RESEARCH ARTICLES

The nurse in the early detection of breast cancer in primary health care

Ana Luiza Barreto Zapponi^I; Florence Romijn Tocantins^II; Octavio Muniz da Costa Vargens^III

^I Obstectric Nurse. Master's degree in nursing. PhD student in nursing at the State University of Rio de Janeiro. Brazil. Email: analuu@gmail.com
^II PhD in nursing. Full Professor at the Federal University of Rio de Janeiro. Brazil. Email: florenceromijn@hotmail.com
^III PhD in nursing. Full Professor at the State University of Rio de Janeiro. Brazil. Email: omcvargens@uol.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.11297

ABSTRACT

The objectives were to identify the actions performed by nurses in caring for women and to discuss the nurses' professional action regarding the early detection of breast cancer in primary health care. This is an descriptive study with a phenomenological qualitative approach, carried out from December/2011 to November/2012. The participants were 12 nurses working with women's health in primary care. Data were collected through semi-structured interviews, which were recorded and transcribed for later analysis. The actions identified were categorized based on the common sense of nurses' actions. It was identified that nurses in primary health care, do not have the purpose in their professional action the early detection of abnormalities in the breast, but the implementation of preventive actions aimed mainly to the pregnancy period. It is concluded that is urgent to redirect of nurses' actions in order to prioritize the early detection of abnormalities in the breast. Keywords: Nursing care; primary health care; early diagnosis; breast neoplasms.

INTRODUCTION

Breast cancer is the leading cause of death among women¹. Worldwide, it is the most common cancer among women, covering 23% of female cancers that are diagnosed in more than 1.1 million women each year^2,3. Annual mortality of this neoplasm is more than 411 thousand deaths being responsible for more than 1.6% of female deaths from all causes, and the second most frequent type of cancer in the world⁴. In Brazil, breast cancer is also the most common among women, corresponding to 22% of new cases each year and with estimated 57,120 thousand new cases in the year 2015⁵.

Breast cancer is a public health problem in Brazil and a challenge, which it has represented, for the health system in order to ensure full and balanced access of the population for the diagnosis and treatment of this disease⁶. Therefore, early diagnosis must be done as soon as the disease process is detectable, at the beginning of the pathogenesis⁷. For early detection of breast cancer, it is recommended that screening through the clinical examination of the breast; mammography screening for women aged 50 to 69 years; clinical examination of breasts and an annual mammogram from 35 years to women belonging to population groups with high risk of developing breast cancer and ensuring access to diagnosis, treatment and follow-up for all women with changes in the exams carried out⁸.

In the last three years, the National Cancer Institute (INCA) and the Ministry of health are expanding the strategy to alert this neoplasia both to women and to health professionals⁵. This communication strategy recommends that all women should know the main risk factors for breast cancer, the age of greatest risk of occurrence of the disease and its most frequent signs and symptoms. It is also recommended that women, by identifying such signs and symptoms should seek immediately a health service for diagnostic clarification. In this context, primary care allows the active participation of women in their health promotion and early identification of the disease.

Primary care is characterized by a set of health actions within the individual and collective environment, which includes promotion and protection of health, the prevention of diseases, the diagnosis, treatment, harm reduction, rehabilitation and maintenance of health with the aim of developing a comprehensive care that impact on health status and autonomy of individuals and in conditions of health determinants and collectivities⁹. It is part of the professional assignment of nurses perform in primary health care, comprehensive care for individuals and families at all stages of human development^9,10. Therefore, are the responsibilities of the nurse, from the integral care, stimulate the women empowerment as their health and their body. With this understanding the professional, in the consultations focused on women's health, should be able to detect early abnormalities in the breast of the woman who may eventually be in the early stages of breast cancer.

The high incidence and mortality rates from breast cancer in Brazil for the implementation of effective strategies to control this disease that include health promotion, prevention and early detection¹¹. The National Policy for Integral Care for Women's Health reiterates the earlier statement emphasizing that breast cancer is diagnosed late in 60% of cases and to change this situation is a necessary challenge, since early diagnosis significantly increases the prospect and the quality of life for women¹².

Early detection should be discovered at this level of care to avoid detection in the advanced Stadium, since at that stage favors the mortality from this specific cause. Still, even this level of care to health professional-user relationship is present in conditions that enable a connection without necessarily being sick woman (or not), creating a relationship of responsibility and allowing the role of this woman towards her health.

Thus, the objectives of this study were to identify the actions developed by the nurses in attention to women's health and discuss the action of professional nurses in early detection of breast cancer as part of primary care.

THEORETICAL-METHODOLOGICAL REFERENCIAL

The quest for understanding the meaning of the action of the nurse in the early detection of breast cancer in the context of primary care is based on the theoretical referential of the phenomenology of Alfred Schutz^13-16.

The Phenomenology, according to Husserl, aims to describe things about themselves, such as they are manifested consciousness. This to unveil what is present in what is shown to the consciousness. Thus, there is a method for practical purposes. It proposes an understanding and human interpretation as it is lived and as it stands before it becomes the object of scientific insight¹³. The social phenomenology of Schütz is based that every action that the subject develops have an intentional meaning and search then meets your expectations. However, this sense and meaning, only the individual himself can unveil¹⁴. The reasons for each subject are expressed in actions in the world of natural life. When the reasons for this subject are expressed in actions to address each other and this likewise relates to an action, Schütz¹⁵ styles of social relationship.

When speaking of social relationship, Schütz points out that this has its own characteristics, whose actions occur in a conscious and intentional, possessing a meaning to the actor. In this sense, the crucial aspect of action is its intentional character and projection, which has its origin in the consciousness of the person and, as such, any action can only be understood by the meaning that this person gives their action – interpretation of the meaning of an action can only occur by the person's own subjectivity¹⁶.

To understand the phenomenon studied - the meaning of the nurse's professional action in the early detection of breast cancer in primary care environment - , it is necessary to return to the consciousness of the professional who performs out the assistance and care. According to the phenomenology of Schütz ¹⁵, it seizes the meaning of an action through the seizure of the reasons to. These refer to the purpose of an action, the result that is expected to be achieved. The motive to instigate the action and, therefore, are directed to the future. Thus, the goal is to find out the reasons that are driving the human action and, yet, each unit of human action is just a hack that the observer draws the total social context. So when the nurse carries out its actions, along the next, materializes the intentionality in the form of these actions. It is through the relationship to the next that it is possible to establish the health care of women in primary care, making the proper motion of the professional world in which we live¹⁷ .

Under this perspective, the action of nurses focused on women's health in primary care brings in itself a reflective attitude about the action that aims at an intentionality to perform professional actions directed to particular purpose, the reason for. Hence, the importance of seeking the meaning of this action through the social Phenomenology, from the analysis of social relations between individuals, between the nurse and the woman cared for in primary care.

Thus, it is sought in Schütz¹⁵, reasons to understand the meaning of the action of the nurse in the health care, enabling the analysis of the prospect of early detection of breast cancer in women's healthcare in primary healthcare.

METHOD

This is a qualitative research, based on the sociological phenomenology of Schütz¹⁵. The study was conducted in the city of Rio de Janeiro, with reference to the actions developed in basic health units - Municipal Health Centers and Family Health Strategies - and as such, with planned actions of promotion, prevention and rehabilitation, aimed at women's health.

The research subjects were 12 nurses who develop such actions in the context of primary healthcare. These were identified by E1 to E12, in accordance with the letter and the insertion in the process of carrying out the interviews. Data collection was held in the period December 2011 to February 2012, occurred through phenomenological interviews, recorded on an mp3 device and transcribed in its entirety for further analysis. The data collection instrument was an interview script consisting issues regarding activities in the treatment of women and a phenomenological question: What you have in mind when watching women in a primary healthcare unit?

The analysis of the information and of the interviews was the theoretical methodological basis of Schütz¹⁵. The transcripts of the recorded interviews brought questions about the activities developed by nurses in care for women and answers regarding the phenomenological question. In this stage of the study, there were reading and re-reading these interviews with the aim of identifying the activities developed by the nurses and group them by marriage, seeking to identify categories that involve the action of nurses in addition to identifying their reasons for.

In response to the guidelines and regulatory norms for Research Involving Humans resolution No. 466/2012, National Health Council, the research was submitted to and approved by the Research Ethics Committee of Municipal Health and Civil Defense-RJ (CAAE: 0036.0.313.314-11) and by the Committee of ethics in research at the Federal University of Rio de Janeiro (UNIRIO). All participants signed an informed consent prior to the start of the interviews.

RESULTS AND DISCUSSION

After reading and rereading of the exhaustive interviews, the activities performed by nurses who attend women in basic health units were grouped by affinity trying to identify those involving the actions of nurses. Three activities-actions emerged from the interviews and forwarding them, and educational actions directed to the physical body.

The referrals made by nurses in primary care health has as a basis the organization directly and/or indirectly in the functioning of the institution. The relationship established with other health professionals is through the need to address situations in which the nurse has no qualification or do not feel able to perform them. The educational activities are related to health education in different scenarios, not just the institution as a place for health promotion activities. The action of the nurse in this context is to stimulate the participation of the population to health care, recognizing their body. The third activity-action that emerged from the interviews were actions directed to the physical body. This activity-action emerged the speeches of all the respondents. The nurse's attention to the physical body of woman is one of the main actions carried out by professionals.

Is... Physical Examination? Measure the bottom of uterus, i heard, is ... (E1)

Has those routine actions [...] That would be the physical examination, the collection of early history, uterine, Fund measure auscultation of BCF, prescriptions for medicines of the Ministry routine we achieved that independence (E2)

Note that the actions directed to the female body are concentrated in the gravid period, and many of these actions are aimed at the physical body of women objectively and subjectively for the well-being of the fetus. Even with the focus on the physical body of the woman, the professional action also consists in preventing abnormalities in the body, another theme that emerged in this category:

Thus, the physical examination to detect if she has a problem, if she has edema... Because we do the physical examination too. (E1)

[...] make a good anamnesis, guide it well, for her to have a safe delivery, a safer pregnancy, the baby is born healthy, look at this happy binomial ...[...] decreased the incidence of the most common problems of maternal and child morbidity and mortality and healthy born child. (E2)

After they have the baby, we take care of, which vaccines they have to take, [...] breastfeeding care. Everything that we do in this period [...] (E9)

The focus of the nurse to guide the woman in attendance is to prevent damage to the woman and/or for the newborn, as well as a strategic for her to feel safe about questions related to signs and symptoms of any faults in the care of his/her body and/or with the newborn.

And the orientations. Because in the right, the orientations would be part of nursing [...] (E1)

After reading and re-reading exhaustive interviews, observed that the three activities-action that emerged from the statements allow point as primary action of nurses who attend women in basic health units are those aimed at the physical body of the woman in the gravid period. The Organization and analysis of all of the interviews for the understanding of intentionality of actions developed by the nurses involved in the context of the meaning of the action via their intentionality – reason for according to Schütz¹⁵. From the Organization and analysis of all reasons for common ideas emerged, experienced by the subject of the action, and called concrete categories of living¹⁶. This analysis allowed the emergence of the concrete categories of living: avoiding issues of women's health. That is, this is the meaning of the professional nurse's action in the care to women's health in primary care.

It is understood that in the context of primary care, the professional action of the nurse covers preventive actions, to diagnosis, treatment and recovery of this population group in the Gynecologic clinic, pre-natal, childbirth and the puerperium, menopause, family planning, sexually transmitted diseases, cancer of the cervix of uterus and breast, as well as the care of other needs identified from the population profile of women^9,12.

Thus, the main action of the nurse identify as those aimed at the physical body of the woman, whose meaning is to avoid health problems, it is understandable that these actions the professional establishes an attitude that aims to identify precociously bodily changes in various periods of a woman's life, reaching thus the preventive and diagnostic actions that the various programs of the Ministry of health advocate^{6, 8, 11, 18,19}.

However, it is observed that the concrete category living that emerged from the intentionality of the nurse assisting women in the primary care-avoid problems-present on avoid problems of pregnant women, turning their professional action for woman who finds herself in this specific period of life. It is noteworthy in this perspective that the nurses to assist women do not have as professional action early detection of abnormalities in the breast. The action of the nurse turned to the woman's breast in the context examined, is directed to breastfeeding of the child.

[...] carry out prevention and for her benefit even to prevent mastitis... (E6)

Thus, measures to avoid problems are focused on actions that affect the process of breastfeeding: the breast is inserted in the care actions to the mother-infant relationship and not for citizen women.

In view of the importance of early detection of breast cancer, it is necessary to qualify the primary care teams in this role⁵. Screening for breast cancer should happen in the relationship between the funding of women to the basic health unit in the work of professionals of these units with the users of the public health system and participatory dialogue between the Basic Health Units with the average and high complexity, putting in practice in integrate care^5,11. Thus, health care must be permeated by the reception with sensitive listening to their demands as a human and social being ¹². However, nurses develop, mainly actions for a physical body and addressed to reproductive health by keeping in the dark other situations they've experienced.

Although mammography and clinical examination are recommended for screening^{1, 8,11}, 90% of breast cancer cases are detected by the women themselves⁸. It can be affirmed, so that the promotion of self-examination is an effective strategy for its detection. However, the hegemonic exercise of a clinic focused on prescriptive act and production procedures in substitutive action practice that values the clinic as the extended exercise of multiple professionals, contributes to the promotion of actions aimed at the physical body for the purpose of identify abnormalities without considering the complaints and specificities brought by the healthcare system user²⁰. Although, this screening method is not recommended, as an isolated method, its association with clinical breast exam performed correctly, can be an efficient way to detect this cancer, being carried out at a low-cost in a health service²¹.

The analysis of the actions developed by the nurses as well as the reason for and the concrete category living identified shows that care practices aimed at women are targeted by the biomedical model²², which does not always consider female specificities, especially those related to sexual and reproductive health in its broadest sense^20,23.

Although not considered early diagnosis mechanisms of cancer, clinical breast examination and self-examination consists of early detection strategies abnormalities in breast tissue Even if it's not features that detect cancer in the pre-clinical stage, they enable the identification of these abnormalities in clinical phase early, becoming an effective way in stopping the evolution of the disease from specific treatments^24,25. However, the exercise of the clinic, translated into acts of speak/listen, in which the diagnosis of Pathology becomes the central focus of care, was being over time replaced by prescriptive Act, on summary relationship between professional and user²⁰. There is, therefore, in health services, and in this case, in the primary health care, an imaginary where quality care is synonymous with prescription medications and specialist consultations.

It is worth noting that early detection of abnormalities integrates the biomedical model²⁴. Although the professional action of the nurses interviewed is grounded in this model, the actions of early detection for breast cancer remain hidden in their healthcare practice. They corroborate with this model of the professional practices recommended for primary health care for assistance manuals advocated by the Ministry of health^11,18,19, all of which have reference to actions aimed at prevention of occupational disease, predominantly for the physical body of the woman.

Thus, the nurse should have as one of their purposes of professional action, early detection of abnormalities in the breast, which has taken place. Even with their professional action based by the biomedical model, this does not result in actions aimed at early detection of abnormalities in the breast, the nurse attending to women in primary care is predominantly concerned with the prevention of problems in the gravid body.

The work process can be observed nowadays unaware of the full subject that brings besides a health problem, certain subjectivity, a story of life, which are also determinants of their health and disease process²⁵. Accordingly, in the context of early detection of breast cancer, the actions of the nurse practitioners to do more than necessary. It's up to them from the integral care, promoting the empowerment of women as their health and body. With this understanding, both the professional, in the consultations focused on women's health, as the user will be able to detect early abnormalities in the breast that may characterize eventually the initial phase of breast cancer. It is essential in nurse's action during the consultations in health care of women to detect abnormalities through acceptance, the clinical breast exam, health education and the application of more complex tests when necessary. Healthcare professionals should take the responsibility to participate in detecting abnormalities in the breast.

CONCLUSION

This research identified that the actions of professional nurses to meet women in basic health units are, primarily, the actions directed to the gravid women's physical body. Therefore, the nurse who assists women in primary health care has as purpose of your professional action, that is, as reasons for, early detection of abnormalities in the breast.

Considering the importance of early detection through clinical examination of breasts and the self-examination of the breasts, these strategies help to reduce morbidity and mortality of breast cancer in the Brazilian scenario.

Thus, it is effectively important to know, who is the care subject, so that the assistance can be provided effectively and satisfactorily. It is suggested that the nurse take on the responsibility of healthcare practice participating in the early detection of abnormalities in the breast as part of his assignment and professional commitment with health as a right.

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