Interaction between professionals and cancer survivors in the context of Brazilian and Canadian care 1

ABSTRACT Objective: analyze cancer survivors’ reports about their communication with health professional team members and describe the similarities and differences in interactional patterns between Brazilian and Canadian health care contexts. Method: This study adopted a qualitative health research approach to secondary analysis, using interpretive description as the methodology, allowing us to elaborate a new research question and look at the primary data from a different perspective. There were in total eighteen participants; all of them were adults and elderly diagnosed with urologic cancer. After being organized and read, the data sets were classified into categories, and an analytic process was performed through inductive thematic analysis. Results: This resulted in three categories of findings which we have framed as: Communication between professional and survivor; The symptoms, the doubts, the questions; and Actions and reaction. Conclusion: This comparative study allowed us to bring to the attention of health professionals, especially nurses, findings regarding effective communication, humanization and empathy, supporting both inside and outside support groups, giving pieces of advice, and advocating for the survivor as is necessary. The study also showed the importance of self-development of these professionals as they fight for better quality in the health system for their patients.


Introduction
Cancer survivorship represents the state or process of living after the cancer diagnosis, living with cancer, through and beyond it. The term is used by healthcare professionals, researchers and patients themselves with cancer, extending to their families. It is a concept that seeks not only to identify and understand the survivors' physical, social, spiritual and psychological issues, but also offers the idea that proper care involves promoting quality of life for this group (1)(2)(3) . Thus, in order to understand and address these questions, the cancer survivorship care plan acts as a tool that facilitates the coordination of care by the survivors themselves, the multidisciplinary team, and others involved (4) .
It is the time after the end of primary treatment that is neglected by health professionals and researchers though. At this moment, the survivors become confused and are confronted with new challenges and anxieties in returning to their "normal life" (5) . Following on this idea, professional and patient interaction should help the survivors rebuild a new normality. Nevertheless, as the authors (3) delineated, there are still barriers that harm the quality of care in the cancer survivorship process. Among those that matter most is what the authors highlight as poor mechanisms for communication. Communication is complex, dynamic and linked to the context (6) , it is difficult to quantify and control (7) ; furthermore, it is strongly influenced by behaviors of both the patient and the health professional (5,8) . The literature related to communication in the cancer context indicates that the patient and professional relationship is vital to survivors' quality of life and a powerful factor in the quality of care (9) .
Moreover, effective communication is fundamental and is directly linked to the patient's well-being and satisfaction with care services (9)(10)(11) .
Therefore, in the context of a research internship in Vancouver, Canada, one of the authors had the opportunity to make a technical visit and meet members of the health system at an oncologic hospital in Vancouver, which is a reference cancer treatment center and also delivers followup care to cancer patients. Because of this opportunity, she realized that, in the context of her country's health system (Brazil), there is still a lot to be done; there are operational barriers in the health system that need to be surpassed and new frontiers that have to be achieved. On the basis of this insight, in analyzing both the Canadian data and data collected during her doctoral research in Brazil, the researcher realized that the patients from both countries always -directly or indirectly -expressed at some point within their discourse either praise or criticism of the

Method
This study was a qualitative study with interpretive description as a methodology. Interpretive description is designed for the explicit logic of knowledge development in the applied health disciplines. Rather than grounding theoretical scaffolding in the social sciences from which conventional qualitative approaches emerged, this method draws upon disciplinary logic to guide the inquiry process toward knowledge forms with direct practice utility (9,12) .
Secondary analysis is a strategy that allows us to elaborate new research questions and look at the primary data from a new perspective; thus, it explores existing data in a manner that was not previously explored. Moreover, although connections between professional team members and patients' interactions were not the focus of the original interviews, these themes were clearly represented in the data from both studies and largely informed the secondary research questions (13) . In other words, despite the fact that the Canadian data focused on participants' experiences of helpful and unhelpful cancer communication, and the Brazilian data focused on cancer survivors' experience after the treatment, the authors reviewed the data sets to address this new research question, related to the theme of the original studies but not formally examined (12) . Thus, the secondary analysis process created the potential for the development of wider theories about cancer communication through a comparison of two distinct and theoretically representative databases (14) .
Because qualitative inquiries often involve intensive data collection using methods such as semi-structured interviews, participant observation and fieldwork approaches, they typically create data sets that contain www.eerp.usp.br/rlae 3 Oliveira RAA, Zago MMF, Thorne SE. a wealth of information beyond what can be included in a primary research report. Furthermore, as time goes by, new questions often arise for which existing data sets may be an efficient and appropriate source of grounded knowledge (13) . Qualitative secondary analysis is a method for study of phenomena within a data set that would not have been considered significant at the original time of inquiry. Moreover, it can be an efficient and effective way to pose questions that extend beyond the scope of any individual research team's findings (13) .
The form of secondary analysis used here is "analytic expansion" -a term used to refer to the kind of study in which a researcher makes further use of a primary data set in order to ask new or emerging questions that derive from having conducted the original analysis but were not envisioned within the original scope of the primary studies aims (15) . The interviews had a minimum duration of one hour and a maximum of two hours. They were scheduled and recorded with the consent of the participants and took place according to the participants' availability to receive the researcher at their residences. Several interviews were obtained from each participant until we were able to achieve the study objectives. During the meetings, we observed the environment, the contacts between family and friends, paying attention to the nonverbal messages displayed and participating in some daily activities.
The project was submitted to and approved by the Research Ethics Committee at the Ribeirão Preto College of Nursing from University of São Paulo (process 503.385, December 9th, 2013). The patients were assured of their rights to be informed about the study and freely consent to participate in it, also being assured of the confidentiality of identification and the information that was provided.
The second dataset is from Canada. The data for the Canadian sample was part of a larger database consisting of interviews (an average of three for each participant) with nine men ranging in age from 54 to 81 (mean=69.2) and with primary prostate cancer. The participants included those diagnosed with early and advanced stages of cancer, some living with metastatic disease, and others who selfidentified as cured or in remission. All participants selfidentified as Caucasian (n=9). Regarding the educational level, while a few had high-school education, the majority of the participants had concluded university or college and most of them were married, while one was single. The characteristics of all Canadian and Brazilian participants are described in Table 1, as follows. The original study using this subset of survivors (9) used interpretive description (12) and nursing's disciplinary epistemology to frame the study and conduct the analysis. what we understand it to mean in relation to the problem we are addressing (9) .
Within the interpretive description, we used thematic analysis as a method for identifying, analyzing and reporting patterns within data. This kind of analysis consists of an interpretive process of organizing the data based on searching for sense according to the commonalities, relationships and differences between cases (16) . Moreover, the analysis is not a linear process where you simply move from one phase to the next. Instead, it is a more recursive process, where you move back and forth as needed, throughout the six phases of familiarization with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report (16) .

Results
Through the data analysis process, it was observed

Discussion
The findings from this study indicate that the issues raised by the participants are not different from what can be evidenced in the literature (5,9,(18)(19)(20) .  to expect in this phase of their cancer journey (9) . In other words, to enter into the survivorship universe typically became confusing and emotionally disturbing, instead of the sense of relief and normalcy most had expected (5) .
Many had to adjust to new responsibilities associated with work and family post-treatment and were concurrently coping with feelings of loss or/and abandonment arising from an abrupt separation from the feeling of security that regular contact with experts afforded. What helped many during this emotionally complex period was assistance to contextualize their new state of "normal", including anticipation and management of these dependencies that had arisen during the active treatment phase (5) .
Despite widespread acknowledgement of the importance of communication for both quality of life and cancer outcomes in cancer care, the evidence continues to confirm that significant numbers of patients cannot access suitable communication (5) . patients (11,21) and the responsibility of conveying complex health information to the patients while also managing their emotions (10) besides insufficient training, low selfefficacy and poor emotional regulation (22) , are some of the challenges that affect communication in the professional and patient dyad in the context of cancer. Authors who have been working in this field have found over a decade that cancer communication is so complex and difficult that effectiveness seems improbable (5) . Nevertheless, from the patients' perspective, it is apparent that patients expect individualized approaches to communication and that involves awareness of their individually distinct contexts.
They prefer that relevant communications occur within the context of the human connections associated with effective healthcare relationships (5) .
In one study (22) , the authors realized that, although the majority of care models that were developed and tested in Western cultures kept the focus on individuality, their findings noted the importance of developing culturally appropriate care and education for the patients in their context. Culture is a symbolic and public system focused on the individual (23) . Therefore, culture is learned, shared and standardized, and its constituent elements are values, symbols, rules and practices. Thus, communication that takes into account the cultural issues might improve access to healthcare and quality of healthcare, and reduce and/ or eliminate health disparities (10)(11) . Internationally, there are already studies (10,11,24) (18) .
There are some aspects of effective communication that only apply to nurses; these include educating patients about lifestyle and health promotion, giving support, spreading good humor and cheer, serving as a go-between for doctors and patients, balancing professionalism and close relationships with patients, and checking whether patients have everything they need (18) .
This study includes perspectives for all professionals involved in health care within the cancer survivorship process, especially for nursing, in which the nurse acts as a key part in all thematic patterns outlined here.
It is already known that the healthcare professional's ability to effectively and sensitively communicate with cancer patients and their family has a huge impact on the cancer survivorship experience. That ability is honed through years of intricately weaving together theoretical knowledge, evidence derived from research, ethical reasoning, experiences and critical self-reflection about patient care experiences, in conjunction with the nurse's own evolving capacity for therapeutic communication (25) .

Conclusion
The and also fighting for a better quality in the health system.
It can be seen that the Brazilian health system remains in a situation of enacting health policies in theory, with little evidence in practice. It is necessary to build research programs that will make explicit the optimal role of the nurse in relation to warranting cancer survivors' quality of life, especially after the end of the treatment, when they bear the complications of the disease and, at the same time, have a strong desire to return to their "normal" social lives.