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Escola Anna Nery

Print version ISSN 1414-8145On-line version ISSN 2177-9465

Esc. Anna Nery vol.21 no.4 Rio de Janeiro  2017  Epub Aug 07, 2017

http://dx.doi.org/10.1590/2177-9465-ean-2016-0380 

RESEARCH

Work of family health strategy nurses in oncology care

Actuación de los enfermeros de la estrategia salud de la familia en la atención oncológica

Geize Rocha Macedo de Souza1 

Luiza Helena de Oliveira Cazola1 

Sandra Maria do Valle Leone de Oliveira1 

1Universidade Federal de Mato Grosso do Sul. Campo Grande, MS, Brazil.


Abstract

Objective:

To identify the qualification of and to know the work of Family Health Strategy nurses in oncology care.

Methods:

A cross-sectional, descriptive study, using a quantitative approach, was conducted with 77 nurses working in the Family Health Strategy units of Campo Grande, state of Mato Grosso do Sul. Primary data were collected in structured interviews, using a form with closed-ended questions.

Results:

Professional training in oncology care is less frequent, reflecting a high lack of knowledge regarding the National Policy on Oncology Care. It was evidenced that 95% of the professionals assisted oncology patients, with home visits and nursing appointments being the most prevalent methods. Regarding the National Policy on Oncology Care, 96% of the nurses declared that they did not know about it.

Conclusion:

There was evidence of weakness in the care provided by the nurses to oncology patients and the need for investment in continuing education for professional nurses regarding oncology care.

Keywords: Primary Health Care; Family Health Strategy; Oncology Nursing; Nursing care

Resumen

Objetivo:

Identificar la calificación y conocer la actuación de los enfermeros de la Estrategia Salud de la Familia en atención oncológica.

Métodos:

Estudio transversal, de abordaje cuantitativo, integrado por 77 enfermeros actuantes en unidades de Estrategia Salud de la Familia de Campo Grande, Mato Grosso do Sul. Datos primarios recolectados mediante entrevista, utilizándose cuestionario con preguntas cerradas.

Resultados:

La capacitación en atención oncológica es poco frecuente, reflejando el elevado desconocimiento de la Política Nacional de Atención Oncológica. Se verificó que 95% de los profesionales realizaban atenciones a pacientes oncológicos, prevaleciendo la visita domiciliaria y la consulta de enfermería. Sobre la Política Nacional de Atención Oncológica, 96% de los enfermeros declaró desconocerla.

Conclusión:

Se evidenció falta de preparación de los enfermeros para atender a pacientes con cáncer, y la necesidad explícita de educación continua.

Palabras clave: Atención Primaria de Salud; Estrategia de Salud Familiar; Enfermería Oncológica; Atención de Enfermería

Resumo

Objetivo:

Identificar a qualificação e conhecer a atuação dos enfermeiros da Estratégia Saúde da Família na atenção oncológica.

Métodos:

Estudo transversal de abordagem quantitativa, constituído de 77 enfermeiros inseridos em unidades de Estratégia Saúde da Família de Campo Grande, Mato Grosso do Sul. A coleta de dados primários foi realizada por meio de entrevista, utilizando-se um formulário com questões fechadas.

Resultados:

A capacitação, em atenção oncológica, é pouco frequente, refletindo o elevado desconhecimento da Política Nacional de Atenção Oncológica. Verificou-se que 95% dos profissionais realizavam atendimentos aos pacientes oncológicos, sendo a visita domiciliar e a consulta de enfermagem as mais prevalentes. Sobre a Política Nacional de Atenção Oncológica, 96% dos enfermeiros declararam não a conhecer.

Conclusão:

Evidenciou-se despreparo dos enfermeiros para assistirem os pacientes portadores de câncer e a necessidade explícita de educação permanente.

Palavras-chave: Atenção Primária à Saúde; Estratégia Saúde da Família; Enfermagem Oncológica; Cuidados de Enfermagem

INTRODUCTION

The World Health Organization (WHO) estimates that by the year 2030, there will be 27 million cases of cancer, with 17 million deaths, and 75 million people annually living with cancer.1 In Brazil, the Brazilian Cancer Institute (INCA) estimated approximately 600 thousand new cases of cancer for the biennium 2016-2017.2

In 2005, the Brazilian Ministry of Health (MH) created the Brazilian National Policy on Oncology Care (PNAO, as per its acronym in Portuguese), which determined that cancer patients should receive care that includes the different levels of care, i.e., medium- and high-complexity, primary and specialized care, with actions focused on the individual and the community, on health promotion and cancer prevention, as well as on timely diagnosis and support for tumor therapy and palliative care.3

Basic care (AB), a structuring scenario for the development of several actions in the control of neoplasms, is the user's gateway into health services, being characterized as a local privileged place for promotion and prevention actions.4 The Family Health Strategy (FHS) should work focusing on family care, the development of bonds, care longitudinality and comprehensiveness, and on the action of population health determinants.5

The work performed by FHS nurses involves monitoring the population's health conditions as the essence of nursing care, either individually or collectively, monitoring health problems, and intervening in pathological issues.6

Nurses who are members of a FHS team have a position of relevance because they play a proactive role in their activities and stand out as the most prepared and available professionals to support and guide patients and their families in the process of illness, treatment and rehabilitation.7

Health professionals, especially nursing professionals, should include, in their daily activities, home care for cancer patients and their families, and work to support these families, to establish bonds, to identify the patients' distressing thoughts of having their wishes met, to be reconciled with him/herself and with others, as well as to support families in the process of death, in a caring and humane manner.8

It is worth mentioning that the nurse's role in hospital oncology care is widely discussed, but the literature has not highlighted actions of promotion and prevention, extra-hospital care, and/or palliative care present in basic care.

In view of this issue, the present study aimed to know the work of FHS nurses in oncology care, because the care given to these patients and relatives is challenging, due to their illness singularities and the different types of cancer that the professional identifies in the workplace.

METHODS

This is a descriptive, cross-sectional study, using a quantitative approach, developed at family health units in the city of Campo Grande, capital of the state of Mato Grosso do Sul.

The population was made up of 99 nurses who worked in the 39 basic family health units, three of them rural units. Teams that did not have nurses were excluded. Thus, the researchers excluded nine teams that, at the time of data collection, did not have a nursing professional; nine nurses who were on vacation or on medical leave; and four who did not accept to participate. At the end of selection, the sample comprised 77 nurses from 37 units, who were invited to participate in the study and who, after accepting it, signed a free and informed consent form.

Primary data collection took place from October to December 2015 in the health units and according to the nurses' availability.

Data were collected using a form containing 25 closed-ended questions, which addressed the following variables: nurses' sociodemographic and professional characterization: gender, age group, employment relationship, length of service in the FHS, and in the assigned area, type of employment relationship, specializations and skills carried out regarding oncology care; regarding oncology care: cancer patients in their area, and activities with patients and their families, comprehension of the PNAO, facilitating and hindering factors in assisting patients, and skills mentioned as necessary by professionals. The form was validated after a pre-test applied to 10 health professionals, namely a nurse with specialization in oncology, one with experience in oncology patient care, and eight who had already worked in the Family Health Strategy.

Interviews took place at a time previously scheduled by the nurses, individually, performed by the researcher, with average length of 45 minutes.

A descriptive analysis of the data organized in Microsoft Office Excel® spreadsheet was performed, with the questions being grouped according to similar answers, and presented in tables.

The study was approved by the Research Ethics Committee of the Federal University of Mato Grosso do Sul, under report no. 1.249.953.

RESULTS

In the analysis of the sociodemographic and professional characteristics of the FHS nurses, the study found a predominance of women (91%), in the age group of 31 to 40 years (54%), with a permanent employment contract (77%), and time spent in the FHS and in the assigned area of 24 to 72 months, corresponding to 40% and 46%, respectively.

Regarding specialization, 77% stated that they had one and, among these, 58% of specializations related to the area of public health or family health. More than half (65%) said that they did not have specific oncology health training.

As it can be identified in Table 1, most nurses had oncology patients in their assigned areas, and followed them up mostly through home visits and nursing appointments.

Table 1 Profile of care and activities developed by primary health care nurses in oncology care in the city of Campo Grande, state of Mato Grosso do Sul. 

Variables n N %
Cancer patients in the assigned area 77
Yes 60 78
No 17 22
Cancer patient care/follow-up 60
Yes 57 95
No 3 5
Activities performed with cancer patients(1) 57
Home visit 52 91
Nursing appointment 31 54
Technical procedures 29 51
Discussion in the team meeting 24 42
Assistance to cancer patients’ family members 60
Yes 32 53
No 28 47
Activities performed with cancer patients’ family members(1) 32
Guidance about care for cancer patients 19 59
Guidelines about the caregiver’s health 18 56
Psychological support 11 34
Cancer patients’ rights 1 3
Others 3 9
Has knowledge on palliative care 77
Yes 66 86
No 11 14
Performs palliative care 66
Yes 31 47
No 35 53
Palliative care performed(1) 31
General guidance on care regarding food, hygiene, comfort, ulcer prevention, and alcohol and smoking avoidance 28 90
Pain reduction 12 39
Medical care and control of tests 2 6
Does not perform palliative care(1) 35
There is no need 20 57
Does not have cancer patients 10 29
Not prepared to care for this kind of patient 5 14
There is no demand by the patient 3 9
There is no demand by the team 2 6
Work overload 1 3
Offers guidance regarding chemotherapy and radiotherapy 77
Yes 30 39
No 47 61
Guidelines about chemotherapy and radiotherapy(1) 30
Nutrition care 26 87
Side effects 16 53
Skin care 13 43
Treatment frequency 10 33
Fluid intake 3 10
Care with physical effort 2 7
Hygiene care 1 3
Vaccines 1 3

(1)More than one alternative could be chosen.

Most respondents reported having knowledge about palliative care, but more than half said they did not employ it because they considered it unnecessary. Regarding chemotherapy and radiotherapy, there was a prevalence in the non-implementation of guidelines oriented to the topic and, when these occurred, it was mainly directed to education about food intake.

Table 2 shows that most nurses were unaware of the PNAO, and that few had a good understanding of oncology care. Regarding the difficulties in assisting oncology patients, less than half reported having them, with the lack of training in oncology being the predominant reason. As for the facilitating factors, among those who reported recognizing them, the guidelines with no emotional appeal were the most reported.

Table 2 Knowledge, and facilitating and hindering aspects for primary health care nurses working in oncology care, in the city of Campo Grande, state of Mato Grosso do Sul. 

Variables n N %
Knows PNAO 77
Yes 3 4
No 74 96
Knowledge about oncology care 77
Cancer patient care 53 69
Cancer prevention and diagnosis 25 32
Care actions including promotion, prevention, diagnosis, treatment, rehabilitation, and palliative care 10 13
Guidelines regarding the disease 9 12
Collection of preventive tests, and monitoring of those that show alterations 2 3
Facilitating and hindering factors in oncology patient care 77
Hindering 35 45
Facilitating 23 30
Did not answer 19 25
Hindering aspects(1) 35
Lack of knowledge on oncology 23 66
Lack of knowledge on the disease and treatment 16 46
Work overload 12 34
Lack of materials and resources 7 20
Patient and family members do not accept the disease 5 14
Facilitating aspects(1) 23
Guidelines with no emotional appeal 21 91
Performance of technical procedures 4 17
Professional experience 2 9
Need for courses/trainings 77
Yes 74 96
No 3 4
Oncology care themes(1) 74
PNAO 57 77
Palliative care 55 74
Care for family members 50 68
Treatments 43 58
Promotion, prevention 39 53
Others 3 4

(1)More than one alternative could be chosen.

Regarding courses and training, almost all nurses stated that they had an interest in acquiring new knowledge, mainly on PNAO and palliative care.

DISCUSSION

In this study, there was a predominance of female nurses, similar to the findings of another research that showed the participation of women in a higher proportion in nursing, since this job is associated with female work.9 Age ranged from 24 to 62 years, with a predominance of the age group from 31 to 40 years old, differently from that found in a study carried out in a city in the south of Brazil, which identified younger professionals.6

Stable employment relationships are a favorable condition that allows the consolidation of primary health care guidelines,10 which can be considered as a positive result for this study, since most nurses have permanent employment contracts. Length of work in the FHS and in the same assigned area ranged from 2 to 6 years; in other studies, the mean time in the same area was 3 years.6,10

Most nurses had a specialization, and more than half related to public health and/or family health; these results were similar to those found in another research where only 62.5% of the professionals were trained in these areas.10

The lack of professionals trained in oncology care may indicate weaknesses in the development of their activities, since 65% of nurses do not have it. This fact evidences a need for interventions, since the PNAO recommends the qualification of health professionals at all levels of care.3

The reality of patients undergoing oncology treatment is increasingly frequent in the community; thus, nursing care requires from the health professional, in addition to technical-scientific knowledge, affectivity, communication, sincerity and empathy, which are constructive elements of care.11 Nurses should be prepared to provide quality care, because most of them have declared the presence of cancer patients in their areas, and that they follow them up.

Among the activities developed for oncology patients, this study identified home visits and nursing appointments as the most frequent, which were also found in an observational study carried out in 27 family health units, distributed in 10 Brazilian states.12

Home visits are strengthened as a strategy of care, disease prevention and health promotion, and proved to be care tools for users conditioned to chronic diseases.13 In the present study, almost all professionals reported performing them, providing the oncology patients and their family members an evaluation with the nurse's special attention. On the other hand, a study conducted in the city of Assis, state of São Paulo, found lower percentages (78%) in their execution, and 22% said they did not perform home visits.14

Nursing appointments are an important instrument that brings individuals and families closer to nurses, so all professionals are expected to perform them, although it was the second activity most cited in this study. It contributes to reduce rates of depression, fatigue, sleep disorders, stress, and pain level, ensuring patient's quality of life and well-being.15

In addition to performing follow-up activities for the patients, the FHS team should provide assistance to the patients' families. Another study showed that caregivers and relatives of people with terminal illnesses need physical, practical and psychosocial support to face the demands of home care; however, there is reluctance on the part of caregivers and family members to express their own needs.11

In this research, more than half of the professionals assisted oncology patients' family members, providing them with guidance on both patient care, and care for their own health, contradicting a study carried out in the city of Botucatu, state of São Paulo, which did not identify any direct care from FHS professionals to patients' caregivers or relatives in palliative care, although it is their role.16 Care is focused on the person with cancer, and the needs of caregivers or family members are often neglected by health professionals.11 A study carried out in Scotland proposes that primary health care teams be proactive and seek, within their localities, caregivers, as they tend not to identify themselves, and do not ask for help.17

The development of a suitable system for palliative care involves the contribution of the interested parts of each nation state together with world support. UK, Belgium and Canada already have excellent pediatric palliative care systems in place. Patients rely on their caregivers to provide adequate guidance, meet their needs, and provide the necessary support until their death.18 Palliative care is also part of nurses' care, who should be disseminators of palliative care, even if in a careful and progressive way; this assistance can be developed in different contexts, including the home environment.8 Most home palliative care in Ontario/Canada is provided by the public health system that identifies patients in need of such care, coordinates actions, and hires personnel for the provision of services, primarily nursing care.19

Despite being a topic that has been discussed since the 1960s,20 FHS nurses said they did not know what palliative care is, which is disturbing due to the existing fragility of oncology patients and their relatives. This becomes even more serious when the majority of those surveyed stated that they did not provide it, with the main justification that it is not necessary. However, care should start at the time of diagnosis.18 Studies show that FHS professionals feel unprepared to perform this kind of home care for patients and families.16

Most of the treatment of cancer is characterized as a traumatic process for patients and their families, due to various physiological, physical and psychological changes.21 FHS nurses should be aware of these changes and, therefore, give guidelines that contribute to their patients' quality of life improvement.

Among the main side effects of chemotherapy and radiotherapy treatments are nausea and vomiting, neutropenia, mucositis, xerostomy, skin lesions, fatigue and anxiety.22-24 Therefore, it is worrying that only a little more than half of the nurses provide guidelines for better adaptation to treatment.

Providing support, delivering service, and improving the quality of life of oncology patients are priorities in the UK guidelines.25 The PNAO establishes guidelines for cancer control in Brazil, from health promotion to palliative care, strengthening strategies of control, and qualifying cancer care.3

However, in this study, it is worth mentioning that almost all nurses were unaware of PNAO guidelines, and a minority correctly understood the proposals for oncology care, which may have a negative impact on the quality of care provided to oncology patients.

Among the main difficulties encountered in assisting cancer patients was the lack of training in oncology, also cited in a study carried out in Brazil and Portugal,26 in which nursing professionals declared lack of training as a reason for dissatisfaction. A study conducted with Zambian nurses also revealed that the lack of oncology training contributes to negative experiences and prevents the provision of optimal nursing care, a concern that exists in developed and developing countries,27 evidencing, again, the need for training primary healthcare professionals for assisting oncology patients.3

Regarding facilitating aspects reported by the nurses, care with no emotional appeal for cancer patients predominated, a fact that is not reported by other researchers who revealed that cancer is the disease that leads professionals to most suffering.21 Another study carried out in the Isfahan Province, in Iran, with oncology nurses, highlighted the need for intervention programs to relieve stress and prevent these professionals from being fatigued, as they play an important role in the care of cancer patients.28 Psychological and emotional disturbances are expected, due to the highly demanding technical care provided, which can lead to a commotion to be experienced by these workers in their routine.29

A study conducted in the UK with oncology nurses and community nurses assessed their self-reported skills and demonstrated that community nurses were less confident in recognizing the late symptoms of the disease, and identified a greater need for training, as their role is continuous in monitoring patients with cancer.30 Continuing education has been an important instrument for the construction of professional competence, contributing to work organization.31

Thus, most nurses proposed, for the improvement of the assistance to cancer patients, training aimed at the PNAO, which is of great relevance, as it aims at the qualification, specialization and permanent education of health professionals, who have a critical role in cancer control.3

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The care provided by nurses is performed in different ways, in the direct care to both patients and to their families, which shows, mainly, that the professionals inserted in the FHS teams are unprepared to assist patients with cancer in their assigned areas.

Faced with such unpreparedness, the care offered by the primary health care network of the municipality becomes fragile, causing a negative impact on care delivery and on the quality of life of these patients and their families.

Nurses' lack of knowledge about the PNAO is a challenge for managers, because it guides the care of users with cancer, and its wide dissemination within FHS teams is necessary. Investment in these professionals is essential, due to the explicit need for permanent education to qualify them and to ensure an efficient and modifying care to oncology patients and their families.

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Received: January 12, 2017; Accepted: June 26, 2017

Corresponding author: Geize Rocha Macedo de Souza. E-mail: geize01@yahoo.com.br

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