A nursing perspective on community care: for families

Abstracts

OBJETIVO: Identificar como o graduando de enfermagem relaciona a Terapia Comunitária (TC) como uma estratégia de cuidado com a família. MÉTODOS: Estudo qualitativo, em que foram entrevistados 12 graduandos do 2º ano de enfermagem da Universidade Federal de São Paulo que participaram de uma sessão de TC, como vivência do conteúdo prático da disciplina "saúde da família". A questão norteadora da entrevista foi: Como você percebe a TC na formação do enfermeiro em relação ao cuidado com a família? A partir dos dados coletados, realizou-se a análise de conteúdo proposta por BARDIN. RESULTADOS: Duas categorias descritivas foram encontradas: A TC, como estratégia de cuidado de enfermagem com a família - relação com a disciplina de saúde da famíla; A TC, como estratégia de reflexão dos estudantes em relação à dinâmica de suas famílias. CONCLUSÃO: Esta prática pode promover mudança de paradigma, pois coloca a família no centro do cuidado. Mostrou a necessidade de aprimorar a escuta qualificada, utilizar questionamentos que ampliem a possibilidade de reflexão em busca de estratégias para enfrentamento dos problemas.

Enfermagem em saúde comunitária; Educação em Enfermagem; Saúde da Família

ORIGINAL ARTICLE

A nursing perspective on community care: for families^*

Terapia comunitaria: cuidado a la familia en la perspectiva del estudiante del pregrado de enfermería

Ana Lúcia de Moraes Horta^I; Nicole Hannes Caldeira^II

^IPhD in Nursing, Adjunct Professor of the School of Nursing of the Federal University of São Paulo - UNIFESP - São Paulo (SP), Brazil

^IIRegistered Nurse graduated from the Federal University of São Paulo - UNIFESP - São Paulo (SP), Brazil

Corresponding Author

ABSTRACT

OBJECTIVE: Identify how the undergraduate nursing students relate to community therapy (CT) as a strategy for care of the family.

METHODS: This was a qualitative study in which 12 undergraduate students were interviewed about their perceptions of the practical content of the "family health" discipline, which is taken during the 2nd year of nursing at the Federal University of São Paulo. The main question of the interview was: How do you perceive the CT in nursing education as it relattes to the care of the family? Data were analyzed using the content analysis method proposed by Bardin.

RESULTS: Two descriptive categories were found: CT, as a strategy for nursing care with the family - it´s relationship with the discipline of family health; CT as a strategy for student reflection regarding the dynamics of their families.

CONCLUSION: This practice can promote a paradigm shift, because it puts the family at the center of care. This research showed the need to improve reflective listening, using questions that broaden the possibility of reflection, in search of strategies to deal with problems.

Keywords: Community health nursing; Nursing education; Family practice

RESUMEN

OBJETIVO: Identificar cómo el el estudiante del pregrado de enfermería relaciona la Terapia Comunitaria (TC) como una estrategia de cuidado a la familia.

MÉTODOS: Se trata de un estudio cualitativo, en el cual fueron entrevistados 12 estudiantes del 2º año de enfermería de la Universidad Federal de Sao Paulo que participaron de una sesión de TC, como vivencia del contenido práctico de la disciplina "salud de la familia". La pregunta norteadora de la entrevista fue: Cómo percibe ud. la TC en la formación del enfermero en relación al cuidado de la familia? A partir de los datos recolectados, se realizó el análisis de contenido propuesto por BARDIN.

RESULTADOS: Fueron encontradas dos categorías descriptivas: La TC, como estrategia de cuidado de enfermería a la familia - relación con la disciplina de salud de la famila; La TC, como estrategia de reflexión de los estudiantes en relación a la dinámica de sus familias.

CONCLUSIÓN: Esta práctica puede promover cambio de paradigma, ya que coloca a la familia en el centro del cuidado. Mostró la necesidad de perfeccionar la escucha calificada, utilizar cuestionamientos que amplíen la posibilidad de reflexión en busca de estrategias para enfrentamiento de los problemas.

Descriptores: Enfermería en salud comunitaria; Programas de graduación en enfermeria; Medicina familiar y comunitaria

INTRODUCTION

With the implementation of the Family Health Program (FHP) strategy by the Ministry of Health, through the Brazilian National Health System (SUS) in the year 1994⁽¹⁾, there arose the need for the formation of a professional capable of comprehending the structure and dynamic of the families, as well as the strategies for work in social networks and with communities. Such strategies envisage the integral health care of individuals and families⁽²⁾, in addition to the promotion, prevention and recovery of health. In the same year Regulation No. 1721 was created, the Nursing Minimum Curriculum - which advocates care directed towards the hospital and community context, considering the inclusion of the family as the focus of care⁽³⁾.

Within this context, the Family Health Discipline, with a workload of 36 hours, was officially introduced in 2004, into the 2nd year of the Undergraduate Nursing Course of the Federal University of São Paulo (UNIFESP).

This discipline aims to equip the nursing students for reflection and construction of the evaluation proposal and of the care strategies with the family, in times of crisis, in the context of health care. Thus, the Family Health discipline is a proposal that could facilitate the comprehension of the family structure and dynamic in the different contexts in which the family needs attention and care, as an activity of prevention and health promotion, according to the conditions recommended by the Ministry of Health⁽¹⁾.

Thus, it intends to discuss the theoretical and conceptual bases of care and work with the family and community, based on the theoretical frameworks of the General Systems Theory of Communication and the Theory of Change, considering the different moments of the life cycle. In this discipline, it is expected that the student comprehends these theoretical frameworks and their applicability in a new paradigmatic perspective, considering the transformation of the family over time and the family life cycle, as well as the influence of the myths, rituals, secrets, values and beliefs in the structure and in the functioning of the family. In the syllabus, the discipline includes instruments for working with the family that can be used in different contexts, such as genograms, eco-map, the Calgary Family Assessment Model - CFAM⁽⁴⁾, PRACTICE, FIRO, linear, circular and reflexive questioning techniques, narrative practices and Community Therapy (CT).

Community Therapy is an activity developed in the Family Health Discipline, the undergraduates participate in a CT session performed at the Basic Health Unit or within the University space. It is a strategy of group work that is believed to facilitate the comprehension of the content described above, as well as being a technique of active listening to the other and to the group, the themes of which are experienced situations or feelings/emotions that refer to the family context or moments of the cycle of family life. In the nursing consultations these themes are not always approached in a way that is systematic and centralized on the care with the family.

With a predicted length of 2 hours, CT is developed through the six following steps⁽⁵⁾: (1) Welcome: with the aim of welcoming the group, acclimatizing them and leaving them comfortably accommodated. Life is celebrated through the identification of the celebrations of the month, the concept of CT is talked about and an agreement is made, where the rules for carrying out the activity are established: to talk about themselves, maintain silence, not to judge or give advice, not to mention "big" secrets and, if appropriate, to interrupt the speech of the other to introduce a song, joke, proverb or story that makes sense with the context being discussed; (2) Choice of the theme: this is a moment in which participants positioned themselves concerning their feelings, needs, discomforts, achievements and conquests that they want to share. At this moment, the group should choose only one theme to be discussed; (3) Contextualization: the theme chosen by the group is expanded by the person who proposed it, providing more information on the subject supported by the questions asked by the group, so that the problem can be comprehended in its context. At this moment, it is important that the questions make the people reflect, think, and cause them to doubt their beliefs and convictions; (4) Problematization: This is the moment a situation-problem is identified and the tone is created, which is a key question that allows the reflection of the group on the theme defined and expanded in the previous step, (5) Rituals of aggregation and positive connotation: this is the closing moments of the group process where chants and rituals can be found, which are based on an understanding of what the participants discovered about themselves and learned from listening to the other, and how to incorporate this into their lives. The end of this stage is characterized by the positive connotation that the therapist should give to the fact that was worked with in the meeting, (6) Evaluation: reserved for the team that performed the community therapy, and for the nursing students to discuss the process and the correlation of this strategy with the care with the family.

Considering the knowledge that was discussed in the classroom and experienced on the stage of this discipline, by undergraduate students in nursing, it was sought to understand how CT can be a strategy for working with the family based on the necessity of family-centered care, and how it can be an introduction to the content in the undergraduate courses that help in comprehending this area of knowledge. Thus the research question arises: How do you perceive CT in nursing education in relation to the care with the family?

The aim of this study was: to know how the undergraduate nursing student relates CT as a strategy for care with the family.

METHODS

This descriptive, qualitative, study was submitted and approved by the Institutional Research Ethics Committee, considering Resolution No. 196/96. Study participants were 12 students who were enrolled in 2006, in the 2nd year of undergraduate Nursing of UNIFESP. Inclusion criteria were: being available and agreeing to perform the recorded interview in a reserved room at the end of 2007, as well as being a member of one of the four internship groups of the Family Health Discipline that had participated in at least one session of CT, totaling three students per internship group.

After the participants signed the Terms of Free Prior Informed Consent, they were interviewed individually by the researchers who used a guiding question in a thematic script, aiming to promote the free discourse of the respondent regarding the CT experienced, then the significant content of each of the participants was extracted. The guiding question was: How do you perceive CT in nursing education in relation to care with the family? The thematic script sought other aspects, comprehended by the students, linked to the possibility of CT as an instrument for care together with the family, such as: to identify the relationship of CT with the theoretical content of the discipline of family health, and whether there was any significance, in relation to the family histories of the students, related to this experience, believing that knowledge also goes through a moment in which an individual learns and perceives based on the experiences lived and that usually there is a personal content that is transformed by the meaning attributed to each shared situation. These situations can promote reflection on a process of change or a greater comprehension of the situation. Thus, it was expected that the participants would also comment on the findings and personal reflections that CT might have favored, based on experience.

The data were analyzed, guided in the accurate transcription of each interview, using the content analysis proposed by Bardin⁽⁶⁾. Thus, not only the apprehension of what has been previously mentioned was considered, but also its emotional context, as a way of paying attention to both the content and form of the discourses⁽⁶⁾. Therefore, it was considered that the discourse was not a transparent transposition of opinions, attitudes and representations that exist in a unique and final way. What is expressed is not the finished product, but a moment in a process of elaboration, including contradictions, inconsistencies and imperfections. Thus, the interviews were analyzed in the search for comprehension of the significances, taking into account the alignment and dynamic of the discourse. The statements of the participants were organized, sorted into categories, based on the themes that emerged in the discourses which were relevant to the aim of the study. The participants, in their statements, were identified with the letter P and a number from 1 to 12.

RESULTS

Data were grouped by similarity and two descriptive categories emerged from this analysis, which were: Community Therapy as a strategy for nursing care with the family - relationship with the family health discipline; Community Therapy as a strategy for reflection of the students in relation to the dynamics of their families.

Community Therapy as a strategy for nursing care with the family - relationship with the family health discipline

Analyzing the interviews, it was identified that the nursing graduates reported that Community Therapy can be an important instrument in mental health practice, particularly in family health care, whether in the resolution of conflicts or in the possibilities of coping with problems, as seen in the family health discipline. This was also reinforced when they commented that CT is an instrument that facilitates the expansion of listening to the other, as it links the context, the content and the relationships between people and the problems they are facing. Based on experience, they perceived that the community sought a space where they would be encouraged to speak and be heard, without advice or magic answers to solve their difficulties, just to reflect and seek possible alternatives in the resolution that they need. The well-being and sense of competence they commented on at the end of the therapy can be a strong incentive not to give up on themselves or their needs, avoiding isolation, and may prevent possible diseases triggered by discouragement, worry, insomnia or irritation. Thus, they described the CT as an instrument for prevention and health promotion, as in the comment below.

"... I think it's very important to reach a resolution without arriving in the hospital, because everything that is not resolved will later become pathological, so the sooner you resolve these issues the better... it seems that sometimes, just to talk, to be heard, already helps you find a way out and they said that the pain improves" P2

"... you involve several things, both the biological and psychological parts and everything else, today I understand the role of the nurse in this community therapy. I just do not think I had this vision before and I did not understand all this, I thought that we could be occupying a space that was not ours, but rather the psychologist's... suffering, they all understand and have the solutions ... they just need a space to be accepted and valued to not give up on themselves or on life ..." P8

Community Therapy is also seen as a strategy that can facilitate the formation of a bond and social network. Thus, they stressed that the realization of CT may facilitate a space for listening, sharing of experiences and meeting for training and the expansion of bonds, helping in the care of the people and of the community, as well as promoting awareness of the nurse in relation to the community assisted, according to the following statements.

"...The nurse has to create a bond with the family, and the therapy helps..." P11

"...(CT) opens a lot of space for her (nurse) to know all the families in more depth..." P7

For the study participants, based on what they heard from the community, CT was a facilitator instrument in the pursuit of autonomy and independence for the individual guided by the co-responsibility. The students participating in the study perceived that apart from not being something isolated, they carry histories, experiences, beliefs, values and family cultures, to understand both what is happening, and how to develop strategies to solve their problems. So it can be understood that overcoming the problems cannot be an action exclusive of an individual or "savior" as some health professionals are positioning themselves as they care for their clients, increasingly emphasizing the statement: "Who has a problem, has a solution and who has a problem is part of the problem". It is believed that when it comes to solving the problems of the community, there is an increase in self confidence. These aspects reinforce some of the topics of the theoretical framework of family healthcare, such as personal empowerment, resilience and the search for strategies created with the people who experience the problems, considering the context and moment of life, the possibilities for change and communication.

"...to listen and make the person recount it, so that she can find her solution, we are not here to say what is right and what is wrong, just to make the person review their history and find the solution they need... which seeks to make them reach for what they known, what is learned or lived in their history or in what is believed and which often makes up part of the family values" P3

Regarding the participation in CT, the students commented on the understanding of an amplification of the concept of family in the contemporaneity, being inclusive and more realistic.

"... we knew that the family is not made up like the old days, with a father and his children. Now there are more members in the family, and in the class and the community therapy we learned a lot about the dynamic. People always speak about the family dynamic, the problems that bring about this dynamic.... This also helps the nurse in the care, thinking not only about the individual but that there are other people who are involved in the problem..." P1

The students also achieved a systemic view regarding the individual and their family in relation to the process that they are living and not just the problem they report as a short statement without context. This helps to understand that CT may be a strategy that facilitates the systemic understanding of care with the family, considering that each member of the family system influences and is influenced.

"... a disease may be related not only exactly to the disease itself, but as an interaction in the family who are not working too well and therefore generates, causes the disease, then, you have to see not only the individual but his entire family.... it seems that others also may be suffering and they also cannot help, because they do not have good communication between them" P9

"... you involve several things, both the biological and psychological parts and everything, today I understand the function of the nurse in this community therapy... now I understand that suffering paralyzes the individual and not just them, but also their relationships, but they know the solutions ... they just need a space to be accepted and to be valued for not giving up on themselves or on life..." P8

This reinforces the understanding of the communication theory as the concrete use of steps that facilitate the expression for the understanding of the other and the possibility of space for reflection. The individual is able to express and to be heard by the group, to legitimize their pains and their victories. Another important aspect is that we communicate with words and also non-verbally, or even through symptoms or diseases, as an internal dialogue between the emotional and our body.

Community Therapy as a strategy for reflection of the students in relation to the dynamic of their families

For meaningful learning to occur, the life experiences of the people involved in the process must be considered. The students might recognize themselves in the statements of the other participants and in the experiences cited during CT and apply this in their personal lives, based on the identification of the themes.

"... I can share my problems and, then, I see that there are other people who have the same problems as me and that sometimes my problem is not as great as what the other person has ..." P10

Some interviewees commented that they have revealed things, in the CT space, that they had not yet talked about with anyone else. They identified that CT helped to seek, or at least to think about, new strategies for coping with conflicts, which confirms the Theory of Change in relation to system complexity, as well as the moment of their life cycle.

"... what I took from the therapy, my immaturity, it was good. I brought the immaturity; the worst is not being able to work today in the third year with this immaturity". P6

"I was very moved by the statement of the person... I listened and felt childish... I have to think about what the others are feeling, not only me. To attempt to hear and process, not just at that moment, but also later not to underestimate the problems, and to try to understand and not give advice". P5

During the session, the students interviewed mentioned that they had developed active and therapeutic listening. They stated that, based on the problems and reflections of the other histories they heard, they managed to make a relationship with their personal histories and could think about their problems and difficulties and left the CT, with new perspectives to rethink their histories or even strengthen their belief that they are on the right path.

DISCUSSION

In Nursing, care can be understood as assistance directed toward the individual, which is intimately linked to the cure, prevention and health promotion⁽⁷⁾. In this study, the undergraduate students showed that it is possible to expand the vision of care of the individual in a systemic way, perceiving that the problem of one affects and is affected by the other, including the context, relationships and understanding of change as a process. They perceived that the family and the community also need to be looked more attentively to encompass prevention and health promotion.

Since the implementation of the of the Family Health Program strategy, the vision of nursing care has been focused on the integrality of actions, considering the individual as a biopsychosocial and spiritual being, that is, care not only focused on the physical, but also on the mind and the soul of the individual⁽⁸⁾. According to the theoretical principles of CT and of the frameworks of care with the family, it is expected that the focus of action is dedicated to the individual in their context, considering the family, the community and their social network. With this, the students reinforce the importance of a multicultural view which includes beliefs, values and rituals that belong to a particular group and community and must be respected and valued when the intention is to understand the history and needs of the other. The actions of the nurse show a search for strategies for achieving care centered on the health of the family that focuses on health promotion in an attempt to be a facilitator⁽⁹⁾ for the comprehension of problems, broadening of concepts and reinterpretation of experiences and above all to expand the knowledge of adequation of theoretical frameworks that sustain this practice of care centered on the family.

The discourses analyzed in this study highlighted CT as a possible instrument in nursing care for working with families, which meets the proposal of this technique and its theoretical pillars. The study participants commented that the CT can be an activity which is possible to be developed by the nurse, facilitating the process of prevention and health promotion, as it acts in the biological, social and political dimensions, favoring the growth of the individuals, based on questions that stimulate autonomy and the social conscience of the community, and the formation of bonds⁽⁵⁾. To provide assistance to families, it is considered necessary to know and respect the values and cultural differences, because these factors determine the way people think and act⁽⁵⁾ and thus may facilitate communication and the bond between the nurse, the family and the community.

Today, the family is considered a group formed by people regardless of consanguineous links. In Brazil, the family is defined as a social group, based on legal approval, or at least on a long and intense period of social co-existence. It is also seen as a value considered by the Brazilian population as an institution fundamental to the social life⁽¹⁰⁾. Thus, in CT the study participants might experience situations in which the amplification of the concept of family, regardless of the crisis experienced, is a reality and should be respected and understood without prejudice, seeking inclusion guided by the need and reality of this community. The interviewees mentioned that CT can promote the comprehension of the importance of learning to "hear" the other and amplify the context within a systemic perspective. These data correspond to another study that identifies the transformations in the concept of family, such as structure and dynamic, as well as the value of this in nursing care⁽¹¹⁾.

The participants and other researchers have mentioned that the nursing care to the family should be focused not only on the individual but on the family and on their interaction with the context and support network, highlighting the strengths and skills, as well as acting as a facilitator for the comprehension and solution of problems in the family⁽⁹⁾. Using the systemic focus of the family, the care process can be a meeting that permits the defining of possible strategies for care and is co-constructed by people involved in the process⁽¹²⁾.

Thus, in accordance with the experience they had in the CT, the participants showed that they possess a systemic vision of the family in which, as described in the literature, it is believed that the family dynamic can influence the evolution of a health complication, as much as this can influence the family dynamic, in a continuous process⁽¹³⁾. The fact becomes evident when the participants commented on the effect observed in the people who attended the CT. They were even able to correlate the theory in the family health discipline, in relation to the systemic process in working with the family, to the understanding that it is possible to deal with questions that plague the quotidian of people and the community, and to provide a warm welcome, the opportunity to speak about themselves and to be heard with respect and without judgment. To learn and practice communication techniques can help the members of the CT group to develop a sense of belonging, improving interpersonal relationships, self-esteem, expression and promoting improved quality of life⁽¹⁴⁾.

It is important to highlight that CT, as a care proposal, brings people together in a non-hierarchical way, based on mutual help, with the aim of seeking practical and collective solutions, and, in the belief in the autonomy and responsibility of each other⁽¹⁴⁾, is an co-constructed instrument that facilitates the search for citizenship. Furthermore, it can be used as a type of prevention in the area of Mental Health⁽⁵⁾, it can promote the care of the self-esteem, and the valorization of cultural practices, of the family and of the community. The people who attend TC expose feelings and emotions without judgment. When they are reprimanded in their social context, psychic suffering and somatization can be generated⁽¹⁴⁾. This moment includes discussions aimed at identifying the communication process of the individual and of the group, beliefs and values of the participants, as well as the use of techniques of active listening and comprehension of the context. Community Therapy can be an instrument that facilitates knowledge of the attended community and transforms the paradigm in relation to the ways of resolving the problems of this community, since the individual who expresses their problem or difficulty, also communicates a content inserted in a context that involves the family relationships.

The students perceived the importance of the people having the opportunity to express what they think or need. They also comprehended that, based on the speech and the reflection; the people can better live with these feelings and emotions, which can prevent major physical and mental health complications. It is important to highlight that when caring for the other we are also taking care of ourselves, which was reinforced by the study participants when they commented on what they experienced as participants in the CT and their reflections. It is worth mentioning that new strategies are being created to comprehend and work with the family in the different contexts of practice of the nurse, and CT may be another instrument that can facilitate this practice. Overall, the study participants reported that, according to their experience, CT was perceived as a viable technique to be practiced by the nurse and can facilitate: social inclusion, the search for different understanding based on the inclusion, paying attention to what is being said and an increase in the family and community contexts. They also managed to comprehend the relevance of this strategy in relation to the content taught in the Family Health Discipline, strengthening the continuity of this activity.

The Theory of Change defines change as an alteration in the structure, which occurs spontaneously and continuously, based on the interaction of the individual with the environment⁽⁴⁾. In this respect, CT, as a space for exchanging experiences and knowledge, makes each individual who attends the session, responsible for seeking their own solutions to the quotidian problems, allowing them to reconstruct their identity and give continuity to their own history. It must be remembered that change does not happen immediately, an undetermined time is necessary to allow them to formulate the new information received and, from there, begin a process of change. But the information alone does not generate behavioral change.

Community Therapy is expected to be a health promotion instrument, which offers a community space to share knowledge and life experiences in a horizontal and circular way⁽⁵⁾, and that, when hearing the history of the other, each person seeks solutions and ways to overcome their problems, which becomes a therapeutic group action It is also important to note that CT is not only a therapeutic action, but may relevantly contribute to social transformation, as it promotes the autonomy of the individual and the pursuit of the exercise of citizenship. It is an instrument for bringing together and integrating people, aimed at raising self-esteem and recognizing potentialities, awareness of human rights, constructing networks of solidarity in dealing with human suffering rather than with the pathology or disease.

FINAL CONSIDERATIONS

Through the experience in the CT session, according to the category encountered, Community Therapy as a strategy for nursing care with the family - in relation to the family health discipline, the students reported that CT facilitated the understanding of the importance of the care with the family, considering the theoretical framework that supports this approach. They observed that, in developing listening skills, openness and credibility in the group process, they might perceive the human beings and their suffering as a relational network, identifying the problem, beyond the symptoms presented and the suffering of those living with the problem, as well as considering it a rich strategy in the prevention and promotion of mental health. The connection to the health of the family is based on the elaboration of a collective construction, whose understanding and application of the theoretical framework of work with the family can provide an understanding of themselves, one in which the family is part of the context and can be comprehended in a systematic way.

There is a search for strategies to identify the communicational process of the individual and of the group, their beliefs and values, as well as the use of techniques of active listening and comprehension of the context. It is believed that CT can be an instrument that facilitates knowledge of the community attended and transforms the paradigm in relation to the ways of resolving the problems of this community, since the individual that expresses their problem or difficulty, also communicates a content inserted in a context that involves the family relationships. This study also showed, according to the second category found - Community Therapy as a strategy for reflection of the students in relation to the dynamics of their families - the necessity of the students to have a space to listen and share their needs and anxieties when confronted with the situations that are experienced or related to the future, as professionals or any step of the life cycle.

It is important to consider that further studies should be performed in order to understand how the nursing undergraduate student can continue to broaden their systemic view in family-centered care and how the mode of teaching the practice of CT can facilitate this process not only in the professional training of the students, but also as people that live diverse processes and contexts and have to act and react according to their beliefs and family values built up over their existence.

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*

Artigo extraído do trabalho de conclusão de Curso de Especialização em Intervenção e Prática Sistêmica com Família - Terapia Familiar e de Casal oferecido pela Universidade Federal de São Paulo - UNIFESP - São Paulo (SP), Brasil

Publication Dates

• Publication in this collection
  14 Oct 2011
• Date of issue
  2011

History

• Received
  31 Mar 2009
• Accepted
  02 Dec 2010