Family Health Strategy and Bioethics: focus group discussions on work and training

Abstract

The work of the Family Health Strategy has introduced a number of new bioethical challenges for health professionals. Additional effort has been required in terms of research – mapping the problems faced by staff – and training, focusing on ethical preparation for the creation of care activities. The aim of the present study was to understand this context by identifying, using the focus group technique, the perception of staff from the municipality Viçosa/MG, Brazil, of the concepts of ethics and bioethics, the approach to bioethical problems in the day to day functioning of the health units, and the training process relating to such issues. The results indicate recognition of the centrality of bioethics to the work of the Family Health Strategy and the need to create training areas which prioritize dialogue and lifelong learning.

Keywords:
Bioethics; Education; Work

Resumo

A atuação laboral na Estratégia Saúde da Família tem trazido uma série de novos desafios bioéticos para os profissionais de saúde. Demandam-se esforços, tanto em termos de investigação (mapeamento dos problemas enfrentados pela equipe) quanto de formação, tendo em vista a preparação ética para o desenvolvimento das ações de cuidado. O reconhecimento desse contexto foi o mote desta investigação, que procurou identificar, pela técnica de grupos focais, a percepção de trabalhadores no município de Viçosa/MG sobre os conceitos de ética e de bioética, a abordagem de problemas bioéticos no cotidiano das unidades de saúde e o processo de formação para a condução destes. Os resultados apontam para o reconhecimento da centralidade da bioética no trabalho da Estratégia Saúde da Família e a necessidade de criar espaços de formação que priorizem o diálogo e a educação permanente.

Palavras-chave:
Bioética; Educação; Trabalho

Resumen

El trabajo en la Estrategia Salud de la Familia possibilitó una serie de nuevos desafíos (bio)éticos a los profesionales del área de la salud. De hecho, se han exigido esfuerzos tanto en términos de investigación –mapeo de los problemas que enfrenta el equipo– como en la formación, considerando la preparación ética para el desarrollo de las acciones de cuidado. El reconocimiento de este contexto fue el lema de esta investigación, la cual trató de identificar, mediante la técnica de grupos focales, la percepción de los trabajadores de la municipalidad de Viçosa, Brasil, sobre los conceptos de ética y bioética, el enfoque bioético de los problemas cotidianos de las unidades de salud y el proceso de capacitación para la conducción de los mismos. Los resultados apuntan al reconocimiento de la centralidad de la (bio)ética para trabajar en la Estrategia Salud de la Familia y la necesidad de crear espacios de educación que le den prioridad al diálogo y al aprendizaje permanente.

Palabras clave:
Bioética; Educación; Trabajo

The beginnings of the Sistema Único de Saúde (the Unified Health System) (SUS) are closely linked to the Health Reform Movement and the struggle for democratization in Brazil¹. Its legitimacy was established by the Federal Constitution of 1988². The chapter on health of this document called for universal access – that health is a right for everyone – and its guarantee through social and economic policies. The Estratégia Saúde da Família (Family Health Strategy) (ESF) has emerged as the model of deployment for the (radical) transformation of primary health care (PHC) in Brazil³, the first phase in the structuring of health care networks. It functions as a gateway and the linking element of the system – through referral and counter-referral – to ensure that the SUS provides comprehensive care⁴.

However, the consolidation of PHC and the ESF, which lie at the heart of SUS, faces several obstacles, including political and economic factors and the inadequacy of vocational training⁵, as well as the rotation of professionals who work as private doctors⁶. In addition, the relationship of proximity and continuity of the ESF with the local population has brought new challenges, raising questions not previously taken into account or considered in other contexts, due to the particularities that arise from the introduction of a new care model.

In this context, bioethical problems arise, as the practice of healthcare is built on the daily reality of teamwork and the act of work itself, supported by the relationships between the members of a multidisciplinary team, users, managers and the community⁷–⁹. Multiple questions and even dilemmas, which can be addressed in bioethical terms, develop in such a scenario. Some of these, however, are not perceived by healthcare workers, who are deeply involved with the practical aspects of their work¹⁰,¹¹.

From this perspective, therefore, the delineation of bioethical issues and the process of appropriate and guided training in bioethics for PHC professionals are essential, as they allow the construction of tools for the identification, problematization and, if possible, resolution of the ethical dilemmas that emerge on a daily basis, contributing to the success of PHC, the ESF and the SUS¹²,¹³. It is also necessary to evaluate the entire construction process performed by professionals along this route¹,³.

Based on these considerations, the aim of this paper is to present the results of focus groups conducted in the I° Oficina de Formação em Bioética e Atenção Primária à Saúde (the I ^st Training Workshop in Bioethics and Primary Health Care) (OFB-APS) for professionals from the ESF of Viçosa in the state of Minas Gerais, emphasizing the bioethical reflections developed throughout the educational process. The theme of the importance of ethical and bioethical aspects in training activities was prioritized.

Method

Where did the focus group come from?

The focus group originated from a prior investigation¹⁴, which focused on the delineation of the bioethical problems identified by ESF teams in Viçosa, Minas Gerais. The municipality is part of the Viçosa microregion and the Zona da Mata (Forest Region) macroregion of Minas Gerais, which is composed of 142 municipalities and has a total of around three million inhabitants. The population of Viçosa, in 2012, was 73,333 inhabitants, 93.20% of whom resided in the urban area and 6.80% of whom lived in the rural zone. The estimated population in 2013 was 76,147, with a demographic density of 241.2 inhabitants per km2¹⁵.

The city has a PHC network of thirteen units, twelve of which form part of the ESF, and has fifteen family health teams. A total of 11,286 families are registered with the ESF. Despite being situated in the countryside of Minas Gerais, Viçosa has unique characteristics, as it is home to the Universidade Federal de Viçosa (the Federal University of Viçosa), one of the oldest higher education institutions in Brazil. In 2009 and 2010 the university began undergraduate courses in nursing and medicine, respectively, which has allowed new thinking about education-work-community integration, based on successful projects¹⁶.

The research project was carried out in three stages. The first step consisted of a study with a quantitative and qualitative approach, with the participation of 73 professionals from 15 ESF teams. This phase revealed interesting results such as the low awareness and identification of bioethical issues by team members¹⁴. The perceived problems were categorized into five groups, related to: (1) unequal access to health services; (2) the education-work-community relationship; (3) secrecy and confidentiality; (4) conflicts between teams and users; and (5) conflicts between team members¹⁴.

In the second phase, the I^st Training Workshop in Bioethics and Primary Health Care was held, with 128 professionals from 15 ESF teams, in accordance with the proposal of Vidal et al. (Table 1)¹³. This phase used the following references for the construction of competencies in bioethics: (i) the methodology of pluralism¹⁷, (ii) working in small groups¹⁸, (iii) meaningful learning¹⁹ and (iv) the use of art²⁰. The results obtained through assessment of completed questionnaires and the discourses of the groups involved, were optimistic about the effectiveness of the project, both from the viewpoint of ESF professionals and other participants (facilitators and the teachers involved).

Table 1
ESF bioethics workshop

Duration	Content	Method
1st training phase
1 h	Basic bioethics concepts	Dialogued exposition
15 min	Break for coffee
2 h	The Unified Health System: ethical and political questions	Screening of film Sicko
1 h	The Unified Health System: ethical and political questions	Problematization of film Sicko – considering questions relating to the field of bioethics
2nd training phase
1 h	The Unified Health System: ethical and political questions	Problematization of film Sicko – presenting results of study of questions relating to field of bioethics raised earlier
2 h	Diagnostic communication, secrecy, privacy and confidentiality	Screening of film Goodbye, Lenin!
15 min	Break for coffee
1 h	Diagnostic communication, secrecy, privacy and confidentiality	Instructions for simulated jury based on film Goodbye, Lenin!
3rd training phase
1 h 30	Diagnostic communication, secrecy, privacy and confidentiality	Dramatized/simulated jury
15 min	Break for coffee
2 h	Professional confidentiality in primary health care	Discussion of problem situation
30 min	Closure

Fonte: Vidal SV e colaboradores?¹³

The third (and last) stage was based on focus groups, the theme of this article, in order to highlight the importance of this stage of the study. The project was approved by the Ethics Committee for Research involving Humans of Viçosa Federal University, in accordance with the resolutions of the Conselho Nacional de Saúde (the National Health Council), in particular Resolution 466/12²¹.

Focus group: who were the participants?

The participants of the focus groups were selected by drawing lots and by direct appointment from the Training Workshop group (n = 128). Three convenience groups were selected by the authors, based on an interest in expanding the perception of the role of the 1st Training Workshop in the daily work of the teams: (1) composed exclusively of community health workers (twelve individuals); (2) professionals from different teams (two nurses and ten community health workers); and (3) a full team (one doctor, one nurse, one dentist, one dental hygiene technician, a nursing technician, six community health agents, one administrative assistant and a general service assistant).

After the composition of the groups, a letter of invitation was sent to the Viçosa Municipal Health Service, requesting that the guarantee and authorization of the participation of all professionals selected by the municipal administration. The letter was also sent to the units to invite those chosen to participate.

Focus group: how did it work?

The groups, once constituted, were mediated by the same researchers who had participated in the project from its initial conception to the final evaluation activity. The professionals were once again consulted about the possibility of recording their discourse, as oral consent had already been provided and a free and informed consent form signed by the participants.

To avoid bias, the same guiding script was used with all groups. This consisted of the following questions: (1) What do you understand by ethics? (2) What do you understand by bioethics? (3) How should the bioethical problems that occur in the ESF be solved? (4) What did you think of the training workshop on ethics and bioethics? (5) Do you think that the discussions held in the training workshop will be useful for addressing the bioethical problems that occur in the ESF?

The participants verbally answered each question, and the dialogues were recorded and transcribed by two members of the project team. The results, which include the three focus groups, are described below.

Results

Speaking for themselves

The perception of the mediators is that despite the contact with bioethical concepts during the training workshop, they experienced (and still experience) many difficulties regarding the concepts of ethics and bioethics. Analyzing the discourse of the participants, it was noted that clarity regarding the concepts is quickly lost when, for example, they are requested to present a description of the problems of their daily lives and suggest possible solutions. An association was observed between the two concepts, for example, in the following point: “Bioethics is ethics applied to health professionals”.

It was found that although the workshop aimed to incorporate essential concepts from the bioethics toolbox in the daily work of the professional, it did not achieve total success. Nevertheless, the participants considered the subject to be important, as described in the sentences:

“This question of ethics, we're always worried about it, aren't we?”;

“You experience and hear things, so yes, you have to worry!”.

There was some consensus among the group about the resolution of bioethical issues that arise in the ESF, as it was considered that discussion – in a group, including all members of the team – was the best strategy, representing a wider approach to seeking the best solution. The participants are aware of their responsibilities, as shown in their discourses:

“We need to be divided into teams… To socialize and try and maintain ethics, yes. I think it has to be like that”;

“Discussing things definitely helps”;

“Communication among the team makes things easier”.

As regards the organization of the workshop itself, there were some suggestions for the better use of content: 1) choosing a location closer to the workplace of the participants; 2) using shorter films, preferably dubbed versions; and 3) planning aimed at providing more time for discussion, as highlighted below:

“When it was time for the practical discussions, there wasn't enough time in my group”;

“The problem-situation about secrecy and confidentiality with HIV was very interesting”;

“The key moment in my group (during the discussion) was when the doctor should tell the team or not (the case)”;

“Have more time for discussion”.

The characteristics of the participants considerably influenced the course of the activity. One of these was shyness in terms of the difficulty of expressing one's thoughts. When consulted, the ESF professionals expressed a desire to participate in other workshops, due to the importance of the subject and the desire to continue their professional development. It is clear that work processes, in a multidisciplinary team, have not effectively ensured access to productive in-service training for various professionals, and they commented on the importance of information and insufficient prior professional training. This situation leads to reflection on the importance of not considering team meetings as solely for the discussion of operational issues, but as a tool for generating dialogue and a space for reflection, indispensable for the realization of expanded health care. It is also clear the difficulty that professionals, such as those working in PHC, have in building a close relationship with the scientific knowledge that is essential to their daily practice, which was evident in the following statements:

“As they say, we're human and we make mistakes, but I think we're always remembering information, I think that makes a difference”;

“It's important to always remember”;

“I didn't do a PHC course… just one module…”.

This finding is significant when considering the current recognition of the relevance of bioethics in health work, as clearly expressed in the National Curriculum Guidelines for graduate courses in medicine and nursing:

Art. 5º In Health Care, the undergraduate will be trained to always consider the dimensions of biological, subjective, ethnic and racial, gender, sexual orientation, socio-economic, political, environmental, cultural and ethical diversity and other aspects that make up the spectrum of human diversity that individualize each person or each social group, in order to achieve: (…)

VI - professional ethics based on the principles of Ethics and Bioethics, taking into account that the responsibility for health care does not end with the technical act²².

Art. 5º. The training of a nurse aims to provide the professional knowledge required for the exercise of the following specific skills and competencies: (…)

XXIII – manage the process of nursing work with the principles of Ethics and Bioethics, with resolvability both individually and collectively in all professional areas of activity²³.

The inclusion of bioethics is also prescribed in the Referencial Curricular do Curso Técnico de ACS (Referential Curriculum of the PHC Technical Course):

(…) The concept of training seeks to characterize the need to improve educational levels and professional performance profiles, enabling the increased intellectual autonomy of workers – command of technical and scientific knowledge, the capacity to self-plan to manage time and space at work, to exercise creativity, to work as a team, to interact with service users, to have awareness of the quality and ethical implications of their work²⁴.

In the same way, the questions that the ESF professionals elaborated about their own practical performance emerged, as the workshop provided reflection on the limits of professional practice and the need to create spaces for conversation about everyday problems²⁵–²⁸, issues that are often overlooked because of issues such as time and organizing the processes of work. Also clearly raised was the “objectification” of health care, which for many came to mean paperwork, prescriptions and exams. It was felt that this situation belittles and reduces the workforce, as well as lowers the self-esteem of professionals:

“Today they [the community] come to us; they schedule tests, and bring prescriptions”;

“The whole unit revolves around one doctor”;

“We're losing out… They just want appointments”;

“It isn't common to have time to discuss things in the team”.

The difficulties are many. The reality is complex. The needs are far from being addressed. There is much to be done…

Bioethics and family health: speaking for themselves or (in)conclusions

In the logic of continued work and dialogic training, there is no more rewarding success than that perceived in conversations during a focus group, when we identify the birth of a concern about work in the field, the detection of its importance and the perception that there is much to do and to learn. Certainly, the need for spaces for training and the discussion of bioethical issues was clear to all participants. The ability to bond with the team was noticeable to all who participated, even though the major undertaking that is training is only the beginning. There are needs to be addressed so that dialogue and continuing education are used as tools for more effective, resolute and pleasurable teamwork.

Despite the success we may achieve in the future, if strategies are deployed for the education of health professionals in the field of bioethics, we are only at the beginning of the journey. The process is long, and thinking and putting into action the bioethical toolbox is essential for this work to be carried out in a successful way, because timely interventions will certainly not be as efficient as longitudinal and continued strategies. The assimilation of fundamental concepts, principles and currents are still incomplete in relation to professionals. More work and time are needed for this approach and for the aggregation of knowledge into the repertoire of individuals and teams.

The need for training is therefore evident. New research is necessary to improve the chances of success. But this team, of which the researchers consider themselves part, will not be judged on success. This team thrives on the will and need to care for people. The story, then, is just beginning. There will be many, many new chapters.

• Aprovação CEP-UFV 68/2010
• The authors would like to thank Conselho Nacional de Desenvolvimento Científico e Tecnológico (the National Council for Scientific and Technological Development) (CNPq) and Fundação de Amparo à Pesquisa do estado de Minas Gerais (the Research Support Foundation of the state of Minas Gerais) (Fapemig) for supporting this study.

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Publication Dates

• Publication in this collection
  2016

History

• Received
  09 May 2016
• Reviewed
  19 Sept 2016
• Accepted
  26 Sept 2016