Print version ISSN 0103-2100
Acta paul. enferm. vol.25 no.3 São Paulo 2012
A network of relationships and interactions of the health care team in primary care, and implications for nursing*
Gabriela Marcellino de Melo LanzoniI; Betina Hörner Schlindwein MeirellesII
IPost-graduate Doctoral student in the Post Graduation Nursing Program, Federal University of Santa Catarina - UFSC - Florianópolis (SC), Brazil. CAPES Scholarship Holder
IIDoctor of Health and Nursing Philosophy. Adjunct Professor of the Department of Nursing, , Federal University of Santa Catarina - UFSC - Florianópolis (SC), Brazil
OBJECTIVE: To characterize the networks of relationships and interactions in the healthcare team in primary care, and its implications for nursing.
METHOD: An integrative review of literature for the identification of papers about networks of relationships and interactions between members of the healthcare team in primary care and its implications for nursing, published during the period between January 2001 and July 2008. The search occurred using the databases of the Virtual Health Library and SCOPUS, contemplating a universe of 2,276 publications, of which 14 complete studies were selected for further analysis.
RESULTS: The literature showed that the network of relationships and interactions of the healthcare team requires interdisciplinary and inter-sectoral actions to add to healthcare service in the daily life of the community, aiming at closer contact with the user, as well as strengthening and qualifying health care.
CONCLUSION: It is noteworthy that the network of relationships and interactions is advancing the frontiers of the health unit to add to the service, the daily life of the community and partnerships with other segments and sectors of society, seeking closer ties with the user and his context, and to strengthen and qualify Health care.
Keywords: Nursing; Primary health care; Patient care team; Interpersonal relations; Interprofessional relations
At present work in the field of health has been developed in a collective, multiprofessional and cooperative manner, however, permeated by fragmented actions, in which each are is responsible for a part of the care offered(1). Thus, the interdependence among the agents involved is evident in this process, since the relationship and interactions among the health team members and clients are conditions of human care.
In Brazil, with the implementation of the Family Health Strategy in Primary Care, the health team began to consider users included in their family and community context. Thus, it was necessary to think of health/ disease, not exclusively from the individual's point of view, but based on the individual as a social being(2). The traditional teams have been changed, with the incorporation of new guidelines, and a new worker has been added to health services:: the Community Health Agent, who will preferably work under the supervision of the nurse. Health Agents' main characteristics are as follows: the fact that they live in the community in which they act and introduce health care in the day-to-day life of the families.
Community Health Agents, as well as the other workers in the Basic Health Unit are not incorporated into the health teams alone, to the contrary, they bring with them their networks, experience of participation in groups, associations, indeed their lives in communities3). Networks may be understood as a form of visualizing individuals and their attributes, as regards the relationships they establish between one another. In addition to focusing on the interpersonal tie, the network also considers the material and symbolic resources that are available to members of the groups to compose the dynamics of life, whether in a primary groups, such as the family, or secondary groups, such as in formal associations(2).
From this same perspective, networks are classified by the contexts and strata from which they originated, namely: Primary, secondary and intermediate social networks(4).
Thus, in a primary social network, each person is the center of its own network, which is formed by all the significant relationships established throughout life: Being composed of family members, neighbors, friends, work colleagues and organizations in which they participate: political, religious, sociocultural, among others(4).
Secondary social networks are constituted of professionals and workers in public or private institutions, social organizations, non governmental organizations, organized groups, communital and community associations that provide specialized attention, guidance and information(4).
Intermediate social networks are composed of people who receive specialized training to act in the prevention and support of certain actions. They are denominated promoters, and may come from the health or educational sector, or from the community itself(4).
Moreover, networks are understood as being flexible, informal systems, in which self-regulation appears to be their working mode(5). It is by means of establishing relationships among the team members that workers develop sustainable human relationships, favoring the establishment of inter-relationship between attitudes and knowledge that provide "shared decisions, unconventional approximations, and a convivial society among those who are different"(6).
One therefore understands that the work of Primary Health Care Teams involves various participants who are connected and constitute structural webs that compose and characterize interactions, identified by an "intertwining of networks included in larger networks"(7). Thus, various questions emerge and converge on the need to deepened knowledge with respect to the network of relations and inter-relations in the health team. Among them: Which are the dimensions and characteristics of the relations and inter-relations among the members of health teams? What is the scope of these networks and their repercussion on the field of nursing? In order to meet the amplitude of these questions, it was endeavored to conduct documental study with the aim of characterizing the network of relationships and inter-relations in the health team in Primary Care and its implications for nursing. For this purpose, it was sought to get to know the health team in primary care, demonstrate its characteristics and potentialities, to enable better use to be made of it and its articulation in health actions.
This was an Integrative Literature Review(8) to identify productions about networks of about relationships and interactions between health team members in Primary Care and their implications for nursing.
All the stages of the Integrative Literature Review are based on a formal and strict working structure that allows the simultaneous inclusion of data from theoretical and empirical literature, with a view to the definition of concepts, review of theories or methodological analysis of the studies(9). In addition, it includes the establishment of well defined criteria for data collection, analysis and presentation of the results, starting from the beginning of the study, based on a previously prepared and validated research protocol. From this aspect, six stages (8,9) indicated for the constitution of an Integrative Literature review were adopted, as follows: 1) selection of the research question; 2) definition of the criteria for inclusion of studies and sample selection; 3) representation of the selected study in table forma, considering all the characteristics in common; 4) critical analysis of the findings, identifying differences and conflicts; 5) interpretation of the results; e 6) report the evidence found in a clear manner.
The search for literature was made in the Virtual Library on Health ("Biblioteca Virtual em Saúde") and SCOPUS, using the Descriptors in Health Sciences (DECS-BIREME): Inter-professional Relations OR Interpersonal Relations OR Social Support, Community Networks AND Primary Health Care, which contemplated a universe of 2,276 studies. The inclusion criteria adopted considered studies available free of charge in the complete format, published in the period between January 2001 and July 2008, in the Portuguese, Spanish and English languages, resulting in 80 articles.
In possession of all the studies, in accordance with the protocol, all duplicated productions, letters, editorials and productions not related to the scope of the study were excluded. Thus, reading of the publications began, and considering the criteria of pertinence and consistency of the contents, 14 complete studies were selected for in depth analysis, as they answered the research question. In agreement with the third items of the stages established in the Integrative Literature Review, a table was constructed for the extraction of data from the selected sample, containing columns discriminating the following sets of information: authors, title of the study, year of publication, type of study, characteristics of the networks of relationships and inter-relationships and contributions to practice. It is emphasized that the analytical process was not based on the frequency of citation of the studies; to the contrary, data were aggregated according to the identification of similarities and differences, composing a finding that was interpreted and sustained by other pertinent literature.
From the process of analysis, four categories emerged: Context and characteristics of the network of relationships and interactions in Primary Care health teams; The relationships of power and need for leadership in the health teams; The relationships and interactions in the community context and the Network of relationships and interactions as health promoter: needs and directions, which were supported by 14 studies presented in the data in Chart 1:
Context and characteristics of the network of relationships and interactions in Primary Health Care Teams
To consider the characteristics of the networks of relationships in team work and talk about something harmonious(10). In personal relationships and interactions, moments of conflict occur, which may be considered "negative", "bad", or something to be avoided. However, these are aspects inherent to team work dynamics, and may be transformed into possibilities for growth, if one goes about it the right way.
Conflicts between team members arise due to the variety of opinions and postures; some professionals try to control the entire organization of work and others accommodate themselves, and do not perform their functions adequately(11). Moreover, the non existence of collective responsibility for the results of the work generates discontinuity between the specific actions of each professional, showing disarticulation between curative, educational and administrative actions, as well as a low degree of interaction among doctors, nurses and Community Agents(12).
Thus, many of the barriers in the interactive process are particularly related to the challenges of human relationships and the peculiarities of personality of each team member(12,13). The lack of solidarity on the part of some professionals, who do not support the others, is also emphasized(14).
Such disarticulation and obstacles in the network of relationships and interactions may be related to indefinition as regards the functions of some team member. One study pointed out the Community Health Agent as the team member that geneerates discomfort among the other professionals, due to being a new participant that has joined the family health team, without necessarily having previous training in the area(12). Whereas, certain studies have indicated other sources of weakness in teamwork, however, envisage the importance of integrated work and how gratifying it is to see the result of actions when experiences are shared and problems are solved as a result of knowledge about the situation of each user(11).
Thus, the distinction is shown between the two notions to cover the idea of a team: the team as a group of agents, and the team as the integration of different tasks (15). A team is not established only by the social conviviality of workers in one and the same health establishment, but it needs to be constructed and understood as a structure in a state of permanent destructuring/restructuring(10). Therefore, associations between persons are considered as an extremely complex system that "self-and co-organizes" itself in a set, in which there is no absolutely correct truth, but continual dialogue with uncertainty(16).
The work environment, a stage that provides the development of sustainable human relationships, favors the establishment of inter-relationships between attitudes and knowledge that promote "shared decisions, unconventional approximations, conviviality among different persons"(6). The dynamics generated by the meeting/movement of elements of the health team system has order and disorder, as a starting point for the establishment of a new form/ structure/ organization, also enabling the construction of integrated teams, even when asymmetrical relationships are maintained between the different professionals(15).
Relationships of power and need for leadership in the health team
Historically, the health team was governed by the polarity between people - those who could do more and those who could do less, their actions were directly linked to the domain of knowledge. Thus, medical professionals held the power in teams, which could now make it difficult to include them in a different position, other than in the highest part of the hierarchical pyramid(10). The break with the classical model and the structuring of family health teams, horizontal dialogue has been proposed between professionals and workers, with a view to interdisciplinary and harmonious action.
This transitions was perceived when the figure of the doctor, pointed out as the only and central figure in the coordination of care and services(16) was replaced by the nurse, indicated as a coordinator, with the function of promoting integration among the team members, encouraging professionals to offer integrated assistance with quality, which makes their work recognized and appreciated(11,17). In addition nurses were indicated as a possibility of leadership by someone outside the team, capable of helping the team to discuss things and find answers to problems(10).
In a team at the initial stage of being formed, due to fears and insecurity, there is a tendency to expose difference - how much more one knows than the other - and consequently, how much more this one "can" do than the other(10). It is by means of establishing relationships between team members that the worker strengthens the notion of the movement of information and actions that enable learning, teaching, exchanging, preparing, giving meaning to, re-allocating meaning and transforming knowledge of their health and care practices(18,19). Thus one understands the importance of interaction as a means of exchange, dependence and/or dominance by discourse among human beings. As the team members get to know one another, accept each other, understand their differences and similarity in a broader manner, considering that the relationships of power are complementary and interdependent, it will no longer have dictators and submissive elements, as one does not exist without the other(10).
Relationships and interactions in the community context
Health team professionals perceive that the relationship with the community is dynamic, and goes through and initial stage of distrust that develops into effective participation(12). Some studies have pointed out that this process is favored by the presence of the Community Health Agent, who establishes tie with the population, facilitates adherence to the program and approach to the team. Close contact with the family creates the opportunity form a tie of confidence with these workers, allowing users to confide in them. Thus, the success of communicating with the families creates opportunities for the development of preventive actions and organization of demand.
Nevertheless, communication may also be a barrier, when problems in relationships and cultural differences between the heal team and users make it difficult not only to provide assistance, but access to the service as well(20).
Moreover, in one of the studies it was verified that doctors preferred to communicate with other professionals by formal written means, instead of doing so verbally. Although this type of communication appears to be impersonal and limited, within the context of the study it was well used(21).
Thus, when communication takes place in an effective manner, each professional plays his/her role, exchanging information with other members, in order to know the users well and be better able to assist them(11,22). Both verbal and non verbal communications are basic elements for health activities; and it behooves the professional to be alert to these aspects, and propose the establishment of a therapeutic communication that is suitable for the individual(23), leading to the establishment of effective interactions that broaden health actions and strengthen the ties between those involved.
Network of relations and interactions as health promoter: Needs and directions
Understanding the network as a complex system, with its intertwined aspects, presupposes meeting points in which it is difficult to act individually and independently from the other elements. Thus, establishing joint dialogue between the different sectors appears to be a necessity, when approaching the quality of life and health of persons.
New relationships among health team members are perceived as being necessary for the (re)construction of the objects of knowledge/ intervention and autonomy to use strategies/ intervention technologies(12). Suiting the network of relationships to the conceptual changes of the Family Health Strategy (FHS) when considering the user's health as a whole, implies interdisciplinary work that comprises the construction of new practices and knowledge, from different points of view, including the users'. The new dynamics between the parts that make up the whole, as well as their constant rearrangement, reveal that the "web" of relationships that coexist between the health team members goes beyond the limits of health units and advances towards the community.
Moreover, secondary networks are pointed out as being fundamental for the success of care, especially of children's health(24). Today, there is no way to attend to the complexity of problems that affect society, without association between Primary Care professionals and other institutions - whether they are governmental or not, acting in a closer manner and with open dialogue. "The search for joint actions involving various sectors of society is recognized as the possibility for greater scope in the prevention and promotion of health, however, these actions are still shown to be out of tune"(25) and it is necessary to make greater efforts so that this practice becomes more frequent, because in the present context it involves breaking down the territorial, economic, cultural and information frontiers.
Breaking down the barriers of communication, information and dialogue is put forward not only as a necessity, but as a directive for putting collaboration and solidarity into practice. Educational activities are indicated as facilitators for establishing and strengthening the networks of interpersonal relationships, such as health teams. Investment in the formation of ties between health teams and users also tends to improve relationships and broaden the search for solutions in a shared manner(26). The inclusion of nurses, doctors and users in a daily clinical practice, without any guidance whatsoever, does not favor the consolidation of collaborative practices(22). Therefore, financing for inter-professional education should be increased, as a way of potentiating health actions which need to be centered on the aspects of communication between groups(19,22).
This practice could facilitate the development of care-giving in partnership, characterized as a complementary and interdependent action(27). However, educational actions along the lines of qualification; that is to say introductory training for the work, with instructions that provide integration among the team members and organization of the work, frequently do not add anything new and are not sufficient to prepare persons for action, because they do not offer a more practical visualization(12).
Therefore, other initiatives linked to institutions, such as: Clear goals, measurable results, clinical and administrative systems, division of work and training, allied to effective communication are characteristics that contribute to clarity and confidence of the professionals, competing for their development in collaborative relationships in the team(13,25). In addition, periodical meetings with group discussions are pointed out as being a useful way to encourage reflection on the team's practice, favoring the sharing of information and experiences(19,20).
Human relationships are placed as a challenge to teamwork, comprising the main barriers to the individual conduct of each member and inclusion of workers with a new function, here represented by the Community Health Agent.
The texts indicated dialogue, effective communication, courses and qualifications as resources for resolving the obstacles to the interactive process of team work. Integrated and interdisciplinary action is appreciated as a practice to be cultivated in the services. As strategies to strengthen the heal promotion networks in Primary Care, the practice of interdisciplinary and intersectoriality are pointed out as ways of articulating knowledge and differentiated sectors, with a view to practicing collaboration and solidarity .
Health care is permeated by different actions and instances, with different degrees of opening between professionals, groups and communities that are reflected in health practices. It demands relationships in which interactions occur, based on exchange, which only happens when persons are involved in true and genuine encounter, which is progressively achieved among the actors involved.
Living with and having relationships is a continuous process of learning, considering the difference between subjects and flexibility of actions, a process of constant changes in relationships that are established an based on ethical values and commitment between human beings. This process therefore, consists of a challenge to health and nursing professional faced with the new composition of health teams.
For team leadership, nurses are indicated as promoters of integration between members, strengthening their importance not only in the assistential dimension, but also in management. It is suggested that for future investigations going more deeply into leadership and its influence on the construction of the network of relationships and interactions in Primary Care.
The limitations of this study pertain to the scope of the languages, time limit on data collection and scenario in which health teams are included. The Brazilian national health system - SUS ("Sistema Único de Saúde") and Primary Health Care are unique models in comparison with the rest of the world, with a guarantee of free public attendance to all persons included in the national territory. In addition, the perspective of team work, presence of a community health agent and greater horizontality in power relationships, make nurses the central figures, who must have their potential in the health team explored.
It is emphasized that the network of relationship and interactions has advanced the frontiers of the health unit to add to service, the day-to-day life of the community and partnerships with other segments and sectors of society, with a view to greater approximation to users and their context, as well as strength and qualify health care.
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Corresponding Author: Received article 25/03/2011 and accepted 04/08/2011 * Study extracted from the Master's dissertation entitled "Envisaging the complex network of relationships and interactions of the Community Health Agent" - presented to The Post-Graduation Nursing Program - Federal University of Santa Catarina - UFSC - Florianópolis (SC), Brazil.
Gabriela Marcellino de Melo Lanzoni
Campus universitário UFSC, Departamento de Enfermagem
Florianópolis/SC. CEP: 88040-970
Received article 25/03/2011 and accepted 04/08/2011
* Study extracted from the Master's dissertation entitled "Envisaging the complex network of relationships and interactions of the Community Health Agent" - presented to The Post-Graduation Nursing Program - Federal University of Santa Catarina - UFSC - Florianópolis (SC), Brazil.