Praxis of family health teams in the care of cancer patients

Abstract

Objective

To reflect on the attributes of Primary Health Care and identify the strengths and weaknesses of the care provided to cancer patients.

Methods

Action-research study, performed through educational workshops with professionals who worked in five family health units. Data were collected from January to September 2017, and data treatment was based on content analysis.

Results

Considering the attributes of Primary Health Care, the Family Health Strategies workers reflected on the practice of assistance. The analysis gave rise to the thematic category “Knowledge and practices of health professionals in cancer care: a look at reality”.

Conclusion

The implementation of an educational practice made it possible to determine important aspects about effective care for cancer patients. The use of the method had the potential to encourage reflections on the assistance provided and help professionals to identify weaknesses and analyze and try to overcome them.

Family health strategy; health services research; medical oncology; primary health care; Family health

Resumo

Objetivo

Refletir acerca dos atributos da Atenção Primária à Saúde e identificar potencialidades e fragilidades do cuidado efetivado ao paciente oncológico.

Métodos

Estudo do tipo pesquisa-ação, realizado por meio de oficinas educativas, com profissionais que atuavam em cinco unidades de saúde da família. Os dados foram coletados no período de janeiro a setembro de 2017, e seu tratamento se deu por análise de conteúdo.

Resultados

Considerando os atributos da Atenção Primária à Saúde, os trabalhadores da Estratégias Saúde da Família refletiram sobre a práxis assistencial, emergindo a categoria temática “Saberes e práticas de profissionais de saúde na assistência oncológica: um olhar sobre a realidade”.

Conclusão

Implementar uma prática educativa possibilitou pautar aspectos importantes sobre o cuidado efetivo ao paciente oncológico. Ainda, utilizar a metodologia embasada na pesquisa-ação teve potencial de produzir nos trabalhadores reflexões sobre o fazer assistencial e, na mesma medida, identificar potencialidades e fragilidades, o que implicou em analisá-las e superá-las.

Atenção primária à saúde; Estratégia saúde da família; Oncologia; Pesquisa sobre serviços de saúde; Saúde da família

Resumen

Objetivo

Reflexionar sobre los atributos de la Atención Primaria de Salud e identificar posibilidades y debilidades de los cuidados realizados a pacientes oncológicos.

Métodos

Estudio tipo investigación-acción, realizado mediante talleres educativos, con profesionales que actuaban en cinco Unidades de Salud de la Familia. Los datos fueron recopilados durante el período de enero a septiembre de 2017 y fueron tratados mediante el análisis de contenido.

Resultados

Considerando los atributos de la Atención Primaria de Salud, los trabajadores de la Estrategia Salud de la Familia reflexionaron sobre la praxis asistencial, donde surgió la categoría temática “Saberes y prácticas de profesionales de la salud en la atención oncológica: una mirada sobre la realidad”.

Conclusión

Implementar una práctica educativa permitió enumerar aspectos importantes sobre los cuidados realizados a pacientes oncológicos. Además, utilizar la metodología basada en la investigación-acción permitió que los trabajadores reflexionaran sobre la práctica asistencial e identificaran, en la misma medida, posibilidades y debilidades, y como consecuencia, analizarlas y superarlas.

Atención primaria de salud; Estrategia de salud familiar; Oncología médica; Investigación sobre servicios de salud; Salud de la família

Introduction

Knowledge of the health conditions of a population is an indispensable factor for a resolutive and quality care. The understanding of health condition goes beyond the patient’s previous diseases, as it incorporates physiological conditions and the longitudinal monitoring of the individual’s life cycle.(¹) Yet, health care models are categorized according to acute and chronic conditions.(²)

These health conditions are the responsibility of Primary Health Care, and it is important that chronic diseases be prioritized, considering their greater proportion in the Brazilian territory. Among the main factors that caused the relative increase in chronic conditions are the demographic changes resulting from population aging, industrialization, accelerated urbanization and changes in consumption patterns and lifestyles.(³)

The rapid aging of the population accentuates some chronic diseases, such as cancer. In Brazil, the proportional mortality from cancer has grown considerably in the last decades, according to the world scenario,(⁴) and it is characterized as a public health problem.(³) The disease differs from other conditions, as the uncertainty of the prognosis, the effects of treatments and the need to cope with the possibility of recurrence and death are factors present in all stages of the disease.(⁵)

The assistance in the disease process, in the clinical conduct and in the rehabilitation of everyone involved in the cancer process is part of the work of healthcare teams.(⁶) In this perspective, in the Brazilian scenario, the organization of health care at different levels of complexity is coordinated by Primary Health Care, which is considered the main gateway to the Health Care Network, responsible for identifying the health problems of the population in a system that is transversal to all the different levels of the Unified Health System (SUS).(⁷)

When recognizing the importance of Primary Health Care for the effectiveness of health systems, with the role of organizer and coordinator of care, essential guiding attributes of the service are proposed. These attributes are: First Contact Access, Longitudinality, Comprehensiveness and Coordination – and the derivatives Family and Community Orientation.(⁸) They can be measured using the Primary Care Assessment Tool (PCATool), which allows to identify aspects that require reaffirmation or reformulation, aiming at a quality assistance.(⁹)

With the use of these attributes, the actions and services performed at Primary Health Care can become qualified and centered on the family. It is also the responsibility of Family Health Strategy team to reflect on their daily activities and behaviors, aiming to evaluate and change them according to the professional’s critical view, which allows discussions on good practices in healthcare.(¹⁰)

The development of educational actions with healthcare teams, with a critical-reflective process about their praxis, has the potential to qualify the assistance provided to individuals and to the community.(¹¹) This study is justified, as the incidence and prevalence of cancer in contemporary times gives rise to the need to investigate how cancer patients and health professionals perceive the presence and the extension of the essential and derived attributes of Primary Health Care and how health professionals notice their daily praxis in the unit when providing care.

The objective of this study was to reflect on the attributes of Primary Health Care and to identify the strengths and weaknesses of the care provided to cancer patients.

Methods

This is a qualitative study, based on the action-research model. It was developed in two stages: the first was an outline of an institutional project called Care Demands for Oncology Patients in Treatment: Intervention Proposal for the Convergence of Research and Educational Practice.

This stage involved 268 cancer patients undergoing treatment in Primary Health Care in a city located in the northwest of the state of Rio Grande do Sul. The participants were selected from a list of names and addresses obtained from health facilities and their data were collected at their homes. The selection of patients was done by convenience.

The study also included 15 healthcare workers who were interviewed in their units, at a previously scheduled time. Among the interviewees were municipal health managers, nurses and doctors working in the Family Health Strategy of the same city.

The PCATool self-administered instrument was used for data collection with patients and professionals.(¹²)The PCATool measures the presence and extent of the four essential attributes (First Contact Access, Longitudinality, Coordination – integration of care and information system – and Comprehensiveness – services available and provided) and the two attributes derived from Primary Health Care (family and community orientation). The instrument is validated for the Brazilian reality, in versions for users(¹³) and professionals.(¹⁴)

The data were organized in the Epi Info™ 6.04 software, with independent double typing. After correcting errors and inconsistencies, statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS)® software, version 25.0. For the PCATool analysis, the scores and values of the questions of each attribute were calculated, varying on a scale of 1 o 4, and the final score for each attribute was given by the mean of the answers to its questions. For the evaluation of high and low score of attributes, values of ≥6.6 were used, defining results equal to or greater than that as adequate (satisfactory) and equivalent to a value of 3 or more on the Likert scale.(⁹)

Considering the score defined as satisfactory, the evaluation of Primary Health Care from the perspective of professionals was: 7.14 for First Contact Access; 3.42 for Longitudinality; 7.67 for Coordination – integration of care; 7.49 for Coordination – information system; 7.63 for Comprehensiveness – services available; 7.17 for Comprehensiveness – services provided; 7.08 for Family orientation; and 7.33 for Community Orientation.

In the perception of cancer patients, the results were: 6.96 for First Contact Access – utility; 3.36 for First Contact Access – access; 7.21 for Longitudinality; 4.12 for Coordination – integration of care; 7.02 for Coordination – information system; 5.80 for Comprehensiveness – services available; 3.77 for Comprehensiveness – services provided; 4.28 for Family Orientation; and 5.46 for Community Orientation.

Then, the second stage was initiated. It consisted of a systematized implementation of educational workshops, in which five healthcare teams participated.

The workshops occurred from January to September 2017. The nurse manager of the unit was contacted to schedule the date and time of the activity, so that the entire team could be present.

The workshops were planned with the objectives of facilitating group dialogue, grasping the participants’ knowledge and understandings about the topic, stimulating the evaluation of their services and proposing means and/or measures to strengthen health care for cancer patients. Each meeting lasted an average of 1 hour and 30 minutes, and the number of meetings varied between one and two per unit, depending on the team’s participation and the exhaustion of the topic.

The results of the first stage were presented to stimulate discussion and reflection on the practice carried out with these patients and to find actions with the potential to qualify assistance. All professionals working in the Family Health Strategy were invited to participate in these workshops, as it is understood that the care for cancer patients is carried out by the entire team.

To respect the ethical precepts, the Family Health Strategy units were identified by numbers from 1 to 5. The participants were identified by letters that represented their professional category: NUR for nurse, DOC for doctor, NUT for nutritionist, NUR TEC for nursing technician and CHA for community health agent. The speeches of the participants were recorded and transcribed in full.

The analysis and interpretation included the transcription of the reports of the workshop participants. Data was categorized through thematic content analysis.(¹⁵) Thematic content analysis techniques were applied to the data and the following category emerged: “Knowledge and practices of health professionals in cancer care: a look at reality”.

This study was approved by the Research Ethics Committee, protocol CAAE: 03261712.8.0000.5505.

Results and Discussion

In the educational workshops, the team reflected on and evaluated the essential and derivative attributes of Primary Health Care to deliberate on what took professionals and patients to attribute such scores to each attribute and to define strategies to overcome weaknesses and qualify care practice.

Knowledge and practices of health professionals in cancer care: a look at reality

Currently, due to the emergence of chronic conditions, especially cancer, healthcare teams that are active in the Family Health Strategy must provide health care to these individuals according to the guiding attributes of Primary Health Care. Therefore, these attributes represent important indicators on the quality of the assistance provided.(¹⁶)

In this context, action-research is a methodology that provides interaction and/or mutual cooperation between the researcher and the researched, so that a participatory, active and collective relationship can be established.(¹⁷) Its use in the context of the Family Health Strategy is important, considering that there is already an interaction between the researcher and the researched, through a previously established relationship between health professionals and the community, in which the team allows an open, participatory and reflective dialogue with the users, in a constant pursue for positive transformation.(¹⁸)

First Contact Access is defined as the gateway to healthcare services for users, who identify it as the first resource to be sought when there is a health need or problem.(¹⁹) The observation of the scores made the participants look for hypotheses to explain the sometimes positive and sometimes negative evaluation. The group discussed that the evaluation of the attribute as a gateway to the health service is adequate but understood that the actions and services carried out by the Family Health Strategy do not address all the needs of the assisted population, according to the perception of cancer patients.

The low score attributed to Access in the perspective of cancer patients may be related to the fact that the Family Health Strategies teams work on business hours and only see patients with previous appointments, except for minor emergencies.(²⁰) Extending the work schedule could reduce difficulties in Access and expand the use of these services.

The socialization and reflections in the group made it possible to identify situations experienced and divergences between teams.

“I’m more in favor of the single shift.” (NUR TEC. FHS 1)

“There is no extended schedule, but it would be interesting, as it would help the population that can’t come to the unit’s in its usual opening hours.” (NUR. FHS 2)

“We do some extended shifts, but they are specific, it’s not a regular practice.” (NUT. FHS 3)

The professionals reported that one of the barriers for an effective extended schedule is the lack of authorization from the municipal manager.

“The municipal administration prohibited us to do extended hours, because the staff started doing too much overtime.” (NUR. FHS 3)

“We made a request to the municipal administration, the unit sent a letter requesting an extended shift, but it was denied [...] now they told us that they are thinking about the possibility of doing that.” (NUR. FHS 5)

Ensuring universal access to users in services can favor the resoluteness of health care, which contributes to the assistance to chronic health conditions, coordinating health promotion and disease prevention.(²¹) An important tool to promote the access of cancer users to Primary Health Care services would be extended working hours, as this is considered a facilitator of the care process.

Longitudinality is defined as the regular provision of healthcare and its use over time, without necessarily having health-related problems.(⁸) When reflecting on the unsatisfactory result, the participants understood that it may be related to the turnover of professionals, which weakens the establishment of a bond. However, the establishment of a bond is an assumption of the Family Health Strategy, so its presence is necessary.

“I understand that this low score is related to the turnover of professionals, mainly doctors and nurses [...].” (NUT. FHS 3)

“In addition to the frequent turnover of professionals, what also affects this attribute is the lack of quality of the information in medical records.” (NUT. NUR 4)

Considering the above, it is important to have permanent staff in the health unit to strengthen the bond between health professionals and users, a fundamental assumption of the FHS. In addition, thorough and complete records increase the quality of the information available in the medical records, which enables more effective treatments and contributes to the resolution of health problems.(²²)

The workers participating in the meetings realized that they could and should improve their records. Synthesizing the group’s reflections, it is also possible to infer that the unsatisfactory perception of health professionals on Longitudinality may be related to the inefficiency of the counter-reference of the specialized services, which leads to lack of empowerment of the Family Health Strategies team when assisting users in their care demands.

“We have no counter-reference from the specialized service, or from the hospital, from anywhere, so we don’t know what happens, and patients don’t know how to tell us either, it’s difficult [...].” (DOC. FHS 3)

The applicability of the Longitudinality attribute in PHC has positive effects for the care of the individual, the family and the community, as well as for the effectiveness of the Health Care Network. Still, it is important to note that when care is provided to cancer patients, it is essential that their follow-up is longitudinal, as well as their families’, considering the complex scenario of the health-disease process.

The Comprehensiveness attribute is defined as the range of services available and provided by the Primary Health Care service, including biopsychosocial activities in the health-disease process and actions related to health promotion, prevention, cure and rehabilitation.(²³) In the scenario, despite the importance of Comprehensiveness to guarantee the effectiveness of Primary Health Care, the components of this attribute achieved results below expectations. The participants expressed, after moments of reflection and socialization, that the cancer patient needs a greater range of care than other healthcare users, and sometimes, Primary Health Care can not provide it in full.

“When the person goes through some kind of suffering, in this case, cancer, even if they have a good understanding of the demands of the service, it is still not enough for them [...].” (CHA. FHS 5)

“Sometimes the needs for the comprehensiveness of care in the perception of cancer patients may require greater agility and, if they were suddenly interviewed in another health condition, perhaps, they would not evaluate it in as unsatisfactory.” (DOC. FHS 4)

Still, according to the shared understanding of the group, the professionals considered that, when a new health problem such as cancer is discovered at any level of the Health Care Network, access to services becomes an emergency. In these cases, the delay in referrals, related to bureaucratic aspects of the system, is a trigger of anxiety, anguish and fear, which may also lead to the dissatisfaction of patients with the service and the professionals.

“Cancer patients are in a fragile moment of their lives, so the delay in the service, the way the professionals assist this person, the way the service is offered may not be seen in a positive way by these users.” (DOC. FHS 2).

“[...] I once needed the specialized service and what I could see is that there is a lack of organization in their management. There are many bureaucratic barriers, some even unnecessary [...].” (CHA. FHS4).

Reports also showed that, because it is a chronic and complex disease, the care provided to cancer patients does not always go beyond aspects related to health-disease process. This is at odds with the recommended health care, which must be oriented to the individual, and not only to the disease. This reality demonstrates the need for Primary Health Care to expand the network of services offered, with the objective of meeting the basic health needs of the population and their families along with the provision of care, including services of guidance and management of the prevailing conditions.(²⁴)

The Coordination attribute is understood as the coordination between the different health services and actions, so that they are synchronized and aimed at achieving a single objective, with a view to offering the user a set of services and information that respond to their health needs in an integrated way, through different parts of the Health Care Network.(²⁰)

The integration between services of different levels of complexity, allowing access to Primary Health Care and to specialized services with high technological complexity, is a fundamental responsibility of the SUS.(²¹)

“Primary Health Care should coordinate care, but sometimes there is a lack of adequate tools for assistance to be effective. When we do not have the counter-reference of the cancer patient, care is not performed based on the individual’s real condition.” (NUR. FHS 3)

The participants of the workshop demonstrated to be involved in the qualification process, expressed their perceptions, and suggested intervention strategies to overcome the problems identified. According to the reflections of the Family Health Strategy teams, they understand, agree and welcome the dissatisfaction of cancer users regarding this attribute and, again, refer to the lack of the counter-referral of the specialized service to the PHC.

“[...] If the patients see it as unsatisfactory, I believe they have evaluated it well, because we have to ask them to bring us information about their care in the high complexity service, and this is wrong [...].” (NUR. FHS 3)

“We assume that the referral works, because we have to send the history, exams and other items for any specialist that we refer a patient to, but the counter-referral does not exist.” (CHA. FHS 4)

In this sense, the Coordination of Care for cancer patients needs to go beyond referral, aiming to improve communication between professionals and services and guaranteeing the referral and counter-referral. This means that the system should support the integration of care and the sharing of information generated by professionals in the provision of services, from the entrance door to the health system and back to it, so that continuity and resoluteness of care can be achieved in Primary Health Care.(¹⁶)

The Family Orientation attribute is centered on the assessment of individual needs, which takes into account the family context and its potential for health care.(⁸) The discussions and reflections during the educational actions made it possible to reflect on the situations experienced and to identify weaknesses to be overcome so that this attribute can be implemented in Primary Health Care.

“We were able to provide good follow-up to the patients who open up to the healthcare team, but they are only a few.” (CHA. FHS 4)

“When the disease is discovered and the users start treatment, their reference becomes the specialized service and they do not return to the Family Health Strategy.” (NUT. FHS 3)

“We have some families that belittle the cancer of their relative, do not give it too much importance and seek assistance in the specialized service.” (NUR. FHS 5)

According to the reflections of healthcare workers, even though the Primary Health Care strategy in Brazil is Family Health, the service is centered on the individual attention to the user, focusing on the disease and the demands coming from it, without considering the family context of the patient.

The family, as the focus of Family Health Strategies, must be fully understood in their social space, since the interactions and conflicts that occur directly affect the families’ lives.(²⁵)

Community Orientation is defined as the recognition of needs by the health service, through epidemiological data and direct contact with the community, as well as service planning and evaluation.(²⁶) Unsatisfactory results of the derived attributes of Primary Health Care, from the perspective of cancer users, is a matter of concern, since these aspects are fundamental elements for strengthening the bond between health services and families and community, considering the family as the center of care and the Family Health Strategy as the current health model.(²⁵)

In this sense, the participants expressed that the unsatisfactory perception of cancer users on this attribute may be related to specific aspects.

“In a self-evaluation, patients are right and we professionals are wrong, because in the past we did not have knowledge of the characteristics of our community, today we have it.” (NUR. FHS 5)

“I think the problem is that users take no co-responsibility for social control, they do not seek to know that it is their duty to participate, to set up a local health council [...].” (NUR. FHS 3)

The participants interacting in the group alluded to the low community insertion and the lack of social participation in Primary Health Care as factors related to the weaknesses of this attribute. The low participation of the community in issues of public interest leads to the lack of knowledge of the needs of the inhabitants of a territory, which results in a fragmented care.(²⁷)

Thus, an understanding of the health characteristics of the community and the available resources provides a more extensive way of assessing needs than an approach based only on interactions with patients and their families.(²⁶)These principles are consistent with the proposals of the Family Health Strategy, which aims to break the passive behavior of health teams and extend their actions to the entire community.

In this perspective, the presence and extension of the Primary Health Care attributes allow the consolidation of healthcare services provided by workers in the Family Health Strategies. Therefore, Primary Health Care services oriented to their attributes result in better healthcare indicators, greater efficiency in the path of users within the system, more effective treatment of chronic conditions, a more resolute assistance, greater user satisfaction and reduction of inequalities in access to health services.(²⁵)

Continuous and permanent updating through construction of knowledge is necessary to guarantee the effectiveness of the actions performed by Primary Health Care workers. Therefore, it can be observed that the implementation of educational strategies allows replacing knowledge and rethinking established practices.(²⁸)

Altogether, in the agreements made to provide qualified care for cancer patients, the professionals understood that it is necessary that assistance to this user be carried out through the Health Care Network, based on the specific attributions of Primary Health Care, with the objective of ensuring the resoluteness of care and the effectiveness of the service. Still, it was found that it is essential to know the patient’s therapeutic path at different levels of care during the process of diagnosis, treatment, cure and rehabilitation of cancer, so that it is possible to meet the individual’s health-disease demands in their entirety.

Conclusion

The analysis of the results allows us to infer that the implementation of an educational practice reveals important aspects that are part of the assistance and that, at times, are regular practices that unveil considered weaknesses that must be overcome to provide comprehensive and quality care to users, especially cancer patients. Thus, the use of the method based on action-research with Family Health Strategy workers had the potential to encourage reflections on the assistance provided and help professionals to identify weaknesses and analyze and try to overcome them. The development of the educational practice stimulated the team’s dialogue and the exchange of knowledge and understanding of the care provided to cancer patients. When identifying weaknesses, the groups deemed necessary to understand them and, to the same extent, propose ways to strengthen health care for cancer patients. The socialization made it possible to strengthen the co-responsibility of the team in the care of individuals in their territory, regardless of training. Thus, it is essential that healthcare teams develop care actions for these patients and identify the incidence of these individuals in their territory. It is also necessary to implement tools that assess the presence of the principles that guide the health service, to follow the attributes of Primary Health Care. Therefore, it is important and necessary to evaluate the services offered to individuals to maintain their continuous qualification. It is also worth noting that the workshops allowed an expanded look at the care provided in Primary Health Care, revealed the perception of the different Family Health Strategy teams in relation to the care provided to cancer users in all parts of the Health Care Network and helped enhancing the strength and co-responsibility of teams in the care of individuals in their territory.

Acknowledgements

To the National Council for Scientific and Technological Development that through the Institutional Scientific Initiation Scholarship Program (PIBIC) awarded scientific initiation scholarships, which allowed data collection through the scholarship holders.

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  Loro MM, Zeitoune RC. Collective strategy for facing occupational risks of a nursing team. Rev Esc Enferm USP. 2017;51:e03205.

Publication Dates

• Publication in this collection
  26 Nov 2021
• Date of issue
  2021

History

• Received
  15 Nov 2019
• Accepted
  1 Mar 2021