Flowchart Analyzer and movements of living networks in the trajectory of an elderly person with dementia seeking care

Abstract

Ensuring access and continuity of care for elderly users with dementia in the Health Care Networks has become a major challenge given the changing epidemiological and demographic profile of Brazil. The aim is to analyze the networks traveled and the existential connections established by a user with dementia, from the perspective of a guide team. Qualitative methodology with a cartographic approach, using a focus group, Flowchart analyzer and field diary. The results are narratives, materialized in a Flowchart analyzer, and the following categories of analysis emerged: Possibilities of access and difficulties imposed by barriers in the production of care; Challenges in living a cartographic experience; and Setbacks in the functioning of established care networks. The discussion highlights the need to expand the possibilities of acting in the world of health care in accordance with the SUS guidelines and the need to review ways of caring, seeking possibilities for effective care production. It was concluded that professionals act based on the biomedical model, which ensures that they are in a world of protocols. However, sometimes the micro-politics of their work process is invaded by users who express their voices, undoing this established model.

Keywords:
Aged; Dementia; Community Networks; Healthcare; Access to Primary Care

Resumo

A garantia de acesso e continuidade de cuidados a usuários idosos com demência nas Redes de Atenção à Saúde tornou-se um grande desafio diante da mudança do perfil epidemiológico e demográfico brasileiro. O objetivo é analisar as redes percorridas e as conexões existenciais estabelecidas por um usuário com demência, sob a ótica de uma equipe-guia. Metodologia qualitativa de abordagem cartográfica, utilizando grupo focal, Fluxograma Analisador e diário de campo. Os resultados são narrativas, materializadas em um Fluxograma Analisador, tendo emergido as categorias de análise: Possibilidades de acesso e dificuldades impostas pelas barreiras na produção do cuidado; Desafios na vivenciando uma experiência cartográfica; e Contratempos no funcionamento das redes de atenção instituídas. Destaca-se, na discussão, a necessidade de ampliar possibilidades de agir no mundo do cuidado em saúde conforme as diretrizes do SUS e a necessidade de revisão dos modos de cuidar, buscando possibilidades para uma efetiva produção de cuidado. Concluiu-se que os profissionais atuam pautados pelo modelo biomédico que os assegura em mundo protocolar. No entanto, por vezes, a micropolítica do seu processo de trabalho é invadida pelos usuários que expressam suas vozes, desfazendo este instituído.

Palavras-chave:
Idoso; Demência; Redes Comunitárias; Atenção à Saúde; Acesso à Atenção Primária

Introduction

The object of this study is the production of care for elderly people with dementia monitored by a Family Health team in Rio de Janeiro. This object was investigated based on an understanding of the living networks woven into the trajectory of a user from the team's point of view, guided by a Flowchart Analyzer (FA).

Brazil has seen a sharp increase in the elderly population in recent decades (Brasil, 2018). With increased life expectancy comes the expansion of chronic non-communicable diseases, such as dementias (Brasil, 2018). Dementias are currently the fastest growing chronic and mental health condition (Silveira; Silva; 2020). Its prevalence increases exponentially with age, rising from 5% in those over 60 to 20% among those over 80 (Silveira; Silva, 2020). There is therefore a need to expand care for the elderly beyond the prevention and control of illnesses and chronic diseases, including the promotion of active ageing, with autonomy and functional capacity (Brasil, 2010).

As the gateway to the system, Primary Health Care (PHC) is central to the health care of older people with dementia (Sorialet al.,2022). However, users are sometimes unaware of the health services suggested for their needs, get lost in the network and seek care on their own (UFMA/UMA-SUS, 2016).

The study is justified by the lack of studies on the trajectory of elderly users with dementia in the Health Care Network (Lopeset al.,2023). The gap was identified in a scoping review on the care of elderly people with dementia in the context of healthcare networks (LOPESet al.,2023). This review made it possible to reflect on the care provided to elderly people with dementia, especially those in the more advanced stages of the disease, pointing to the need to restructure care networks in Brazil and around the world (Lopes et al., 2023). No studies were found that used the Flowchart Analyzer (Lopes et al., 2023).

The question to be investigated was: “What are the paths taken by users with dementia in their search for health care?”. To answer this question, the objective was to analyze the networks traveled and existential connections established by a user with dementia, from the perspective of a guide team.

Methods

Based on a guide team, a cartographic methodological approach was carried out, focusing on the processual way in which meanings are produced, while new meanings are established, implying other perspectives on the dynamic processes of everyday life, based on the schizoanalysis of ^{Deleuze and Guattari (2011}) and ^{Baremblitt (2012}). In this approach, the narratives arising from the meetings and the production of care are much more valued than the results (Blasco; Merhy; Pla, 2016), since they enable the expression of intensities and reflection on the daily work in the production of care (Deleuze, 1998; Pigozi; Machado, 2020).

For this study, which is the result of a doctoral thesis, a Flowchart Analyzer (FA) was used as a research tool, understood as a device that provides reflection and reconstruction of what is narrated by workers (Pigozi; Machado, 2020; Carvalho; Jorge; Franco, 2018). In order to enrich the reports, the field diary was added as a data collection tool.

To construct the FA, focus groups were conducted by the main researcher and an assistant researcher was responsible for observing and recording her observations in the field diary. The FA is a research tool that encourages qualitative analysis of the phenomenon based on scenes constructed by the participants' narratives. It is graphically represented by stages in the work process using three symbols: ellipse (represents entry or exit); rhombus (decision points); and rectangle (intervention or action on the care process) (Merhy; Campos, 2002).

The study was carried out in a Family Clinic (FC) in the northern zone of Rio de Janeiro-RJ, which has a total of 22,359 registered citizens. The unit has five Family Health teams. For this study, a team was chosen that was complete in terms of professional categories. The population of the territory covered by the team in question is 3,594 people living in conditions of extreme social vulnerability, most of them beneficiaries of government programs, and the parallel power of drug trafficking is active there (eSUS, 2024). There is an active community leadership and various non-governmental organization (NGO) and volunteer projects aimed at young people and pregnant women.

All team members were invited and there were no refusals. Two focus groups were held with 12 participants, including 1 doctor, 1 nurse, 1 nursing technician, 5 Community Health Workers, 1 dentist, 1 oral health assistant, 1 social worker and 1 physical educator. The meetings, which lasted approximately 60 minutes each, were recorded and transcribed.

In the first meeting, the group reflected on the paths taken by elderly users with dementia through the healthcare networks. In the second meeting, the Flowchart Analyzer was constructed based on two trigger questions: “An elderly person diagnosed with dementia moves to your area of coverage. How do they get care and integrate into the health service?” and ‘What are the paths taken by elderly people with dementia through the health care networks?’.

To answer the questions and start the collective process of drawing up the FA, the team chose a case-tracker (Pigozi; Machado, 2020). The user chosen was an 84-year-old single woman who lived in a brick house with basic sanitation, with her granddaughter and her only daughter, with whom she had a strong bond. She had been diagnosed with Alzheimer's disease for five years and had hypertension, diabetes, urinary incontinence, dysphagia and motor deficits as comorbidities.

The research was approved by the National Research Ethics Committee on 20/05/2020, registered under CAAE n. 36307820.8.3001.5279. The authors declare no conflicts of interest.¹

Results

Despite the difficulty in describing the formal and informal network traveled by the user, the professionals showed involvement and concern when discussing the issue, with greater participation from the higher-level team (doctors and nurses). In turn, the Community Health Workers (CHWs), by positioning themselves as the user's link in terms of access, took on the leading role in reporting on the paths the user took through the services and territories.

Figure 1
Flowchart of the path of the user diagnosed with dementia. Rio de Janeiro, 2023

Flowchart Analyzer - Team A

A - First Entry

CHW reports that the user sought care at a university hospital and was referred by the receptionist to primary care. The daughter, upset, argued that the PHC doctor didn't look after dementia patients and that she had the right to choose where she wanted her mother to be treated. She was referred to the hospital's social services, without success, and decided to look for legal alternatives (transcript of the focus group recording [FG]).

B - Second entry

When the family member started to go to the Disputes' Chamber, a body that conciliates legal claims in the health area, she was met by a public defender who, among various guidelines, referred her to the PHC. A letter was issued guiding the placement of the case in the regulation systems after evaluation by the doctor on the referral team (transcript of the FG recording).

The litigation chamber contacted the manager of the unit via e-mail, requesting that the appropriate steps be taken in the case, with a deadline for implementation (transcript of the FG recording).

C - Decision and referrals

According to the account of a nursing technician, the user's daughter went alone to the referral FC and was approached at reception by a CHW, who questioned her search for the service. The daughter replied rudely that she had gone to the unit to demand her rights and immediate care because she had a legal claim against the unit's manager (transcript of the FG recording).

At the meeting with the manager and a CHW, the daughter described the paths she and her mother had taken in seeking care. She said she had sought help in the private sector through consultations with neurologists and psychiatrists. However, the high cost prevented her from keeping up with the care (transcript of the FG recording).

At the time, the family member was very nervous and tearful, and was welcomed by the team, who explained the role of PHC, explaining that every effort would be made to help the user with care and access to health services. The daughter gradually calmed down, became more receptive, smiled and began to think about collective forms of care for the elderly woman and her family. The daughter was instructed on the need for longitudinal monitoring by the PHC, and that the latter would make the necessary referrals (transcript of the FG recording).

Welcoming was triggered by the tension caused by judicialization, because in practice this type of access doesn't always happen spontaneously and resolutely (field diary).

D - Third entry - Access to Team A

Management took the case to the team for discussion and requested an urgent home visit, in view of the response deadline set by the court. The doctor said he would put the family on the regulatory system as “priority care”, referring the user to another network device.The physical educator, however, questioned this, pointing out that the user was the team's responsibility, as she lived in the unit's catchment area and should therefore be seen and monitored. The visit was scheduled for a week later (transcript of the FG recording).

D - Decision and referrals

During the home visit, the doctor and the CHW were met by the elderly woman's daughter and granddaughter, who described her clinical condition and said that her care was precarious, since they both worked and sometimes left her alone. The elderly woman was lying on a sofa, with dirty diapers and a foul smell. She expressed little, despite her agitation, but the doctor noticed that she became calmer when a bird in a cage in the house sang (transcript of the FG recording).

When they realized the bird's influence, the doctor and the CHW began to provide care. They changed the diaper and the bedding and interacted with the user for hours. Family members were surprised by the reaction of the elderly woman, who allowed the care to take place in a light and calm manner, unlike the aggression common at such times. At the end of the service, the daughter started crying, asking for help with the care, as she was the only caregiver and realized that “her mother was dying” (transcript of the FG recording).

The doctor pointed out the need for secondary care and said he would refer her to specialist doctors and to the Home Care Program for the Elderly (PADI in the Portuguese acronym), saying that together they would find a solution to the situation, reducing the burden. Finally, the doctor invited his daughter to come closer, encouraging her to participate in the care the team was providing and highlighting the influence of the bird song. The daughter smiled and thanked him, heading to the kitchen to prepare a juice for the team. At the end of the visit, the elderly woman was sleeping peacefully and her daughter asked the professionals for a hug (transcript of the FG recording).

The doctor and the CHW left satisfied, with the feeling that they had made a difference and with the assessment that that moment was the start of an effective and resolutive relationship between the user, health professionals and family members (transcript of the FG recording).

The records of this home visit in the electronic medical record do not reflect what was reported by the team, with only a description of the clinical parameters collected during the physical examination of the elderly woman and a report on the insertion into the regulatory systems due to a judicial request (field diary).

E - Decision and referrals

After the visit, the case was discussed at a team meeting. Some of the participants criticized the professionals' conduct (changing diapers and bed linen), as they felt it was the daughter's obligation. Another group argued that this care was a “different way” of getting closer to the elderly woman and her family. The reactive speech of those who were upset was understood as discomfort at the reversal of roles, since the professionals had given up their supposed power in the user-health professional relationship, becoming primary caregivers (field diary).

F and G - New entry

According to the CHW, a few days after the team meeting, the PADI appointment was scheduled and a home visit was made to the physiotherapist, nutritionist and speech therapist. In the end, the PADI team informed us that they would not be taking (over the follow-up due to the overload of users, once again highlighting the difficulty of accessing the care network (transcript of the FG recording).

This conduct on the part of the PADI led the PHC doctor to change the user's risk classification in the referral system to “urgency”, triggering the general coordination of the referral system (SISREG in the Portuguese acronym). However, short-term care was denied due to a lack of vacancies. The family resorted to the living network built up in the territory, asking neighbors for money to pay for the consultation and evaluation by doctors in the private network (transcript of the FG recording).

I and H - Decision and referrals

The CHW went to the user's home, two days after the team meeting, and was greeted by her daughter. The elderly woman was clean and showered, sitting on the sofa and listening to the bird singing. Her daughter offered her a snack. That registration visit lasted for hours and the daughter presented all her care needs and difficulties. At this point, the CHW remembered an NGO located in the area, whose volunteers helped family members who had difficulties caring for bedridden people (transcript of the FG recording).

During the focus group, the CHWs discussed the need for the health team to assess the family and caregivers, as they often felt lost and had difficulty dealing with the situation. At this point, it became clear that the team's view of care had broadened, recognizing the family and caregivers as protagonists in the creation of their living networks (field diary).

I - Decision and referrals

After the visit, the CHW called the president of the residents' association and, with the permission of the family members, asked for help in developing care strategies. Together they came up with the idea of seeking help from volunteers in the community, donating food parcels, a suitable bed and mattress, a wheelchair and other support equipment. A support network was created (transcript of FG recording).

The president of the association showed great interest in the case, affection and admiration for the elderly woman. The FG participants pointed out that the residents of the community had always been very united and helped each other as a support network. The NGO had a nominal list of all the volunteers in the community and their respective roles. In this way, they managed the actions, scheduling the times and days of the visits (transcript of the FG recording).

J - Exit

After reporting on the doctor's and CHW's visit, the team became more aware of the case. The nurse was the only professional who expressed opposition, arguing that the case should be followed up at the Psychosocial Support Center (CAPS in the Portuguese acronym). This position was supported by some community workers, who agreed that users with this type of diagnosis were difficult to manage. With this argument, he canceled the home visit he was supposed to make, because he didn't think it was important, since the doctor had already made the visit a few days earlier (field diary).

The team's dentist pointed out that she didn't agree with the nurse canceling the appointment, because the nursing assessment would be fundamental for the construction of the Single Therapeutic Project (STP). This shows the existence of a dispute over conceptions of the production of care within the team: one group places itself as the holder of knowledge and exclusively responsible for care, while the other assumes the position of changing what is in the protocol, validating the living networks and causing “gaps” in the established flows (field diary).

With the cancellation of the home visit and the impossibility of immediate reception by the specialized services, the formal healthcare network proved insufficient to meet the demands of the user and her family. In the end, the demands were met by the informal network, with a partnership established between the user's family and the community, mediated by community leaders and an NGO. However, the team's participation was fundamental in organizing the care, albeit with a “gap” in the established flows and limited team participation, as not all members adhered to a care process that did not conform to the established flows (transcript of the FG recording).

Discussion

The Flowchart Analyzer pointed to problem situations that gave rise to the following categories of analysis: 1) Possibilities of access and difficulties imposed by barriers in the production of care; 2) Challenges in living through a cartographic experience; and 3) Setbacks in the functioning of established care networks.

Possibilities of access and difficulties imposed by barriers in the production of care

The fragmentation of the healthcare network and the lack of capacity to receive the data brought by the daughter and provide adequate information were evident. It can therefore be said that the procedures adopted initially produced a barrier to the production of care, given the influence that the relationships established in the daily life of health institutions have on the trajectories of users and on the joint construction of their Singular Therapeutic Projects - STP (Castroet al.,2021).

Studies point to the recurrence of difficulties in collaboration between caregivers and health professionals, especially in dementias (Satoet al.,2018). It is therefore recommended that psychoeducational interventions be adopted for caregivers, covering advice on self-care, information on dementia, coping strategies and the service networks available (Satoet al.,2018).

To think of the relationship as an important element in the production of care is to highlight how health work processes are crossed by different technologies (Castroet al.,2021). For the phenomenon in question, we highlight soft technologies, characterized by the bond, welcoming and management of care, in addition to cognitive knowledge (soft-hard technologies) (Castroet al.,2021). Interpersonal relationships can be configured as facilitators of access, bringing into the process the support networks/living networks created by users, thus reaffirming the logic of co-responsibility(Castroet al.,2021).

There is an emerging need for professional practices to break down protocol barriers and start to be driven by encounters with users' experiences, desires and sufferings. There is an urgent need to problematize the positions taken by professionals who set themselves up as the sole coordinators of care, curtailing users' leading role in directing the networks that create margins so that care can take place in the composition of a living network built in the community. It prepares the eye to see not only the given world (instituted), but also the worlds giving themselves (instituting) (Merhy; Feuerwerker; Gomes, 2010).

In this sense, the FA led to the emergence of a dispute over the care project: on the one hand, part of the team that, in a protocol fashion, gave directions to the user, pointing out referrals that were not understood; on the other hand, those who accepted the user's lack of knowledge of the care network flows and understood that going to the health facility was an opportunity to welcome and provide guidance on which places were most appropriate for the demands presented. Welcoming involves an ethical and caring attitude, an empathetic and respectful attitude towards the user, which includes assessing risks and vulnerabilities, choosing priorities and perceiving needs (Giordaniet al.,2020; Merhy, 1998).

It is therefore necessary to develop technologies to welcome the caregiver who, in the relationship established with the person who has some form of dementia, also develops physical and psychological health problems. Studies show that around 40% of family caregivers of people with some form of dementia suffer from depression and anxiety and report a reduced quality of life (Amadoret al.,2021; Rigbyet al.,2021).

Suffering, caregiver burden and lower quality of life for the caregiver and care recipient are associated with the severity of the disease. The duration of the illness, in turn, is related to the lower quality of life of the care recipient. The high workload and emotional strain reported by caregivers calls for interventions aimed at improving the caregiving experience. Good social support has been identified as a fundamental element for greater satisfaction with life and a reduction in depressive symptoms, suggesting that it can act as a buffer against the deleterious effects of care (Rigbyet al.,2021).

Being a questioning user, as the user's daughter initially showed, can sometimes be a barrier to access to care by the referral team. The FG participants concluded that the elderly woman's case was complex and required a lot of dedication on the part of family members and health services, because in addition to the user's health condition, with a chronic illness, the family was sick and wanted to take care of the elderly woman.

“Complex cases” permeate the different health services and are labeled as such because they require mobilization and meetings to discuss the case on the part of the workers, as well as the need to mobilize various services in the network around their care (Badyet al.,2016). In these cases, professionals tend to produce their actions in a prescriptive way, based on a roadmap of how life should be lived and who has the right to it (Seixaset al.,2019).

The CHW reported his difficulty in dealing with this family, highlighting his inability to establish a relationship, pointing out that the way of dealing with the problems, through legal action, made it difficult to manage. The judicialization of processes has become increasingly frequent to guarantee access to health, due to the barriers encountered (Freitas; Fonseca; Queluz, 2020). These include: 1) the regulation systems; 2) the distant location of the unit; and 3) the lack of communication between PHC and the care network (Freitas; Fonseca; Queluz, 2020). Judicialization is therefore a way of breaking through the wall of the established and forcing access to health services.

Challenges of a cartographic experience

The cartographic experience signaled the need to articulate care technologies - soft, soft-hard and hard - in a technological arrangement that, guided by the power of high-density relational encounters, makes care actions more effective (Merhy, 1998). These actions, offered by a health professional to a user, carried out through live work in act, is a relational act, which creates expectations (Rioset al.,2021). The outcome of this encounter will be influenced by a warm welcome, an understanding of the need to take responsibility for the problem being faced and trust. If this is satisfactory, it will begin to produce a bond and acceptance (Merhy, 2005).

The encounter with others who are different and who deviate from what is established in the protocols, in turn, is seen as a threat and a relationship of domination is naturally established, placing them in a posture of passivity in the process of producing their health care (Merhy; Gomes, 2014). Furthermore, practices that don't consider the encounter, the high relational density and, consequently, soft technologies, end up focusing only on dead work, made up of hard and soft-hard technologies, which is part of the production of care, but cannot exist on its own (Merhy; Campos, 2002). Living work is the power that allows for the construction of new knowledge and ways of caring (Merhy; Campos, 2002) In this study, living work took place in the encounter and bond that began during the home visit carried out by the doctor and CHW and, above all, in how it was conducted, offering possibilities for listening (to voices and birds' songs), welcoming and encounters that opened up space for the user and her family to exist.

We highlight the PHC professionals as participants in a living network woven by users with dementia in their search for care. In this network, we also sometimes come across the user's access to other players in the care networks described, which may or may not have been coordinated by PHC. Understanding the context of dementia, we highlight family members and social facilities as participants in these support networks and important elements in the process of managing care for frail elderly people. The actors in these networks should be considered as important elements in the construction of the STP for this elderly woman with dementia by her reference team. In this way, PHC empowers the user to build their living network outside the established one, allowing for qualified care.

Setbacks in the functioning of established care networks

Home care is one of the main care strategies for dependent elderly people, and is particularly important in the process of de-hospitalization and humanization of care (Moraes, 2020; Rajão; Martins, 2020). In cases of incapacitating illnesses, there is a need for continuous care, which requires formal and community support (Silva, 2020). The mobilization of an informal community support system helps elderly people with dementia to remain at home, providing a better quality of life and care in terms of emotional support needs and social relationships (Silva, 2020).

The ability to carry out a comprehensive assessment in patients' homes has been identified as an important strategy for overcoming gaps in knowledge about users and overcoming patients' time and financial constraints, which are barriers to establishing a timely diagnosis and effective care (Dimityet al.,2021).

Home care and caregiver training on how to deal with the daily challenges posed by advanced-stage disease in the home are important components (Kampanellouet al.,2019). Evidence indicates that home support reduces the worsening of individuals' health conditions, delaying entry into long-term care services (Kampanellouet al.,2019). Participation in community-based groups has proven effective in transmitting knowledge about the care of people with dementia, given the power of territorial work that enables health-promoting interventions (Gough, 2019). Experience with territorial groups has shown improvements in participants' attitudes towards ageing, increasing well-being (Gough, 2019).

In this study, the barriers to accessing care networks were evident when the request for PADI was not considered. It is clear to see how the flows and directions hinder the work processes and the direction in the care networks. The delay and inefficiency of referrals to specialists led the family to mobilize a living network, raising money from neighbors in order to pay for private consultations.

In this way, by looking beyond the services on offer for different ways to meet their needs, users start to create living networks from within themselves, constituting a protagonism that is transformative in itself (Tofaniet al.,2021; Merhyet al.,2014). These living networks are shaped by existential connections that go beyond and across formal networks and institutions (Merhyet al.,2014). However, although they are informal and dynamic networks, constituted according to the needs of the moment, there is a dynamic in their constitution, which can be unveiled and understood.

Primary Care is seen as a natural option for caring for people with dementia, as it has the following strengths: the number of services, the uniqueness of care and its more comprehensive, integrated and continuous nature compared to secondary levels of care. Interprofessional actions, in turn, are important mobilizers for the production of care (Dimityet al.,2021).

Studies show that nursing actions, when aligned with the other professionals in the team, have the capacity to produce territorial care in Primary Care, contributing to improved quality of care indicators for patients with dementia compared to patients who only received medical care (Dimityet al.,2021). However, in this study, the nurses' misleading statements show that the professionals are unaware of the care network for the elderly and mental health. The role of the Psychosocial Care Center was not clear and defined for the professional, pointing to the absence of matrix support, which aims to ensure specialized support and ongoing training for mental health teams, as well as contributing to the construction of STP (Silva, 2020).

The National Humanization Policy of the Unified Health System (Humaniza SUS) recommends the use of the STP as a tool to assist in the transition from the traditional medical-biologist clinic to the expanded humanized clinic, thus building strategies aimed at producing comprehensive care and assistance to the user (Brasil, 2004). The STP transforms the reality of users and their families, who, after this experience, can consider themselves important in the construction of their care plan, thus enabling them to experience empowerment in health (Brasil, 2004).

The narratives that allowed to build the FA showed that the construction of the STP is not a routine practice in PHC, which was justified by the high demand and complexity of the cases to be thought about and discussed. The overload of duties makes it impossible to provide an adequate structure and space for continuing education. The time available is for team meetings, which are not enough to cope with the numerous demands. The cases that are selected and discussed are specific and are the ones that most attract the team's attention, especially those that are stressed by managers or come from legal charges.

Final considerations

It was concluded that FC professionals direct their health actions based on a biomedical model that ensures that they are part of an established, protocol-based world. However, sometimes the micro-politics of their work process is invaded by users who express their voices, undoing this form of instituted. This asymmetrical encounter transforms differences into inequalities of knowledge and ways of life, and users are labeled as complex cases, thus producing barriers to access and the production of care.

It's important to note that primary care, as the organizer of care networks, is the priority gateway to the health system. However, as the protagonist of their care through the living networks, users will not necessarily enter through this point of care.

The establishment of symmetry, in recognizing the other as a valid interlocutor, made it possible for the user to play a leading role in the movement of living networks, through encounters between the actors involved in care. It is believed that the actions offered by health professionals should be done through a living work in act and relational, in order to produce bonds and acceptance. This signals the need to incorporate more soft technologies, which materialize in relational practices.

The use of the flowchart analyzer has great methodological value as a form of research-interference, promoting changes in the reality of the service and reflection on the production of health care. For Family Health Strategy workers, immersed in protocol practices, the experience of collective, reflective and participatory work, centered on the protagonism of the user, has awakened a more qualified professional sensibility to understand and express care.

Currently, professionals report that the act of caring has become lighter, and the guilt of not meeting personal expectations has been reduced, even when the results of the interventions do not fully meet the protocols. This has happened by replacing the one-way view of knowledge with a collaborative practice with users.

The research could stimulate new forms of care, considering the user as an active interlocutor. Equally important was the impact on the territory's leaders, who began to contribute to building networks that value belonging, by being included in the work processes, qualifying the care offered to the population.

For the researcher, the experience of a new way of producing care brought about significant changes. Being part of the research has allowed her to listen to care in a light and differentiated way, allowing her to rethink her day-to-day work, which is often invasive for both users and professionals.

A space set aside to discuss, reflect and schematically observe a situation from multiple perspectives was remarkable for the group. While some maintained a position of knowledge holders, others allowed themselves to be led by the user, abandoning the idea of sovereignty in care and opening up to new ways of conducting their work processes.

The construction of the flowchart analyzer made it possible to value soft technologies in healthcare, highlighting their role in humanized care, in which the user's protagonism and symmetry in relationships create a support network that is often neglected by institutional practices.

Among the resources highlighted in the construction of the flowchart, the home visit stood out as a powerful tool for creating bonds and experiencing everyday realities, which would not be possible if the user traveled to the institution. Participating in care in the user's environment, with practices such as active listening, allows for assertive care that emerges from their desires and needs.

As such, the results of this study provide points and indications that can support public health policies aimed at elderly people with dementia. It is clear that there is a need to invest in training through continuing education for these workers and managers in comprehensive, welcoming and humanized health practices that take the user as the protagonist of their care.

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• 1
  All research data are available in this text.

• Editor:
  Breno de Oliveira Ferreira

Data availability

All research data are available in this text.

Publication Dates

• Publication in this collection
  15 Sept 2025
• Date of issue
  2025

History

• Received
  24 June 2024
• Reviewed
  11 Oct 2024
• Accepted
  26 Nov 2024