Caring for tuberculosis patients in the Family Health Strategy: the nurses' perceptions

Abstracts

Analisar percepções de enfermeiras sobre o controle da tuberculose, segundo o eixo teórico da integralidade em saúde e os conceitos de vínculo e trabalho em equipe. Pesquisa qualitativa que envolveu 13 enfermeiras da Estratégia Saúde da Família de município prioritário da região Metropolitana de João Pessoa, Paraíba, Brasil. As informações foram coletadas mediante grupo focal e analisadas conforme a técnica de análise de conteúdo e modalidade temática. Elementos potencializadores do controle da tuberculose: tratamento supervisionado, medicação gratuita e oferta de insumos. Elementos fragilizadores: rotatividade dos profissionais, retaguarda laboratorial, falta de incentivos para os doentes e ações educativas incipientes. Os elementos que fragilizam o cuidado ao doente de tuberculose, identificados pelos enfermeiros, devem ser refletidos por gestores, profissionais, usuários e formadores, de modo que na prática seja possível redefinir ações de cuidado que fortaleçam o vínculo, a integralidade e o trabalho em equipe.

Tuberculose; Programa Saúde da Família; Enfermagem em saúde pública; Cuidados de enfermagem

ARTIGO ORIGINAL

Caring for tuberculosis patients in the Family Health Strategy: the nurses' perceptions

Cuidado al enfermo de tuberculosis en la Estrategia Salud de la Familia: percepciones de enfermeras

Lenilde Duarte de Sá^I; Annelissa Andrade Virgínio de Oliveira^II; Anna Luiza Castro Gomes^III; Jordana de Almeida Nogueira^IV; Tereza Cristina Scatena Villa^V; Neusa Collet^VI

^IPh.D. Professor, Department of Public Health Nursing and Psychiatry, Federal University of Paraíba. Professor, Graduate Program in Nursing. João Pessoa, PB, Brazil. [e-mail]

^IIRN. Master Student, Nursing Graduate Program, Federal University of Paraíba. CAPES fellow. João Pessoa, PB, Brazil. [e-mail]

^IIIPh.D. Professor, Department of Public Health Nursing and Psychiatry, Federal University of Paraíba. RN, João Pessoa Family Health Program. João Pessoa, PB, Brazil. [e-mail]

^IVPh.D., Professor, Department of Medical-Surgical Nursing and Administration, Federal University of Paraíba. Professor, Nursing Graduate Program. João Pessoa, PB, Brazil. [e-mail]

^VRN. Ph.D. in Nursing and Public Health, University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, SP, Brazil. [e-mail]

^VIPh.D. Professor, Department of Public Health and Psychiatric Nursing, Federal University of Paraíba. Professor, Nursing Graduate Program. João Pessoa, PB, Brasil. [e-mail]

Correspondence addressed

ABSTRACT

The objective of this study was to analyze the nurses' perceptions regarding tuberculosis control, according to the theoretical axis of comprehensive healthcare and the concepts of attachment and teamwork. This qualitative study involved 13 nurses from the Family Health Strategy of a priority city in the metropolitan region of João Pessoa, Paraíba, Brazil. Data were collected in focal groups and subjected to thematic content analysis. Factors that strengthen tuberculosis control were: supervised treatment, free medication and the provision of supplies. Weakening factors were: worker's turnover, the lack of encouragement for patients and incipient educational actions. The factors that, according to the nurses, weaken tuberculosis patient care should be reviewed by administrators, workers, users and educators with a view to redefining healthcare activities that strengthen attachment, comprehensive healthcare and teamwork.

Descriptors: Tuberculosis; Family Health Program; Public health nursing; Nursing care

RESUMEN

Analizar percepciones de enfermeras acerca del control de la tuberculosis, según eje teórico de integralidad en salud y conceptos de vínculo y trabajo en equipo. Investigación cualitativa que involucró 13 enfermeras de la Estrategia Salud de la Familia de municipio principal en región metropolitana de João Pessoa-Paraíba-Brasil. Las informaciones fueron recolectadas mediante grupo focal y analizadas conforme a técnica de análisis de contenido, modalidad temática. Elementos potencializadores del control de la tuberculosis: Tratamiento supervisado, medicación gratuita y oferta de insumos. Elementos fragilizadores: rotación de los profesionales, respaldo laboratorial, falta de incentivos para los enfermos e incipientes acciones educativas. Los elementos que fragilizan el cuidado al enfermo de tuberculosis, identificados por los enfermeros, deben ser objeto de reflexión por parte de administradores, profesionales, pacientes y formadores, para que en la práctica se puedan redefinir acciones de cuidado que fortalezcan vínculo, integralidad y trabajo en equipo.

Descriptores: Tuberculosis; Programa de Salud Familiar; Enfermería en salud pública; Atencón de enfermería

INTRODUCTION

Within the context of the Brazilian Family Healthcare Strategy (FHS), the professional nurse can be seen as the protagonist in the history of the country's tuberculosis (TB) control interventions⁽¹⁾. Since the 1920's - and more precisely since the 1960's - these nurses have been playing the role of sanitary educators, performing and supervising TB treatment protocols. However, although nurses occupy a place of honor in the nation's healthcare historical records, nursing practice – as part of the healthcare public policies in this field – faces the daily challenge of imprinting new logic on the organization of related work processes, with the aim of shaping a healthcare system that is built under the perspective of comprehensiveness.

This present study is grounded on the theory of comprehensiveness, a practice that is based upon healthcare professionals and on the multifaceted gathering points of these workers in and at the service⁽²⁾. The study also complies with the definition of comprehensiveness described in organic healthcare law (Laws 8.080 and 8.142/90) as an articulated, continuous set of preventive and curative, individual and collective actions and services required for each individual case, in all levels of complexity in the healthcare system.

The nursing work process in the healthcare system is translated into a network of subprocesses, namely: care or assistance, administration or management, and research and teaching⁽³⁾. Within this scope, the nursing activity plays a specific role in the FHS, which stands out as a new way of organizing healthcare work processes and points to the reorganization of such processes under the perspective of the development of actions that value the autonomy of the patients and ensures that the caregiving process will be executed in accordance with the users' needs.

Aimed at carrying out caregiving based on comprehensiveness, the work process in the FHS requires the following tools: interdisciplinarity, intersectoriality, teamwork, humanization of services and the creation of bonds between users and healthcare professionals/teams. Regarding the specific work of the healthcare team in assisting TB patients and their families, the teamwork process should comply with the DOTS (Directly Observed Treatment Short-Course) pillars of care, namely: case detection by sputum smear microscopy; standardized, directly observed short-term treatment; regular drug supply; a standardized recording and reporting system that allows for assessment of treatment results; and government commitment to TB control systems⁽⁴⁾.

As generally thought, the DOTS should not be restricted only to actions related to the observation and monitoring of specific drug intake processes. In the search for a comprehensive and decisive TB control agenda, in addition to being technically prepared, family healthcare teams should take into account the application of technologies that favor the therapeutic process that aims particularly at the construction of attachments.

The construction of attachments has contributed as a relevant tool that can ensure the compliance of patients and the continuation of treatment, as it favors the development of a trust relationship between the subjects involved in the therapeutic process. In this sense, in addition to comprehensiveness as the theoretical grounding element of this study, the work of the family healthcare team and the attachment concept were also taken into consideration. The attachment between the population and the healthcare center requires the establishment of strong interpersonal ties that reflect a mutual cooperation between the community at large and the healthcare professionals⁽⁵⁾.

In Brazil, the number of studies that approach the assessment of the performance of the Basic Healthcare Attention (HBA) program in TB^(6-7) control has been steadily increasing. Among these, studies that show the nurse as the professional who is mostly responsible for creating attachments with TB patients can be highlighted^(8-9). Nonetheless, bearing in mind the history of this professional – and his subjectivity - in TB control programs, as well as the protagonist role of the caregiving actions in the FHS, a study of the elements that contribute to comprehensiveness-based caregiving becomes mandatory.

This study took into account the huge challenges of TB in Brazil, especially in the country's Northeastern region, which recorded 20,137 cases in 2009 and displays an incidence rate of 37.58/100,000 inhabitants⁽¹⁰⁾. At the same time, the study also considered the national healthcare policy, which has reorganized healthcare programs based on the FHS toward the implementation of the DOTS. Having these two objectives in mind, this research intended to analyze the perceptions of nurses regarding the caregiving processes carried out by the family healthcare team in controlling TB in a town that integrates the Greater João Pessoa (metro area). The Tuberculosis Control National Program is deemed as a priority here.

METHOD

This study is an exploratory-descriptive and qualitative-based research. In March 2007 a free observation of the field to be studied was made in order to study the organization of the services of the HBA program in the above-mentioned municipality, as well as the implementation of the DOTS strategy by the local family healthcare teams. At the time of the study, the city had 28 family healthcare teams who were responsible for the implementation of the DOTS. The town contained two polyclinics, one a maternity clinic (where BCG vaccines were administered) and one a Municipal Lab (responsible for sputum smear microscopies for diagnosis and control), as well as five sputum collection centers, one in each Sanitary District.

The study counted on the participation of 13 nurses from the 28 family healthcare teams who assisted TB users under treatment up until March 2007. Those professionals were between 20 and 52 years old. Their length of experience working for the FHS varied from three to six years.

The information-gathering process made use of the Focal Group (FG) technique. As these groups should be small and homogeneous – limited to a maximum of 12 subjects each – two meetings were arranged in the month of April 2007. The first meeting included seven nurses and the second meeting included six nurses⁽¹¹⁾. The FG discussions were guided by a previously elaborated script. The conversations were recorded and the researchers and observers used several worksheets prepared beforehand, so that relevant issues could be recorded. In both meetings, discussions were encouraged by means of the presentation of three real-life situations involving the actions of the family healthcare teams in caring for TB patients.

In compliance with Resolution 196/96 that sets out the norms and guidelines for research involving human beings, participants were informed regarding the goals of the meetings, the reason for the use of the recorder and the privacy of any gathered information prior to the implementation of the recording process. Statements were codified with alphabet letters and Arabic numbers, in order to safeguard the nurses' anonymity. The project was approved by the Research Ethics Committee of the Healthcare Science Center of the Federal University of Paraíba – CCS/UFPB – under protocol number 936/07.

The Content Analysis Technique – thematic modality⁽¹²⁾ – was applied to the analysis of the empirical material. The analytical reflection was carried out by following the next steps.

Pre-analysis and constitution of the corpus: 13 interviews carried out with the nurses that took part in the two FG sessions were selected. For the exploration of the material and the treatment and interpretation of the achieved results, all recordings were listened to and the transcriptions of the recorded material were done again. In this process, the thoroughness, homogeneity, representivity and pertinence of obtained contents were observed. Next, both the fluctuating and the longitudinal readings were performed. The first was individually carried out; the second was carried out by three researchers, followed by a discussion regarding the coherence and pertinence of the content of the speeches. The next step was transversal reading and the beginning of the codification process based on the registration units, and formulation of pre-hypotheses and codification.

After analyzing the FG sessions' recorded speeches of the nurses who worked with TB patients in the HBA, and in order to reach the proposed goal, the following registration units were highlighted: multiprofessional approach; fragmentation of caregiving; the nurse as the primary caregiving reference in the FHS; actions carried out by the nurses; political issues and their effect on the nurse's work process; professional qualification; medical professionals' turnover; early diagnosis and treatment continuity; and political-social commitment. The registration units developed the following Core Meanings: the family healthcare team's work process in TB control and Singularities related to the ethical-political commitment towards TB control in the HBA.

Subsequently, the study sought to identify convergent-divergent and repeated content among the speeches, including the extracts of the speeches in each one of the identified core meanings. This format allowed for the identification of the Central Thematic Unit toward which all speeches streamed: Caregiving to the TB patient in the Family Healthcare Strategy: perceptions of the nurse.

RESULTS

The work process of the family healthcare teams in TB control

This first core meaning presents the perceptions of interviewees regarding the family healthcare team's work process in TB control. This core meaning was comprised of the following registration units:

Singularities related to the ethical-political commitment towards TB control in the HBA program

This second core meaning presents the perceptions of the interviewees concerning the singularities related to the ethical-political commitment towards TB control in the HBA program. This core meaning was comprised of the following registration units:

DISCUSSION

The family healthcare team's work process in TB control

The nurses revealed that the family healthcare team's mode of operation in caring for TB patients is carried out using a multiprofessional approach, as shown by the speech fragments of N1 and N4. Regarding team work, technical differences may open doors for distinct fields of knowledge to cooperate together toward caregiving. Workers carry out activities from their own professional field, but at the same time execute common actions in which functions from different areas are integrated⁽¹³⁾.

However, not every team articulates their actions. The nurses – as can be noticed in the speech fragments of N5 and N6 – reveal that TB control actions occur in a segmented way; in other words, caregiving is not carried out by the whole team, since the TB patient first receives assistance from the nurse, followed by other professionals. It can be realized that the studied family healthcare teams have an already defined way of doing things, delineating tasks in a certain order regarding the statuses of both the illness and the ill person, regardless of the specific demands required by the caregiving process.

Thus, two teamwork strategies were identified in the way nurses organized the work toward providing TB patients with care: the grouping team is characterized by the fragmentation of interventions, and the integration team is characterized by the articulation of multiple sources of knowledge. The first shows a juxtaposition of actions and the grouping of agents, but comprehensiveness toward articulated healthcare actions is not achieved. The isolated actions diminish human beings into fragments. On the other hand, the integration of the teams showed that the agents sought to establish correlations within the work environment, thus highlighting the interconnections among the wide variety of executed professional functions. This way of organizing the work promotes the articulation of actions and the interaction among the agents, unlike the grouping team, defined by a fragmented work⁽¹³⁾.

In their statements, nurses do not mention the individual needs required by each human being accessing the healthcare service. They do not take into account the social condition of these citizens, nor their lifestyle, their economic status or their family context. The objectification of the sick person who needs the technical intervention of the healthcare professionals stands out as a clear feature, as well as the concern regarding TB symptomatology. In this sense, the lack of a qualified hearing impairs the construction of a favorable field toward the production of intersubjectivities. Any work based on these characteristics weakens both the building of attachments and the accountability process between the ill person and the family healthcare team⁽⁹⁾.

It is worth emphasizing that in both team caregiving modalities described above technical differences in the specialized works and the inequality of the values assigned to these distinct works were identified⁽¹³⁾. Both displayed tensions concerning the conception and the execution of the technical autonomy, and also between the conception regarding the independence of the specialized work and its objective complimentary role⁽¹³⁾. Therefore, the reorganization of the team work demands an articulation of actions, a communicative interaction between agents and the overcoming of the isolation of knowledge⁽¹³⁾. In this sense, it is important that the caregiving processes are produced from an interdisciplinary standpoint, thus achieving an articulation of knowledge and actions, defining the field and the core of competencies of each professional in their daily healthcare service activities, aimed at warmly receiving the ill person and establishing attachment and accountability with him.

The statements also recorded alterations in the teamwork process provoked by different relationships within the political arena concerning the healthcare professionals' competencies. We should bear in mind that the discussions regarding the Medical Act law point to the consolidation of a biomedical-based thought process, thus provoking the dispute for power among the professional categories.

Political interferences in the organization of work reflect the weak points in the existing relationships among family healthcare team members; among these, the resistance against the prevalence of medical knowledge over the knowledge of the other professionals in the family healthcare teams can be highlighted. The nurses' speeches showed that the Medical Act law triggers a delay in the diagnosis and treatment of patients. As the Act focuses clinical activities on physicians, it weakens the integration-based team practice⁽¹³⁾, consequently compromising the relationship between the family healthcare team workers, the interaction between the team and the TB patient and, finally, the healthcare team work process itself in its ability to control the disease.

In order to provide the TB patient with comprehensiveness-based care, it is necessary that the essence of the teamwork be built during the healthcare worker's educational and training process, so that he is offered learning strategies that favor dialogue, exchange of ideas and multidisciplinary cooperation among the distinct knowledges⁽¹⁴⁾. In this sense, although it is recognized that the plurality of knowledges favors the control of the disease, statements revealed that the nurse centralizes the caregiving actions around the TB patient.

The speeches lead us to believe that the nurses working in the FHS are the ones who lead the caregiving actions toward TB patients. These professionals are seen as the ones who more intensely carry out caregiving actions toward TB patients, and this fact provides plenty of room for the strengthening of built-in attachments. In this perspective, whenever healthcare attention is centered on a healthcare professional, several benefits to the caregiving relationship can be identified. As patients have a healthcare professional as a reference, this relationship makes a clearer recognition of his needs/problems possible, thus allowing for more adequate therapeutic management⁽⁵⁾.

One of the specific assignments of the nurse within the FHS context is to carry on activities related to the priority areas of intervention in the HBA program set out by the Pact for Health, established in 2006. Taking the control of TB into account, the HBA nurse is expected to identify respiratory symptoms, acquire sputum smear microscopy for the diagnostic process, carry out nursing consultations, perform supervised treatment (ST) and notify the appropriate entities regarding the disease, among other duties⁽¹⁵⁾. Following these guidelines, the nurses in the studied municipality confirmed their participation in the development of activities related to the active search for disease, diagnosis, notification and treatment. This fact reveals a meaningful potential for the establishment of attachments with patients, as the attachment depends very much upon the way the teams account for the group of people living in their area of influence⁽⁹⁾.

The active search for respiratory symptoms toward the control of TB within the context of the FHS demands a set of actions taken both in the external scope (family approach at home, identification of suspected cases) and in the internal scope (reception of materials, forwarding of materials to the lab, diagnosis) of the healthcare services, in order to ensure the longitudinal reach of the attention, quite necessary for the creation of an attachment⁽¹⁶⁾.

As regards disease notification, the TB is included in the Ministry of Health's National Norm 4.052, from 23^rd December 1998, which defines the Compulsory Notification Diseases nationwide. The Ministry of Health assigns the nurse the responsibility of notifying authorities regarding the disease by use of the Notification Grievance Information System statement (SINAN)⁽¹⁵⁾. The nurses' statements revealed that they do indeed carry on notification activities. Notification activities have become powerful tools in controlling the disease, since after this action is triggered, control measures and actions are put in motion together, thus improving the caregiving process toward the patient and his family under the area of influence of the Family Healthcare Center (FHC).

Regarding diagnosis and treatment, the effective performance of the nurses in demanding both the sputum smear microscopy and the medicine was observed. It is known that the earlier the diagnosis and the treatment, the shorter the transmissibility time. It is worth highlighting that more important than simply decreasing the time of the diagnosis, and consequently the time to begin the treatment, the warm reception of the users and their immediate integration into the family healthcare team is an essential step, since early diagnosis may be rapidly achieved, as well as the conclusion of the treatment.

By focusing their attention on the ill people in their units, and being dedicated to the early diagnosis of TB and the provision of the related medication, the nurses in the studied municipality lead the actions toward controlling the disease among the professionals of the family healthcare team. If on the one hand this finding reveals their protagonist role in the family healthcare team's work process in controlling TB, on the other hand it clearly shows the frailties observed within the scope of the HBA program, in which caregiving should be promoted using a multiprofessional approach grounded on the concept of the integration of teams, thus complying with the healthcare definition of comprehensiveness.

Singularities related to the ethical-political commitment towards TB control in the HBA program

Therapeutic success against TB requires, among other actions, the establishment of attachments between the healthcare professionals and the TB patient. The synergy between the healthcare team and the patient will pave the way for such an achievement. Trust, affinity, accountability and mutual commitment are the pillars of this construction^(9,17).

The early diagnosis of TB by means of an active search for respiratory symptoms within the community is quite a relevant and important assignment of the family healthcare teams. Whenever a suspicious case is identified, a sputum smear microscopy exam should be immediately demanded. For this to happen, all necessary equipment must be available, such as cups, labels, methods of adequate conservation and storage of collected materials, lab activity flowcharts and information systems⁽¹⁵⁾.

Some excerpts of the interviews point out that the lack of collection sputum cups makes the TB diagnosis a more difficult process. The absence of such important equipment can delay the beginning of treatment, in addition to extending the time of transmissibility. The availability of equipment, therefore, is considered to be of vital importance to the sustainability of DOTS, particularly in regards to the feasibility of sputum smear microscopy.

Similar to the overall distribution of equipment, the lack of free medication for the ill could interrupt treatment. The speeches reveal statements that lead us to believe in the existence of an active TCP (Tuberculosis Control Program) coordinator (manager) in the studied municipality that could ensure the distribution of medication. However, the management of actions toward TB control should not be solely limited to guaranteeing the ill person access to necessary equipment and medicine.

From the standpoint of the HBA program, coordination (or service articulation) presupposes some form of continuity, be it assistance by the same professional throughout treatment, by means of consistency in medical records, or even both, in addition to the identification of old and new problems. It still includes the forwarding and the follow-up of assistance processes in other specialized services⁽⁵⁾. An active coordination program favors the sustainability of DOTS, as it expresses the political commitment of managers toward the quality of the work process of the healthcare teams that provide care to TB patients.

Based upon the nurses' statements, it was verified that the lack of professional qualification may weaken the TB control process and compromises the TCP coordination work in maintaining the sustainability of DOTS. Professional qualification is one of the major aspects that negatively influence the incorporation of TB control into the HBA program⁽¹⁸⁾. Nurses reveal that professional qualification activities for the family healthcare teams are unsatisfactory, since there is not a steady offering of training programs. Doctors are the workers who most often lack professional updates regarding TB-related works. A study carried out in the city of Medellín (Colombia) shows that the limited knowledge of healthcare professionals regarding TB risk factors and the diagnosis process, together with poor use of sputum smear microscopy, lead to the delay of the diagnosis⁽¹⁹⁾ and the beginning of treatment.

The absence of a permanent healthcare educational process for the professionals of the family healthcare teams – an observed local problem – contradicts the guidelines of the Ministry of Health. The Ministry of Health recommends that every family healthcare team to be qualified in order to provide better assistance to TB patients, and that all professional categories should be included in the planning of training courses by the State and Municipal healthcare departments⁽¹⁵⁾.

TB caregiving must be a humanized process, grounded in a warm reception and having the comprehensiveness principle as the guiding axis of collective healthcare practices. For this reason, sanitary practices must be based upon the reorganization of knowledge, in which a wide array of qualification processes is made available. The teams must embody pedagogical and strategic techniques in order to be able to cope with subjectivity and, ultimately, with the construction of standardized, reasonable attachments⁽²⁰⁾.

The professional turnover was another element pointed out by nurses. According to their reports, this phenomenon damages the work of the healthcare team in dealing with TB control. The constant change of professionals in a family healthcare team brings about enormous difficulty in establishing attachments between the team and the people they serve. The problem concerning professional turnover generally evolves from interruptions generated by political party-based movements that produce negative impacts on the local healthcare systems. In order to provide standard therapeutic processes successfully, the construction of a trusting, committed and accountable relationship should be established between the family healthcare team and the TB patient⁽⁹⁾.

In addition to professional turnover, the delay in the reception of the results of sputum smear microscopies was another problem indicated by the nurses. Aiming to receive these results more quickly, users of the healthcare system in the related town go directly to the Unit of Reference located in the capital, João Pessoa. This fact points to clear weaknesses related to the managerial process and the political commitment of managers. It should be once again highlighted that the political commitment of managers should encompass more than simply guaranteeing the delivery of medication in the FHU.

Reports reveal that TB patients lack financial resources that can provide them with food and shelter. Patients not provided with basic-needs grocery packages, transportation stipends or breakfast may eventually quit the treatment process, and also hamper the decentralization process of the control actions for the disease, as the assistance provided by some healthcare services located close to the patients' homes may be replaced by the services of those units that make such incentives available. It is worth highlighting, however, that the mere availability of these incentives is not enough to meet the needs of patients; nonetheless, it can be deemed as a relevant factor within a series of actions encompassed by the DOTS strategy, adding to other types of stimulus toward the implementation of such a strategy⁽¹⁶⁾.

The singularities pointed out, as well as the problems presented herein, reinforce the findings of other authors^(21-22) indicating that, in spite of the advances brought about by the decentralization policy, the FHS has yet been proven capable of providing effective responses to the demands of patients. It has been shown that not all of the teams have been committed to the actions toward the control of TB , especially concerning the early diagnosis of the disease.

CONCLUSION

Reports revealed that the nurses are committed to the care of TB patients and that they are the ones who carry out the activities set out by the TB control policy. However, regarding the control actions against the disease, the statements of several nurses point out that their work and the work of the family healthcare teams belonging to their area of influence is an action-focused process, exemplified by the active search for respiratory symptoms, treatment follow-up and the demand for medication. The way in which the family healthcare teams have organized their work processes lacks articulation with the program's own professionals and with the program's managers. A comprehensiveness-based therapeutic project that focuses on the establishment of attachments and accountability, and on active listening and dialogue, is considered an indispensable tool in the process of providing satisfactory care.

The elements necessary for the sustainability of the DOTS strategy were listed as follows: performance of ST (Supervised Treatment); improved physical structure of some healthcare centers; and availability of equipment (medicine and sputum collection cups). Nurses identified elements that weaken the family healthcare team's work process in TB control: segmented caregiving actions focused on the technical responsibilities of each professional belonging to the teams; and lack of incentives and benefits toward patients. Political issues, such as the Medical Act law and professional turnover, reduce the autonomy of the nurse and compromise the creation and consolidation of attachments among professionals themselves and between professionals, patients and managers.

From an operational standpoint, the care provided to TB patients is weakened because the system's coordination does not guarantee, in an articulated way, that the needs of the users identified in the HBA program, which demand a series of actions from specialized departments responsible for exams and diagnostic procedures, will be supplied.

Although DOTS is a way to promote the establishment of a new level of relationship between the family healthcare teams and TB patients, the nurses' statements clearly indicated that the implementation of this strategy by the family healthcare teams does not match the HBA program's policies. It is evident that the decentralization of TB control actions within the scope of the FHS is an ongoing process; however, gaps that compromise the continuous attention to sick people and their family members have been created, thus reducing the strength of ties and jeopardizing the comprehensiveness principle of the Brazilian Integrated Healthcare System.

In a nutshell, the elements that weaken the caregiving actions toward TB patients identified by nurses – renowned professionals in the FHS program – should be jointly reflected by managers, professionals, patients and educators, in such a way that the caregiving process can be redefined in the practical field in order to consolidate attachments and generate co-responsibility under the perspective of comprehensiveness-based team work.

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Correspondência:

Annelissa Andrade Virgínio de Oliveira

Rua Alípio Cunha Machado, 50 – Cristo Redentor

CEP 58070150 - João Pessoa, PB, Brasil

Publication Dates

• Publication in this collection
  07 May 2012
• Date of issue
  Apr 2012

History

• Received
  21 Feb 2011
• Accepted
  16 Aug 2011