Article linked to research:
Conflicts of interests: none.
Receipt date: Oct 31, 2013.
Approved date: Feb 10, 2014.
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Julie A. Moss 
 APRN, FNP-C. Ph.D. Professor, University of Carolina Upstate, Spartanburg / NC, United States.
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|Title Annotation:||Original article|
|Author:||Moss, Julie A.|
|Publication:||Investigacion y Educacion en Enfermeria|
|Date:||May 1, 2014|
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