INTERDISCIPLINARY TRAINING FOR THE FAMILY APPROACH IN PRIMARY HEALTHCARE

ABSTRACT Objective: To reflect on the interdisciplinary training of health team professionals to work with the family in Primary Healthcare, considering the complexity of the family phenomenon in their health and illness experiences. Method: A reflection article in which the need to incorporate new concepts for training professionals to work with the family in Primary Healthcare is discussed. Results: The theoretical articulation between the Patient- and Family-Centered Care Model, Interprofessional Education and Primary Healthcare is fundamental to guide interdisciplinary training in health, aiming at including the family as the protagonist of the care of its members and active in the teaching and learning process of the healthcare professionals. Conclusion: It becomes necessary to promote changes in the training model of health professionals to incorporate collaborative practice with the family.


INTRODUCTION
Taking care of families demands therapeutic and interdisciplinary care relationships from professionals, implying in a critical and creative knowledge construction and recognition process, as well as permanent dialogue with different perspectives, namely individual, family and professionals [1][2][3][4] .It is necessary to bear in mind that family health incorporates collective health and its interaction with individual health, and reflects the biopsychosocial and contextual reciprocity of phenomena and lived experiences 3,5 .Family health is intertwined with global and planetary health and requires interdisciplinary actions 5,6 .
Changes in the world's ecosystems impose unprecedented challenging contexts on families which requires investment in training professionals to become competent in caring for the demands of global health 7 .It reinforces the need for professionals to understand the principles of health on the planet, as well as their impact on the family system, so that they promote the health, adaptation and resilience of individuals and families 8 .This is a challenge which presents itself and imposes the need to transform health education, as it must break and overcome the knowledge and power structures colonized in our society and transpose the centrality of courses and curricula, excessively organized into disciplines and specializations 9 .This transformation is decisive to constitute professional competences for collaborative practice that considers an approach in which the family becomes the care focus and scenario, and in which there is greater closeness of the professional with the family nucleus.
Therefore, it is necessary to make a change in work and in health education with a greater political and epistemological scope in the field of knowledge and professional practices in order to actually correspond to the principles of the Unified Health System (Sistema Único de Saúde -SUS) which endorses interprofessionality and interdisciplinarity.
However, a fragmented system with a pyramidal structure in which care is organized by hierarchical levels predominates in our history, with a concept of complexity that follows a linear and increasing order from primary to quaternary care 10 .
It is certainly a mistake to think that Primary Healthcare (PHC) is less complex and therefore requires less professional preparation.The complexity of the health contexts of individuals and families is found in the subjectivity of their interactions and worldview which requires dynamic professional training, stimulating thinking and enhancing dialogues with the knowledge and experiences of the family 11,12 .
Since the health reform in Brazil of the 1980s and 1990s, there has been a movement to transform the training of health professionals, aiming at an interprofessional collaborative practice with cooperation between knowledge and actions.However, it has not yet been fully incorporated by professionals in PHC 13 .
A change in healthcare is necessary, with a focus which must shift from the professional to the user-patient and their family, considering the diversity of family organizations, social determinations and healthcare training and education processes.Furthermore, there needs to be a change in the profession-centered teaching model to one that is focused on knowledge, considering that a profession alone is not enough to meet the complexity of health and illness experiences experienced by the family.
The future professional needs to be actively involved in the "real experience" of the patient and the family; understand the health needs from their perspective; learn to think about the family in an interactional way; learn to relate to other professionals and exchange care experiences; learn to manage intra-family and intra-and interprofessional conflicts; understand that the illness experience belongs to the individual and his family, and that they need support to fulfill the task of taking care of themselves and their members 3,4,14,15 .

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We asked ourselves how to promote interprofessional health education to approach the family in PHC and how to develop skills in students and healthcare professionals for collaborative practice, involving the family as a participant.Therefore, our objective is to reflect on the interdisciplinary training of healthcare professionals to work with the family in PHC, considering the complexity of the family phenomenon in their experiences of health and illness.
In this text we present a reflection on interdisciplinary training for collaborative health practice aimed at family participation based on the assumptions of the Patient and Family-Centered Care Model (PFCC), the premises of Primary Healthcare (PHC) and Interprofessional Health Education (IPHE), proposing a framework for collaborative health practice, in which the family composes the healthcare team.Next, we reflect on the development of competencies for interprofessional practice with families in PHC.

Interdisciplinary training for collaborative health practice aimed at family participation
Interdisciplinary training in health should promote skill acquisition by students to perform collaborative practice in which the family is understood as a member of the healthcare team, whose knowledge and practices are respected, and who the healthcare team professionals are encouraged to share their knowledge with, aiming at better patient and family care.
We consider the theoretical articulation between the assumptions of PFCC the structuring axis of PHC, and the milestones of (IPHE) as fundamental:

Patient-and family-centered care
This is an approach which provides for planning, delivering and evaluating healthcare based on mutually beneficial partnerships between professionals, patients and families with the aim of improving the quality and safety of healthcare, as it includes the perspective of patients and family members directly in the planning, provision and evaluation of healthcare, and favors increased satisfaction of users and families [16][17] .
From this angle, the family is the first care scenario for its members, acting and reacting according to the meanings it attributes to the lived experiences.It is configured in a complex unit of relationship and interaction, being an interlocutor of the well-being of its members.The family is the space for health promotion and decision-making in which care actions are based on a set of values, beliefs and knowledge; it has the ability to transform the quality of life and promote the health of its members.The family builds its own way of life that starts from a dynamic and continuous structure of interactions and interrelationships with its members, with the professional health team, with society and with the situations that emerge in their daily lives.
In this model, patient and family are the center of care and their participation in care and decision-making must be encouraged by all professionals whose actions must be based on the following four central assumptions: 17 .
Dignity and respect: Healthcare professionals listen to and consider patient and family perspectives and choices.The patient's and family's knowledge, values, beliefs, and cultural backgrounds are incorporated into care planning and delivery.
Shared information: Healthcare professionals share complete and unbiased information with patients and families in an affirmative and useful way.Patients and families receive complete information in order to enable effective participation in care and decision-making.
Participation: Patients and families are encouraged and supported to participate in care and decision-making as they wish.

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Collaboration: patients and families, health professionals and community leaders collaborate in policy and program development, project implementation and evaluation with the formulation of research and professional training, as well as in care provision.

Primary healthcare
PHC represents the first access level for families to the healthcare system when they have needs and constitutes an essential element in a continuous care process, developing actions and services for prevention, promotion, protection and health rehabilitation 18 .It is pointed out as a strategy for reorganizing and expanding the effectiveness of health systems, standing out on the world stage as a way to reduce health inequalities.
It is in the context of PHC that professionals embrace the family in their health and illness experiences, with the care environment being adequate for access to safe information and guidelines which allow the family to make decisions [19][20] .The four structural elements of primary healthcare comprise four items 21 .
First contact access: implies the family's easy access to the service at each new episode in health and in the resolution of the demands presented.
Longitudinality: existence over time of a regular space of attention in care, favoring the formation of interpersonal bonds and mutual cooperation between health professionals and family, as well as follow-up within the health services network.
Comprehensiveness: allows an arrangement between health services so that the family receives care at any care level.It is important that professionals adequately recognize the family's functional, organic or social problems and seek joint solutions and/or referrals to other services.
Care coordination: requires integration between professionals, families and patients so that there is recognition and evaluation of the health problem by all involved in order to enable continuous and collaborative care.
Furthermore, the aforementioned author reaffirms the existence of derived attributes, which are intercomplementary to the essential ones, described as the family and community approach and cultural competences in convergence with the model described.

Interprofessional health education
Interprofessional health education proposes learning together to work together, meaning when two or more professions learn about others, with others and among themselves for effective collaboration and improvement of health outcomes [22][23] .
The interdisciplinary training process of healthcare professionals creates conditions for coexistence between different areas and triggers a shift in the original training of each specific area, which generates "sharing"; a space for awareness and agreement based on the practical experience that creates an effect of belonging and enables dialogue between knowledge areas.The growing isolation of professional specializations has prevented situations of dialogue, and therefore, the search for a common experience is necessary 24 .
Recently, the Institute for Patient and Family-Centered Care (IPFCC) reinforced the idea of the family in an equal position with healthcare professionals, being considered a member of the team, participating in decision-making regarding the care of its members and in the training processes in health 6 .

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The framework presented below integrates the milestones of IPHE with the PFCC and the PHC to guide the approach of the family in this care area, as represented in Figure 1.
The framework represents the objective of training professionals so that they learn from each other, working collaboratively in order to promote family participation in care.PFCC provides the basis for the professionals' work, considering it as a care unit whose practice must be based on respect and dignity, participation, shared information and collaboration.PHC is the access to the system, ensuring care longitudinality, comprehensiveness and coordination.This interlocution guarantees the collaboration and effective participation of all actors in the family care process.

The development of generalistic competencies for interprofessional practice with families
Interdisciplinary training should be able to encourage the student to develop generalistic competencies based on knowledge, skills and attitudes towards family care in an interprofessional collaborative practice 9 .This training should start at undergraduation, both in the interdisciplinary model and in the pedagogy of problematization with the integration of students from different disciplines in the health area in joint learning experiences.Thus, the student becomes able to carry out joint planning of actions and interventions in the family in a singular project.
It is proposed that the general competencies of nurses to promote family care according to the International Family Nursing Association (IFNA) can be applied in interdisciplinary training, considering that the focus of all professionals should be the quality and well-being of the family 25 .The competencies of the generalist nurse in the practice of family care are described below: 1. Improve and promote family health.
2. Focus nursing practice on the strengths of families; supporting the development of the family and the individual; improving the family's self-management capabilities; facilitating successful transitions; on health improvement and management; and family resource mobilization.
3. Demonstrate leadership skills and systems thinking to ensure quality nursing care with families in everyday practice and in all contexts of practice.
4. Commit to a self-reflective practice with families based on the analysis of the nurse's actions and the family's responses.
5. Practice using an evidence-based approach.
Such generalistic nursing competencies are consistent with the position of the International Family Nursing Association, "All nursing students in pre-licensure education should be committed to learning about the importance of the family to individual health and well-being, and to assessing, planning, implement family-focused interventions" 5 .
There are several models of Interprofessional Education (IPE) described in the literature 26 .For the development of courses in our reality, one can take the IPE model of the University of Montreal as an example, in which the development of collaborative competencies occurs in a process of three phases, ensuring the student the opportunity to participate in small group discussions together with field healthcare professionals and patients and families.It also offers the opportunity for students and professionals to experience real cases of guidance to patients and families 27 .
Thus, the training of healthcare professionals needs to be transformed in order to make the family's participation in PHC effective.The use of significant teaching strategies for incorporating new conceptions about conducting collaborative practice with the family becomes urgent.The use of active teaching methodologies enables students to be the protagonist of knowledge, provides greater motivation, learning, and encourages group interaction, encouraging reflection and providing rich moments of experience exchange.
In addition to undergraduate training, multidisciplinary residencies in family and community health can play the role of integrating professions for family care.There is a need for continuous learning in the daily work, be it care-management-participation, or learning and teaching.

FINAL CONSIDERATIONS
The relevance of promoting changes in the training of healthcare professionals is captured from the reflection carried out herein, aiming at interprofessional practice.It is necessary to invest in education from undergraduate, graduate and in-service education, with practices that include patient and family embracement, patient and family-centered care, and knowledge sharing, in order to consistently prepare healthcare professionals for their performance in a convergent manner with the Unified Health System.
The framework presented herein aims at family participation in care, moving towards a collaborative process in which the family is a participant.Thus, when creating common experiences of patient and family care, interdisciplinary and intercultural training is sought to promote meaningful learning in which the student and professional develop skills and attitudes based on the ethical and moral commitment to the singular individual experience of the person and the family.

Figure 1 -
Figure 1 -Graphical representation of the Interdisciplinary Training Model for Interprofessional Practice in PHC, aiming at family participation in care, Campo Grande, Mato Grosso do Sul, Brazil, 2021.