Family Health Program: the experience of a multiprofessional team

Abstracts

OBJETIVO: O Programa Saúde da Família propõe uma nova dinâmica para estruturação dos serviços de saúde, assim como para a relação com a comunidade e para diversos níveis de assistência. O objetivo do estudo foi analisar o significado da experiência do trabalho em equipe para os profissionais do Programa Saúde da Família. MÉTODOS: O estudo foi realizado no município de Conchas, Estado de São Paulo no ano de 2004. A abordagem utilizada foi qualitativa, na vertente da fenomenologia, buscando a essência da realidade vivenciada por oito profissionais de duas equipes do Programa Saúde da Família. RESULTADOS: Os temas revelaram que o trabalho em equipe se caracteriza por dedicação durante as atividades diárias. É necessário haver interação entre todos os membros para ações integrais, embora haja diferenças de ideologias e condutas entre os profissionais. O contato próximo com as famílias permitiu melhor intervenção nos problemas e o trabalho integrado é fundamental para atuação eficaz e de qualidade. CONCLUSÕES: O fenômeno desvelado engendra nova perspectiva de atuação para os profissionais e possibilita a compreensão do trabalho em equipe multiprofissional.

Programa Saúde da Família; Equipe de assistência ao paciente; Pesquisa qualitativa; Psicologia do trabalho; Satisfação no emprego

Family Health Program: the experience of a multiprofessional team

Elaine Machado de Oliveira; Wilza Carla Spiri

Departamento de Enfermagem. Faculdade de Medicina de Botucatu. Universidade Estadual Paulista. Botucatu, SP, Brasil

^{Correspondence}

ABSTRACT

OBJECTIVE: The Family Health Program proposes a new dynamics for the structuring of health service, as well as for its relationship with the community in its different levels of care. The aim of the present study was to analyze the significance of teamwork for professionals working in the Family Health Program.

METHODS: The study was carried out in the city of Conchas, Southeastern Brazil, in 2004. We used a qualitative approach based on phenomenology as an attempt to reveal the essence of the reality experienced by eight professionals from two Family Health Program teams.

RESULTS: Themes revealed that teamwork is characterized by dedication to daily activities. Interaction among all members is required for integral action, although there are differences in ideology and conduct between professionals. Close contact with families has allowed for more efficient interventions, and integrated work is essential for efficacious, high-quality care.

CONCLUSIONS: The phenomenon unveiled gives origin to a new perspective of action for professionals and furthers our understanding of multiprofessional teamwork.

Keywords: Family Health Program. Patient care team. Qualitative research. Occupational psychology. Job satisfaction.

INTRODUCTION

The close relationship between health worker and family, established in the Brazilian Programa Saúde da Família (PSF - Family Health Program), facilitates the recruitment of individuals for frequent follow-up and the search for fulfillment of health care needs.

One of the demands of PSF is the return of the family's status as a participant in the health-disease process, within which the program attempts to develop preventive, curative, and rehabilitation activities.

The PSF proposes a new dynamics for the structuring of health service, as well as for the relationship between service and community in its different levels of care. It is committed to providing integral care to the population, both at the health care facility and at home, according to the patient's needs, identifying risk factors to which the population is exposed and intervening as required. The program also proposes to humanize health care practice, attempting to satisfy users by means of a close relationship between health workers and the community, regarding health always as a right related to citizenship.¹¹

The PSF was created in 1993 to provide care for families by facing the problems arising from the implementation of the Brazilian Health System (Sistema Único de Saúde - SUS), decentralizing services according to the actual needs of the population, manifested as priorities.⁹

The Brazilian Ministry of Health¹ (1994) determines that the PSF must provide care to a maximum of 4,500 people, and must include at least one physician and one nurse, in addition to nursing assistants and community health workers.

Other issues are also relevant for multiprofessional teamwork. Pedruzzi² (1998), based on extensive debate, argues that this is a means of compensating for ultra-specialization. Multiprofessional teamwork reconstitutes, in integral care, the partial measures that often fail to solve health-related needs in their entirety. This author also reports² that the concept of team is etymologically associated with the carrying out of tasks, of work that is shared between individuals who, based on their collectivity, are able to succeed in performing the given task. This notion, when estranged from certain concrete conditions, may become a "mythical symbol of the ideal of health care practice, or a magical and reconciling solution to conflicts between different professional areas." These concrete conditions include "the division of tasks, inequities in work and in the different degrees of professional autonomy, the differing technical and social legitimacy of the different fields of knowledge, and the rationality typical of professional practice."

The above suggests that teamwork in the PSF is not immune to such wider and historically constructed composition. Thus, the aim of the present study was to analyze the meaning of teamwork experience for PSF professionals.

METHODS

The subjects of present study were eight professionals working for PSF teams in the city of Conchas, Southeastern Brazil. Subjects included two physicians, two nurses, two nursing assistants, and two community health workers Two subjects were males and six were females; all subjects had been working in PSF for at least three years, and were predominantly in the 25-30 years age group. The study was conducted in 2004.

We chose to employ a qualitative approach from the perspective of phenomenology: the search for the essence and meaning of the reality experienced by study subjects, aiming at understanding this reality. Investigation consisted of three moments: description, reduction, and comprehension:

• Description. According to Merleau-Ponty

  ⁷ (1994), the moment of description includes three elements: perception, conscience, and the subject. For this moment, we recorded the statements of PSF team members aiming to perceive the study subjects in terms of the meaning produced by awareness of the teamwork that takes place in PSF with the goal of providing care to families in the community.

• Reduction. This moment is aimed at determining and selecting parts of the description deemed essential to understanding. Based on the recorded and transcribed statements, were proceeded to reduction, carefully considering the statements collected in order to extract their essence.

• Comprehension. This moment reveals the "meaning" of statements, that which is essential to description and reduction, as a form of investigation of the experience. Based on the essence and on the subjects' speech we interpreted the topics unveiled, synthesizing the meaning units detected and their convergences, divergences, and idiosyncrasies.

We used as a driving question: "What does it mean to you to help families and to work as a team in the Conchas PSF?"

The study project was reviewed and approved by the Research Ethics Committee of the Faculdade de Medicina de Botucatu, UNESP. Statements were recorded in audio tapes after subjects had signed terms of free informed consent. Statements were collected until the information obtained was deemed sufficient to extract the essence of the studied phenomenon.

RESULTS AND DISCUSSION

The subjects' statements unveiled the following topics of greater incidence and meaning: "PSF is teamwork," "habilitation for work," "establishment of a connection," "integration between team members," "tasks performed at the PSF," "conflicts at work," "professional history," and "gratifying experience." These topics elicited both convergences and divergences, which are described below.

The PSF is teamwork topic shows that teamwork provides for the continuity of follow-up and for greater involvement with the family through approach by the entire team. Thus, good interaction between team members is essential. Community health workers, who, at times, fail to be adequately appreciated, constitute an essential link between team and community, forwarding any problems encountered among the population for discussion with the team. The nurse has an important role in coordination and integration, encouraging teem members to provide high-quality integrated health care. Speeches include statements such as: " it is easier to work as a team you don't do things alone community health workers are fundamental they see the problem " (S VI). " I liked the fact of beginning to work in a team, the continuity of teamwork, you visit the patient, the nurse visits the patient, and then the physician " (S IV).

The PSF is composed of multiprofessional teams that must perform under a multiprofessional perspective. Team members articulate their practice and knowledge, while responding to each identified situation, in order to propose solutions as a group and to intervene appropriately, given that all members have knowledge of the problems being faced. The community health worker is fundamental in the communication between team and family, since this professional works directly with the population, closely following it and generating subsidy for obtaining information that will be transmitted to the team.⁸

The most active nurse, which is close to the team, allows for the support and coordination of activities, planning, along with the team, the necessary interventions, so that this nurse's work is widely acknowledged and appreciated.

The literature shows that teamwork is the basis for integral action in health⁹ and for providing high-quality care for users' needs according to each scenario and based on previous experience.¹⁰ Approaching the patient within his or her biopsychosocial context is facilitated, for the client is seen by all members of the team, thus involving the patient in the resolution of the problem, encouraging patient autonomy with respect to health care (Teixeira et al,¹³ 2000). The PSF health care team is committed to promoting health and quality of life among the population, not only by means of sanitary and epidemiological interventions, but also considering the biopsychosocial context of the human being.¹²

The team provides integral, effective, continued, and high-quality care, considering the perspective of the family, by means of an interdisciplinary approach, planning of action, work organization, and shared decision making.³

It is necessary to allocate human resources in order to cover all actions; however, the team – which is multiprofessional – does not ensure integral care to the patient. Integrated teamwork requires knowledge and appreciation of the work of colleagues, reaching a consensus regarding the goals to be achieved and the most appropriate way to achieve them.¹⁰

In the habilitation for work topic, statements show that habilitation, even with its orientations regarding territorialization, teamwork, and the duties of each member, may not be sufficient because it does not provide an exact understanding of how the program works. Habilitation must take place before the team is structured, but it is daily work with the orientation and follow-up of the unit's nurse. For example, meetings between teem members to discuss conducts, studies aimed at providing better care and that allow for greater understanding of the program's objectives, especially when training itself does not take place, encouraging professionals to seek knowledge.

Quotes from the statements provide evidence of this analysis: "... when I got here to work, I didn't know what it was to be a community worker we had some training before, a course, but still, that was very new. You watch the person explaining, telling you how things are. It's different from going there and knocking at a door to collect information " (S IV).

According to Pedrosa & Telles⁸ (2001), habilitation includes introductory training for work, with orientation that allows for the integration between team members and for the organization of work. Training often adds nothing new, and is insufficient to introduce the task because it fails to offer a more practical visualization. Training may also consist of following more experienced workers and nurses, that provide orientation to trainees regarding the program's activities.

Teixeira et al¹³ (2000) reported that the population may be exposed to risk and that workers may feel dissatisfied for not performing their work efficiently when there is no planning of activities and only training tasks are carried out.

In the topic establishment of a connection, we found that the connection established between health worker and community through frequent contact facilitates adherence to the program and approach by the team. However, it may lead to feelings of impotence, given the agent's limited power of resolution. Contact with the family ultimately generates trust in the community health worker, who becomes a confidant. In these cases, confidentiality is always ensured, according to the ethics learned during orientation. According to the following statement: " the community agent ends up by knowing the entire population it is difficult to say: we didn't make it' " (S VIII).

The establishment of a connection is an important feature of the Ministry of Health's proposal for PSF (1999):⁴ "thus, PSF elects as its central feature the establishment of connections and the generation of commitment and co-responsibility among health professionals and the population."

In order to establish a connection, professionals must first gain the confidence of the population, which emerges with the recognition of this professional as a participant in the individual's own treatment, being considered by the patient as a reference and as a confidant when his role is understood.^8,13

This connection is a consequence of a closer relationship between team and population due to household visits, which facilitate the population's adherence to the health service. The population feels better cared for, for the team intervenes with a wider view because of the greater knowledge of the population, stimulating autonomy and participation in treatment, in a relationship of respect and valorization of particularities, including the co-responsibility for its own welfare.^12-14 The population commits to the proposed activities and allows for a connection to be established when it is satisfied with health services, thus improving quality of life and disseminating the program throughout the country.^11,12 These factors contribute to the promotion of health and reduce the number of hospital admissions.⁵

According to Campos¹ (1997, p. 235): "(...) the recovery of connection-based clinical practice is a practical means of combining autonomy and professional responsibility." Care centered on a connection allows for the health service to follow the patient and identify the results of the work of each professional, granting, through his or her practice, citizenship to both patient and family.

Community health agents identify with the program through frequent contact with the community, and the community's demand for interventions that are beyond the agent's power of resolution may be frustrating.⁸

The commitment of health policies may expose the limits of their action alongside the population in the context of the community's socioeconomic status. This is a very difficult scenario to operate in, and may cause health workers to suffer for not being able provide solutions to all the social problems that inherent to community health care.¹³

The analysis of statements related to the topic of integration between team members showed that the integrated team works towards family health, sharing experiences, fulfilling needs, and solving problems through their knowledge of the situation of each individual user, as indicated by the statement: " everything is done in order to help the patient everything is discussed so as to avoid contentions " (S II).

According to Pedrosa & Teles,⁸ a good relationship between team members facilitates contact with families and the carrying out of preventive measures such as immunization, antenatal care, and organization of demand by scheduling. The community appreciates integration and ratifies by participating in the care process.

A variety of factors can hinder team work and affect the quality of work. These include the community's social problems, precarious working conditions, internal conflicts, and low wages. The team is required to organize itself so as to be able to promote measures capable of preventing the growth of such problems. Promoting dialogue between team members to improve collective work, increasing the team's morale, and including all members in the definition of actions to be implemented and goals to be met are measures that promote team integration and increase care quality.¹²

In the topic tasks performed at the PSF, statements showed that the care provided to the community by the physician and nurse is generalist in character, covering all medical specialties. Tasks performed vary according to professional category. Each professional performs his or her own tasks while exchanging information with the other team members in order to acquire integral knowledge of users and family members and to provide better care. The team holds periodic meetings and household visits, through the community health worker, who collects the history and health problems of each user and transmits them to the nurse or physician, who orient the team during visits and appointments. With time, users perceive that appointments with the nurse may solve certain problems, and accept such appointments as part of PSF.

This can be seen in the following statements: "... the PSF physician must be prepared to cover all specialties " (S II). " we do the visit and take the problem to the nurse along with all the patient's history " (S I). " during the first visit the person says 'I don't want you in my house' so I talk to them now I'm getting some feedback " (S V).

Campos¹ (1997) argues that health care professionals have their own realms of action and specific knowledge, but that all of them must consider the patient within his or her biopsychosocial context.

The nurse orients and organizes the population's demand; however, this may be a difficult task, as it encompasses other problems in addition to health, such as violence and drug use. In the beginning, communities resist to the program due to mistrust regarding the type of care proposed, but later, communities become involved in the program's activities. The community health worker plays an important role in the process of engaging the population to participate in the promotion of health and prevention of disease.⁸

As seen in the topic conflicts in work, conflicts between team members arise because of the diversity of opinions and postures. While some of the team members attempt to control the entire organization of the program, others idle, failing to adequately perform their tasks. This is supported by the statement: " in the case of this unit they didn't fit the profile people making trouble " (S VI).

The coordinating role of the nurse must be well established in order to maintain the organization of activities among team members and to discuss proposals for the solution of problems, as evidenced by the statement: " the unification that I'm achieving here makes me happy the care the doctor and I, we work as a team " (S V).

Conflicts in interpersonal relationships may arise when teams face situations that are difficult, or that generate competition.⁸ This shows a lack of commitment towards the continuity of each member's work, often caused by the insufficient interaction between team members.¹⁵

The different styles of management of family health teams may generate conflicts between members, or between team and community, since the program may become unable to fulfill the demand for services due to lack of organization and integrity in work.^3,4,11

Working conditions, wages, competences, and responsibility are frequent causes of segmentation in the team and of disregard for its health measures.¹

The nurse must reclaim the concept of teamwork in the Program, the remuneration and acknowledgement of which must compatible to its role as a means of social construction guided by social needs.²

The topic professional history revealed that the different professionals that compose the PSF team share a common trait regarding their new experience. Work in PSF is generalistic in character, differing from the monodisciplinary view of medical specialties. Professionals ultimately identify with their profession, and, despite the lack of financial incentive, follow a course of improvement in the field. This is evidenced in the following statement: " PSF experience new to me interesting because I had a very monodisciplinary view "(S VI).

Teixeira & Mishima¹⁴ (2000), unlike what is discussed in the present article, show that professionals usually have prior experience in primary health care.

In another article, Teixeira et al¹³ (2000) highlight that nurses have prior experience in primary health care facilities and hospitals, and nursing assistants each in a different field, in addition to community health workers with university degrees.

In the gratifying experience topic, we found that, when work is done with commitment and pleasure, results are gratifying and patients acknowledge the team's performance, accepting the program's conducts and demanding household visits, because adequate intervention solves their problems through teamwork, which allows greater proximity with the community and better follow-up. As shown in the statements: " it is very gratifying work I like what I do it's great to work in a team " (S I).

In order for an experience to be gratifying, it is important that challenges to improve quality be overcome. To give life to work, to experience solidarity, to live the present while constructing the future, to seek professional and personal equilibrium, are all goals to be achieved that lead to satisfaction for both professional and patient.⁶

According to Garaudy⁵ (1979) "the decisive force is motivation, a passionate and critical, lucid and creative awareness of our reasons to live, the safeguard, in each man and in all men, of what is specific to him, the additional strength that comes from faith in transcendence and love, the only forces capable of granting to a man, that is, to an autonomous being, solidarity, creativity, and responsibility."

The Figure represents in a synthetic form the topics and units of meaning revealed by the study subjects.

CONCLUSIONS

According to our findings, we can discuss the relevance of teamwork in the PSF: the integration between team members allows professionals to exchange information related to patients in order to take appropriate action according to the needs identified by the team. Each member has a role in the Program, and fulfilling this role with dedication makes work gratifying and leads to acknowledgement by the team and by the community. Teamwork is very important to provide integral assistance to patient and family. When all members are aware of the families' needs, approach is total and more efficient, since the entire team participates in the follow-up.

Patient and family are satisfied when problems are solved, which leads to trust in the team, allowing for greater involvement. The connection established improves the quality of care, because the patient/family adhere to the program and participate in interventions. In addition, it allows for personal confidences made during household visits to develop the understanding of subjects' needs and of relationship ethics. The population acknowledges the staff's achievements and the effectiveness of work, which facilitates program dissemination.

Conflicts in work are inherent to the interdisciplinary perspective proposed by the program, and allow for the reestablishment of interactions between team members. The PSF experience allows for the development of measures aimed ad changing health care practice and the autonomy of subjects participating in this proposal.

The phenomenon unveiled gives origin to a new perspective of action for the multiprofessional team, and allows for the construction of proposals that are integrated and articulated to the reality of families in their specific context.

REFERENCES

Received: 12/13/2004

Reviewed: 1/20/2006

Approved: 2/16/2006

Presented at the 56^th Congresso Brasileiro de Enfermagem, in Gramado, Southern Brazil, 2004.

• 1. Campos GW. Subjetividade e administração de pessoal: considerações sobre modos de gerenciar trabalhos em equipes de saúde. In: Merhy EE, Onoko R, organizadores. Agir em saúde: um desafio para um público. São Paulo: Hucitec; 1997. p. 229-66.
• 2. Campos GW. Um método para análise e co-gestão de coletivos. São Paulo: Hucitec; 2000.
• 3. Costa ARC, Melo MC, Oliveira MA, Dias RN. Atuação do enfermeiro no Programa de Saúde da Família em Sobradinho II. Rev Bras Enfermagem. 2000;53(N Esp):127-30.
• 4. Costa MBS, Lima CB, Oliveira CP. Atuação do enfermeiro no Programa de Saúde da Família (PSF) no estado da Paraíba. Rev Bras Enfermagem 2000;53(N Esp):149-52.
• 5. Garaudy R. Apreço dos vivos. Rio de Janeiro: Nova Fronteira; 1979.
• 6. Leopardi MT. Introdução. In: Leopardi MT, Kirchhof AL, Capella BB, Pires DE, Faria EM, Souza FR, et al, organizadores. O processo de trabalho em saúde: organização e subjetividade. Florianópolis: Papa-livros; 1999. p. 9-22.
• 7. Merleau-Ponty M. Fenomenologia da percepção. São Paulo: Martins Fontes; 1994.
• 8. Pedrosa JIS, Teles JBM. Consenso e diferenças em equipes do Programa Saúde da Família. Rev Saúde Pública. 2001;35:303-11.
• 9. Santos BRL. O PSF e a enfermagem. Rev Bras Enfermagem. 2000;53(N Esp):49-53.
• 10. Schraiber LB, Peduzzi M, Sala A, Nemes MTB, Castanhera ERL, Kon R. Planejamento, gestão e avaliação em saúde: identificando problemas. Ciênc Saúde. 1999;4;221-42.
• 11- Sousa MF. A enfermagem reconstruindo sua prática: uma conquista no PSF. Rev Bras Enfermagem 2000;53(N Esp):25-30.
• 12. Souza RA, Carvalho AM. Programa de Saúde da Família e qualidade de vida: um olhar da psicologia. Estud Psicol (Natal). 2003;8:515-23.
• 13. Teixeira RA, Mishima SM, Pereira MJB. O trabalho de enfermagem em atenção primária à saúde da família. Rev Bras Enfermagem 2000;53:193-206.
• 14. Teixeira RA, Mishima SM. Perfil dos trabalhadores de enfermagem no Programa de Saúde da Família. Rev Bras Enfermagem 2000;53:386-400.
• 15. Trench MH, Peduzzi M. Trabalho em equipe e trabalho em grupo no Programa de Saúde da Família. Rev Bras Enfermagem. 2000;53(N Esp):143-7.

1

Ministério da Saúde. Programa de Saúde da Família: Saúde dentro de casa. Brasília (DF); 1994.

2

Peduzzi M. Equipe multidisciplinar em saúde: a interface entre o trabalho e a interação [tese de doutorado]. Campinas: Faculdade de Ciências Médicas da Unicamp; 1998.

3

Ministério da Saúde. Saúde da família: uma estratégia para reorientação do modelo assistencial. Brasília (DF); 1998.

4

Ministério da Saúde. Saúde da família: uma estratégia para a reorientação do modelo assistencial. Brasília (DF): Coordenação de Saúde da Comunidade; 1997.

5

Bertoncini JH. Da intenção ao gesto uma análise da implantação do Programa de Saúde da Família em Blumenau [dissertação de mestrado]. Florianópolis: Departamento de Saúde Pública da Universidade Federal de Santa Catarina; 2000.

Publication Dates

• Publication in this collection
  18 Oct 2006
• Date of issue
  Aug 2006

History

• Accepted
  16 Feb 2006
• Reviewed
  20 Jan 2006
• Received
  13 Dec 2004