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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.45 no.4 São Paulo Aug. 2011
The community health agent and working as a team: the easy and difficult aspects*
El Agente Comunitario de Salud frente al proceso de trabajo en equipo: facilidades y dificultades
Cássia Regina Fernandes Biffe PeresI; Antonio Luiz Caldas JúniorII; Roseli Ferreira da SilvaIII; Maria José Sanches MarinIV
Master in Collective Health. Teaching Assistant at Faculdade de Medicina de
Marília. Marília, SP, Brazil. firstname.lastname@example.org
IIPhysician. PhD. Assistant Professor of the Public Health Department at Faculdade de Medicina de Botucatu at Universidade Estadual Paulista. Botucatu, SP, Brazil. email@example.com
IIINurse. PhD. Adjunct Professor of the Department of Medicine at Universidade Federal de São Carlos. São Carlos, SP, Brazil. firstname.lastname@example.org
IVNurse. PhD. Professor at Faculdade de Medicina de Marília. Marília, SP, Brazil. email@example.com
The objective of this study is to analyze the easy and difficult aspects of teamwork according to community health agents. Qualitative analysis was carried out from the hermeneutical and dialectic perspective; the reference point was the senses interpretation method. The strengths and weaknesses they pointed out revealed that working as a team requires emotional relationships, with emphasis on communication, respect and cooperation, and that team meetings is an important strategy to achieve this. In conclusion, there is a need for continuous investments in team member relationships.
Descriptors: Family Health Program; Community health aides; Patient care team
El estudio se propone analizar las dificultades y facilidades de los Agentes Comunitarios de Salud (ACS) frente al trabajo en equipo. El análisis se pautó en la perspectiva hermenéutico-dialéctica, teniendo como referencia los principios del método de interpretación de los sentidos. Las dificultades y facilidades apuntadas por ellos revelan que trabajar en equipo demanda relaciones efectivas, con énfasis en la comunicación, respeto y cooperación, siendo las reuniones de equipo una estrategia importante para ello. Se desprende la necesidad de constantes inversiones en las relaciones entre los miembros del equipo.
Descriptores: Programa de Salud Familiar; Auxiliares de salud comunitaria; Grupo de atención al paciente
In 1991, the Brazilian Ministry of Health institutionalized the Community Health Agents Program (PACS), with a view to meet the health needs of populations at risk and overcome practices that were being developed in an isolated and focal manner. In 2002, the Community Health Agent (ACS) profession became legal and it was established that this work should take place exclusively with the Public Health System (SUS)(1).
As of 1993, when the Family Health Strategy (ESF) began being idealized, the PACS was implemented as transitory. The ESF, aiming at implementing the principles of integrity, universality, and equity proposed by the SUS, established that work should be performed as a team consisting of: one physician, one nurse, two nursing aides, and four to six ACS, which are essential professionals to develop the intended activities(1).
The ESF proposes, essentially, innovations to the organization of the productive process by changing how the working process operates, mainly focused on the live practice, which means betting on relationships and the constitution of self-analytical and self-managed processed so as to it is possible to overcome the hegemonic health care model(2).
In this context, the ACS represents a new element and is considered a key-character in the organization of health care, as they assume a bidirectional position, because they live within the community where they work and, at the same time, are members of the health team.
Their working process is understood under the logic of the production of procedures as an expression of care, that is, of the technological practice and the logic that favors activities centered in the relationship with users with a view to meeting their needs - communicative practice(2).
The work of the ACS, therefore, occurs under the tension of two poles and is quire complex, considering that they enter homes; directly receive the complaints of the population, becoming directly committed to the need of providing answers and forwarding the problems that are found. At the same time, they must deal with the team and work according to the possibilities and limitations that are established by the team itself and the health system.
When pondering on the inclusion of the ACS in health work and the proposals of work with the PACS/ESF, one must consider the great challenges that are implied, especially that of working as a team, as this aspect is not well understood and incorporated even by professionals who have specific preparation to work in the health area. Furthermore, the other team professionals hold technical knowledge that assigns them more legitimacy when joining a health team.
The work of ACS implies performing actions and interaction, which include several situations to which, in the health area, no systemized knowledge or adequate working and managing instruments have been developed. That includes from approaching the family, to being in touch with precarious life situations that determine the health conditions, to social inequalities and the search for citizenship(3). A study that identified the possibilities and limitations of the ACS in the ESF revealed that the actions they develop still do not correspond to the expectations of the team, government, community, and ACS themselves(4).
It should, however, be highlighted that working in health, especially under the ESF proposal, is essentially collective, in which the contribution from each member of the team and the integration of their knowledge is the essential condition to maintain and qualify the care that is delivered.
Some authors stress on the importance of composing the health team to respond to the demands of the system, but also emphasize on the difficulties that are dealt with when implementing those teams. The main difficulty reported refers to the relationships established every day between professionals, which originate two issues: the loss of professional identity, and the loss of the power of autonomy(5-7).
It should, however, be emphasized that if the challenges of working as a team are not dealt with, there is a strong chance that the health care model centers on biological aspects and on disease will be maintained(8).
Teamwork in health is considered to be
an interrelation of people with their knowledge, feelings, expectations, and fantasies in a game to satisfy the needs of users and workers, which occur differently in the different moments of history and is in permanent interchange(9).
The idea of teamwork is associated with its members performing activities together, sharing the same goals, and should be supported on the relevance of the combination between actions and on recognizing the technical differences of the specialized practices, and the interdependence and autonomy of the professionals(5). Therefore, in this context, emphasis is given on the importance of communication between the work agents.
Founded on the Habermasian perspective, the same author(5) evinced that in the subjects' representation, the communication between professionals is the common denominator of teamwork, however, it may occur in three different forms. In the first, communication appears outside work, it is not practiced or is only practiced as the use of a technique. The agents find tension between the communicative and instrumental aspects of work, and the communicative practice does not take place. In the second form, communication occurs strictly as something personal, and personal relationships are emphasized, with feelings of friendship and companionship, overlapping the personal and technological dimensions. Thought a certain level of communication exists, there is also no communicative practice. In the third form, communication is understood and practiced as something intrinsic to teamwork, and the following are developed by the agents in collaboration: languages, proposals, common culture; thus making it possible to elaborate a common care project. Communicative practice takes place, and may cause tension due to the instrumental hegemony of technical practice. It is understood that to establish communicative practice, in addition to sharing technical foundations, there must be a common ethical landscape, also emphasizing on the dimension of the intersubjectivity of work between professionals(5).
In teamwork, complex conditions permeate the relationships, highlighting the technical division of work, the different levels of professional autonomy and the social legitimacy of the many different types of knowledge implied in the practices of the health professionals(10).
In this context, the purpose of this study is to support the reflection on the dynamics of ACS work in the city of Marília-SP, and make it possible to establish strategies to improve the quality of health care and their work conditions. The objective of the study was to understand the inclusion of the ACS in the working process of primary health care teams by analyzing their strengths and weaknesses, from their own perspective.
The present study uses a qualitative research approach and was performed with all ACS of Marilia-SP, which is a city located in the Central-West region of the state and has a population of approximately 220,000. The Brazilian Primary Health Care network currently comprises 12 Health Care Units (UBS) and 28 Family Health Units (USF), which, in their respective covered areas, serve as a front door to the health system.
The ACS works in every UBS and USF in the city, which means a total 339 professionals, and every UBS has implemented the PACS. Data collection was performed using a convenience sample with the purpose of contemplating the ACS working in both UBS and USF; of both genders; of different ages; different education levels and with different times of work as ACS. Hence, interviews were performed with 16 ACS, identified with the letter "E" (from 1 to 16); and also according to their work unit (USF or UBS). This sample was selected based on the principles of qualitative research, which main concern is on deepening and broadening understanding, using sampling criteria that permit to reflect the multiple dimensions of comprehensiveness. The number of individuals considered sufficient is that which permits a certain recurrence of information; however, not disregarding the unique information whose explanative potential must be taken into consideration(11).
The interview was guided by questions focused on the work relationship with the team, and the difficult and easy aspect of teamwork. The interviews were recorded and fully transcribed for further content analysis.
To take part in the interview, all interviewees provided written consent. The research project was approved by the Research Ethics Committee at Faculdade de Medicina de Marília, as per the National Health Council Resolution 196/96.
The analysis of the data obtained in the interviews was guided by the hermeneutic-dialectic perspective, and the framework was the interpretation of the senses(12), both of which aim at interpreting the context, reasons, and rationale of the statements and actions, correlating the data to the group of interrelationships and conjectures, amongst other analytical bodies.
Based on this perspective, a comprehensive reading of the ACS statements was performed. Next, the regularities and unique experiences were identified, by means of the senses subjacent to the ideas described in the interviews. Finally, an interpretative synthesis was created, anchored to the confrontations of the points of view and the expression of the individuals' experiences. It was included to this synthesis, in the form of critics, the interpretation that the evaluators made about the interpretations produced by the ACS, aiming to evince the easy and aspects they had while working as a team.
RESULTS AND DISCUSSION
ACS: easy aspects in teamwork
The easy aspects of teamwork pointed out by the ACS refer to the construction of interpersonal relationships, which are expressed through the possibilities of discussing on everyday issues, the liberty to speak, communication, and dialogue, attitudes of respect, common language, their will to learn, co-responsibility and bonding. That construction, from the view of the interviewees, is favored by the strategy of team meeting.
...what makes it easier for us is that, like, every week,... we have the team meeting and every Monday we have the community health agents meeting with the nurse, you know, which is when we, like, solve doubts and give instructions... (E3/USF).
In a study performed with a PSF team of a city in Bahia, ACS also valued team meeting, as it was considered a space to relieve any distress they had, and solve doubts, thus consisting of a moment to provide technical information(13).
In the referred study, it was concluded that team meeting had an important role, as it permits team members to discuss on the problems that emerge in everyday practice(8). Team meeting should permit reaching consensus to solve any identified problems(13). We also observed the same fact:
...we have the meeting to discuss on certain cases, their development, I won't say it's 100%..., but we have it to solve small things in the PSF such as organization and all, and we can always give our opinion... (E15/USF).
It is also evinced that building work relationships in teamwork is made possible because of the liberty to speak, which allows for pondering on new paths to follow in the situations brought up in the discussions.
... nothing is left unsaid; we say it's time to do the laundry... this liberty to speak... to see what is right and what is wrong... (E3/USF).
Communication and dialogue are stated by the interviewed ACS as necessary for teamwork.
Communication in the team, I think is essential... the other person cannot guess what you are thinking, I think that having a nice talk, dialogue, exchanging ideas, all of that important for the team (E15/USF).
... if you can't talk, if you are always stressed out and you don't let that dialogue happen, it won't work; it's no use: dialogue is essential and so is respect... (E7/UBS).
Communication is considered an important indicator of the many possible moments of establishing a group(14). There are two ways of having communication, causing misunderstandings and paralyzing situations; however, it can be an instrument for development and exchange. In the teams, many ideas may be presented and shared without being explicitly stated. Ideas stated implicitly must be clarified and set on the table, according to the ACS.
From the perspective of the interviewed ACS, parallel to dialogue, attitudes of respect among the professionals favor the team relationships.
...you should respect that person regardless of his or her position; rather, as a person and there should be dialogue; that is the main aspect to have a good relationship with the team: that dialogue (E7/UBS).
Allied to dialogue, common language is a form of portraying team integration, along with the objectives, propositions, as well as common cultures, culminating in a common care project, which is constructed by the close relationship between technical interventions and communication between the professionals, thus understanding the occurrence of the communicative practice(5).
... if we all care and speak the same language, I think it makes things a lot easier; there is no use in trying on one side and needing help from someone else, if that someone is not willing to help, I think that speaking the same language, getting along, and also respect, from the patient as well as the other [professional]... (E10/USF)
Another attitude pointed out as important to make teamwork easier is the willing to learn and see situations from a broader view, as observed in the following statement.
Having an open mind, I try to see the good things, the good ideas; if something doesn't work we also try it, but when you see it didn't work you don't repeat it, you change again and I think that it means having an open mind, a broad view of the situation... (E13/USF).
Because learning is hand in hand with communication, and learning surpasses one person transferring knowledge to another, that is, learning takes place with the other and not from the other(14), the ACS realize that cooperation, co-responsibility, and bonding (understood as solidarity) contribute to good performance in collective work. Co-responsibility is pointed out as the perception that one's failure can mean the failure of the whole team, and that one's success is essential for the team's success(15).
...I think that, like, here we help each other, a team, a real family, we spend most of our time together... if we all were selfless toward others (E5/UBS).
... that liberty and that co-responsibility is without a doubt what makes living as a team possible and makes it easier... (E11/USF).
... it makes it easier to bond and increases our will and affection we have towards each other... (E1/UBS).
The aspect that, according to the ACS, make teamwork easier recall the assumption that communication is understood as an intrinsic dimension of teamwork, and that its effectiveness depends on establishing interpersonal relationships that express the individuals' experiences, and that they should be valued by each team member as knowledge that can inspire creative thought if shared amongst them.
ACS: difficult aspects in teamwork
The difficult aspects in teamwork, according to the ACS, are translated as the personal differences; the difficulty to see the comprehensiveness of actions; lack of flexibility, communication, cooperation, responsibility and bringing practice to the same level. Furthermore, the ACS revealed that they feel like the weak side in the relationships.
The subjects believe that, despite sharing the same objectives, their personal differences and adaptation the other members' ways of being and working are factors that make it more difficult to establish interpersonal relationships, and interfere in the way that the team is organized, a fact that reflects on their work. The conflicts to be solved by the team involve the lack of understanding and their not accepting differences in terms of behavior as well as techniques(16).
Because it is a lot [of people] working together, right? Each one has his or her own way of thinking, right? So it's really, really difficult (E16/UBS).
Each team member adds specific knowledge, a unique life history, specific education, and there is a tendency of disregarding those differences and working in an unconnected way. Teamwork is constituted, managed on everyday practice, and should be analyzed by workers themselves and the multiple possibilities of meanings, as it goes through moments of difficulties, paralyzing, satisfaction, as it is a process of coming and going from and to several directions(14).
Teamwork becomes compromised by the difficulty that professionals have to see the comprehensiveness of their actions, causing fragmentation and harming the common care project.
...If I feel she isn't paying attention, for instance, to what is happening to the team as a whole or at work as a whole, it annoys me deeply... (E14/USF).
The ACS realize there is a need to make relationships and the specific activities more flexible, as professionals practice in their own areas while also taking part, simultaneously, in common activities.
... we can be a little more flexible, we can work and ... you have to know. Different people have different ways of thinking... but it isn't a difficulty, it is a difference... (E6/USF).
When work is performed side by side, with each member doing their part of the job, without connecting with the work of other professionals, the team becomes dismembered, and loses the potential of providing effective and comprehensive care.
All the activities performed by the team, specific and common, are part of the health care project designed by the team; However, the greater the focus on the flexibility of work division, the closer the team becomes to integration, and, the stronger the emphasis on the specificity of work, the closer it becomes to the possibility of loosing the features of teamwork(5).
The interviewed ACS report that the lack of communication affects the bonding among team members, which is observed by the appearance of subgroups within the team, thus contributing to the distancing between professionals.
...There are certain people who have no dialogue, there is a lack of dialogue; sometimes people get their professional and personal lives mixed up... you can see a small group sitting in one corner, while another group in in the other corner, and you realize the so called clique... (E7/UBS).
The difficulty to communicate reflects the way that the team is organized and structured(17). Team communication permits to divide actions without losing sight of the purpose of the work and the specificity of each professional. Sitting to talk, however, is not that easy because contradictions and differences are made evident, as are the expectations that each team member has of others, which had not yet been exposed(14).
In addition, communication between professionals is the common denominator of teamwork, which s the result of a reciprocal relationship between work and interaction(5).
The interviewed ACS assign the difficulty of working as a team to the fear of expressing their opinions in the team meetings, as they consider themselves to be the weak side.
How can I demand something from the nursing aides, and the others... one day there was a team meeting with them, because some things had to be said, but when the time came nobody said anything, because nobody is brave enough... the rope always breaks at the weakest end and the weak end, in this case, are us (E8/UBS).
Power relationships are established within teams. Eventually there is a polarization among the people, which divides them into those who can more and those who can less, leading to a hierarchy of the relationships. Furthermore, within the team, power relationships are complementary, in the sense that there are no dictators or submissive individuals(13).
We realize that in society, there is a close relationship between having knowledge and employing power. In health team dynamics, the power relationship via knowledge is no different, in the sense that those with the greatest knowledge hold the power in that hierarchy. Therefore, ACS see themselves as the professionals holding the lesser power(18).
When there is no cooperation and responsibility between the team professionals, collective work is compromised because of the work overload that is placed on some professionals.
...because the lack of action from one harms the other, the other has to work more to compensate... because of the lack of responsibility by some, you eventually have to work more to compensate for that (E9/UBS).
Cooperation refers to the association between tem members in relation to their knowledge and activities to complete the task that was proposed by the group (13).
A study that identified the conception that nursing working with the Family Health Strategy have about the development of teamwork shows that the difficulties in associating the activities among the professionals regard the excessive demands of users, the lack of time experienced that the professionals have to plan their practice together and develop collective activities(8).
The interviewed ACS who work with the USF realize that, for teamwork to take place, the working process must be organized based on a horizontal hierarchy of the actions, with co-responsibility between the team members.
That is exactly what makes it more difficult, when you start seeing that opinions and decisions become centralized, when a more directed, vertical hierarchy takes place, you can see that the team really stops working; the team is able to keep the appearance that the roles are being played, but on an everyday basis, at work, and regarding the outcomes, the team no longer exists... If that complicity fails to exist among everyone involved, team co-responsibility does not work (E11/USF).
This perception is in line with the discussion that family health can go beyond a technical hierarchy work, towards work with social interaction between the workers, with more horizontal hierarchy and flexibility of the specific powers, which permits agents to have more autonomy and creativity, as well as more team integration(19).
For the team to integrated and not simply grouped, it is necessary to make an adequate construction of the subjects taking part in everyday work(5). That new construction requires the association between actions and an interaction between agents, which is the most difficult aspect because it is not normalized a priori. It requires ethical commitment and respect towards others, with each and every team member, and, above all, with the clientele(19).
ACS reveal that the easy aspects of working as a team depend on the construction of interpersonal relationships, including the possibility of having discussions about everyday problems, liberty to speak, communication and dialogue, attitudes of respect, common language, willing to learn, co-responsibility, and bonding. That construction is favored by periodical team meetings.
On the other hand, agents indicate that weaknesses of teamwork include: personal differences; difficulty to see the comprehensiveness of the actions; lack of flexibility, communication, cooperation; responsibility; and the horizontal hierarchy of the actions. Furthermore, they report feeling like the weak side of the relationships.
Although the aspects representing the strengths and weaknesses of teamwork appear to be dichotomous from the view of ACS; in the contemporary society work market, which is filled with diversity, complexity and uncertainties, the processes are dynamic and, therefore, oscillate between stability contradiction and antagonism, thus demanding people to show constant creativity and capacity to adjust.
Therefore, there is a need for constant, mature and open mediation of team members' relationships, so that goals may be achieved. Otherwise, there is a risk of perpetuating the development of isolated actions, which hinders the construction of a care model aimed at comprehensiveness and health promotion, considering the determinants of health.
The necessary to mediate the easy and difficult aspects of performing teamwork demands specific strategies. It should be noted that the Permanent Education Policy established by the Ministry of Health is already being implemented, which promotes and encouraged the problematization of reality and the search for solutions as a group to solve everyday difficulties and problems. From that perspective, the development of a dialogical capacity and broadening the perception of relationships in the individual and collective dimensions of the working world should permeate the working process as a whole.
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Received: 23/09/2009 *
Extracted from dissertation "O trabalho do agente comunitário de saúde
no município de Marília-SP", Faculdade de Medicina de Botucatu
da Universidade Estadual Paulista, 2006.
* Extracted from dissertation "O trabalho do agente comunitário de saúde no município de Marília-SP", Faculdade de Medicina de Botucatu da Universidade Estadual Paulista, 2006.