RESEARCH ARTICLES
Collective care in primary health care: conceptions of nursing undergraduate students
Cássia Irene Spinelli ArantesI; Gabriela Alvarez CamachoII; Aridiane Alves RibeiroIII; Renata Gomes Sanches VerardinoIV
INurse. PhD in Nursing. Associate Professor, Department of Nursing, Federal University of São Carlos. São Paulo, Brazil. Email: arantes@ufscar.br.
IINursing Course Undergraduate, Federal University of São Carlos. São Paulo, Brazil. Email: gabriela.ac2 @ gmail.com.
IIINursingMaster’s Program Candidate, Federal University of São Carlos. São Paulo, Brazil. Email: aridianeribeiro@gmail.com.
IVNursing Course Undergraduate, Federal University of São Carlos.Recipient of Scientific Initiation Scholarship from the National Council for Scientific and Technological Development. Brazil. Email: re_verardino@hotmail.com.
ABSTRACT: This study aimed to analyse nursing undergraduate students’conceptions of collective care in primary health care. This was a qualitative case study. The data was collected in November 2010 by focus groups with 11 nursing students from a public university in São Paulo state, Brazil. The data analysis was based in the theme/category-based content analysis. The analysis showed four categories: integral care and overcoming the preventive model; family health is the highlight of the Unified Health System; family health enables approximation in the living context and health of the population; educative groups and health monitoring measurescharacterize collective care. Conclusions show that the nursing undergraduate program is providing critical concepts on collective care in primary health care; however there is a need to overcome idealistic perspectives.
Keywords:Community health nursing; primary health care; education, nursing; family health.
INTRODUCTION
With the creation of the Unified Health System (SUS) in Brazil, a process of reorganization of the care model in public health servicesbegan, which led to the emergence of new practices with a focus on family health1. In this context, the Ministry of Health established the Family Health Strategy (FHS) to implement primary health care actions (PHC)2.
FHS’sprimary guideline is ongoing basiccomprehensive care, based on fairness, resoluteness and the humanization of healthcare practices3. FHS is looking towards a paradigm shift in SUS attention, prioritizingthe preventive and promotional approach, instead of the healing, disjointed and approach centred on the hegemonic doctor’srole2. In this perspective, health workers play a key role in PHC feasibility and effectiveness, requiring the training of professionals not only with technical skills, but with focused attention to the needs of the human being as an individual within their family and a community4.
In this sense, refocusing the training and capacity of health professionals with a view to being complete and to the new model of SUS healthcare shall be incorporated into government policies5. But the changes are slow and the traditional model of university education,focused on individual curative care,still prevails, with little appreciation of the sociocultural health-illness determinants and grounded in the fragmented and reductionist view of the different specialities.
The scientific literature related to nursing care in public health in the PHC area is limited, showing the need to expand knowledge in this field6. This context highlights the importance of studying education in health and nursing, with respect to the knowledge and practice in the PHC.
It was assumed that, for a consistent performance within FHS guidelines, nursing professionals should,during their training,acquire knowledge and experience to develop actions of acollective nature. Initially questioning how the process of training would prepare these professionals to work in the PHC, particularly in the dimension of collective care, the objective of this study was defined: analyze the conceptions of nursing students of the collective care in FHS.
LITERATURE REVIEW
Nursing education in Brazil follows the norms of the 2001 National Curriculum Guidelines for Health Graduation Courses, which among other provisions, requires that the trained professional must attend social health needs, with emphasis on the SUS and ensuringcomplete and humanized healthcare7.
In reality, the Flexnerian model still strongly permeates nursing education, delimiting teaching in two focus points – basic and professional disciplines – with these twocores departing from each other and from practice8.
In search of health education reorientation, focused on completeness and on the development of new SUS practices, government policies have been implemented, such as the National Programme of Reorientation of Vocational Training in Health (PRO-HEALTH) and the Labour Education Program (PET)9.
Health training covers issues on the production of subjectivities, production of technical and thinking skills and proper knowledge of SUS10. Since the FHS has an important role in SUS, the process of nursing education should include the knowledge and practices of PHC, including the ways of attending communities.
The work in the FHS is done by an interdisciplinary team consisting of a doctor, nurse, technician or auxiliary nurse and community health workers with responsibility for the inhabitants of a defined geographical territory11. The nurse shares different responsibilities with the team, acting as clinical caregiver, manager of personnel and of activities related to territory and service, and also participates in the systematization and data analysis and in political, social and community coordination8.
Overall, the practice of public health in the FHS is still geared to a limited list of health needs with low incorporation in the context of healthcare actions production, and could be expanded based on the territory’sepidemiological, sanitary and environmental profile12. Collective care actions are those relating to the process of territorialconstruction of diagnosis, health promotion, social participation and control, monitoring and evaluation of the workand healthcare process, as well as health education and local management, with the goal of developing collective work projects13.
The FHS teams have difficulties in organizing and producing these collective actions, which in large part are of an intersectoral character and encourage public participation12. Nurses have significant actions in teams, proposing, organizing, developing and evaluating collective actions, but are still predominantly based in traditional knowledge of epidemiology, education and clinical practice13.
There is need to increase the means of intervention in public health beyond vaccines and behavioral restrictions and co-build,with the community involved,intervention projects directed to situations of community risk and vulnerability14. The actions of collective care must continue to be built, produced and evaluated by family health teams, as well as be part of health professionals training process, and thus contribute to the transformation of the healthcare model in PHC.
METHODOLOGY
This is a descriptive study with a qualitative approach using the case study method. The qualitative dimension allows us to highlight subjective connections between real-life situations in the context in which they occur15.
The study setting was the undergraduate degree in nursing at the Federal University of São Carlos (UFSCar), whichin 2010 had 3,615 hours spread over eight semesters in theoretical and practical courses, internships, completion papers and complementary activities16.
In obtaining the data, the focus group technique was used because it allows the capturing of perceptions, behaviours, beliefs and cultural representations of human groups on a particular subject17.
The selection criteria for participation in the focus group were: be a graduate student from last semester and accept the invitation. From a total of 29 students, 11 undergraduates participated, aged between 21 and 29 years, the majority (10) being female. Several students justified their non-participation by the accumulation of activities in the final phase of the course and commitments related to graduation.
Two focus groups, one with five and one with six undergraduates, on 17 and 18 November 2010 were held. The average duration of the sessions was 1 hour and 40 minutes.
The focus groups were conducted by the researchers, using a script with open questions on the studytopic. The discussions were recorded and transcribed. To guarantee the anonymity of the participants, the responses were identified by the letters GF and the number 1 or 2 to indicate the focal group, followed by a lowercase letter (a, b, c ...) referring to each participant. The study was approved by the UFSCar Ethics Committee on human research (Opinion No. 379/2010) and all participants signed aTerm of Free and Informed Consent.
In analyzing the results, the technique of thematic categorization18-20 was used, following these steps: initial reading; material exploration; categorization; and inference. Thus, according to the study objectives,the reporting units – phrasesfrom the transcribed focus group discussions – were identified and collected, which were progressively grouped and regrouped into themes until reaching the categorical themes.
RESULTS AND DISCUSSION
Four thematic categories arose: comprehensive care and overcoming the preventive model; family health is the highlight of SUS; family health enables approximation in the living and health contextof the population; and educational groups and health monitoring characterize collectivecare. The categories are described and analyzed below.
Comprehensive care and overcoming the preventive model
The idea of integrated care was in consensus among undergraduates, which according to them it is possible not only to promote health and prevent disease, but also intervene in health problems as they occur and in rehabilitation in basic care.
You can have two actions [...] both the treatment and prevention at the same time [...] (GF1a)
I’ll take care of you if you have a health problem, but I’ll also promote health and work to prevent complications [...] (GF2b)
Physiotherapy students in another study also showed that in FHSthere are healing actions centred on the doctor, but there is also concern about performing disease prevention activities and health promotion in the community21.
The concept of comprehensiveness can be summarized in three areas: assisting people in the network that makes up PHC, hospital care and other services; providing health care that takes promotion, disease prevention, diagnosis, treatment and rehabilitation into account; caring for the human being holistically22.
The longitudinal care in PHC brought by undergraduates refers to the care from the prevention of health problems until their cure and rehabilitation, opening the possibility of overcoming individual curative attention for comprehensivenessin health practices23. In this way, a view of overcoming the polarization between prevention and cure was obtained from the responses.
[...] it’s a level with potential, precisely for that line of care, with this horizontal thing that you can follow [...] (GF1c)
[...] it’s not only focused on pathology, you see everything that is causing it to develop, the weight of the family on it [...] it is long-term accompanying.(GF1b)
In the prevention model, health actions have the scope to prevent diseases and/or control the complications, through physician-centered practices only looking at the individual detached from their family, social and economic context24. Undergraduates showed distancing from this model to describe their understanding of comprehensive care.
Family health is the highlight of SUS
The valuing of family health as a production strategy in health care was seen.
[...] sothat’s the highlight [...](GF2d)
[...] I think it’s at least anintelligent strategy. (GF1c)
[...] I was dazzled by how the strategy is going [...](GF1e)
The discussions expressed strong feelings that the FHS is the primary means of solving the problems of population health. Undergraduates pointed to the potential of this strategy, as the most important policy of SUS, as it has the ability to follow the individual, family and community from health promotion to rehabilitation.
Admittedly, the coverage of the population has greatly expanded with the FHS, which contributed to the improvement of health indicators and the implementation of SUS guidelines25. But on the other hand, it is worth noting that in several contexts, the FHS has been reproducing physician-centred practices, based on complaint-conduct23 and without interdisciplinary team performance.
Participants were unanimous in extolling the potential of FHS, approaching an idealized vision, bringingfew of its limitations to the discussion, as the change to a model of care focused on health needs of the territory’s individuals, also requires structural changes to health teams26.
The undergraduates considered that the knowledge and practices learned in family health are so advanced that they used them in their experiences in hospital care, bringing the idea of innovation in basic care.
Family health, approximation in the living and healthcontext
The way the FHS is organized allows the healthcare team to get close to and learn about the context of the lives of those under their responsibility. For the undergraduates, this was brought about in three ways: in the actions of the community health agent (CHA), in forming bonds between the team and the population, and in home visits (HV). The importance of CHAwas greatly stressed by the participants.
Another big win for the ESF is the community health agent [...] (GF1g)
[...] you can count on community health workers in the community.(GF2b)
In the FHS, to meet the real needs of the community, the CHA acts as a facilitator in identifying health problems27 and as the main intermediary between the healthcare team and the community27,28. The CHA is a worker who shares the customs, languages, cultures and problems with people who live in their service territory, enabling the bringing together of technical/scientific knowledge and popular knowledge and making the relationship between the health team and social life of the population stronger29-31.
On the other hand, the undergraduates did not bring pertinent questions related to the reality of the CHA’ functions, such as the workload28,30 and deviation of its actual function, with its fixation on bureaucratic paperwork or support to the team within the health unit30.
Another aspect considered relevant in the PHC was the possibility of establishing a link between professionals and users.
[...] in the PHC, we can create a greater bond with the user, enabling better adherence to treatment [...] discovering problems [...] (GF1g)
The bond formation favours the creation of commitment and responsibility connections between health staff, users and families32.
With the home visitit is possibleto accompany the family in their reality, because it is within the family living space.
[...] I visit the house, so I can see what happenswith the family there [...] it gives me elements to develop a more effective care plan. (GF1c)
The Home Visit in family health is understood as aninteraction technique in health care33, providing contact and identification of the individual, family and community’s health needs.
In their academic experience, undergraduates witnessed moments of home care, and despite the recognition of the importance of the Home Visit to the FHS, some expressed concern about the need to preserve the privacy of the family.
I have difficulty accepting home visits [...]. For this question of [...] pre-judgement [...] They go too far into that family’s space [...] (GF2d)
The HV can cause an exaggerated interference in the lives of users, which limits their privacy and freedom2, and can even mean a particular intervention in their daily life34. This drawback about the significance of HV demands a critical look at some of the working situations in the FHS.
The importance of the getting closerto the reality of people’s lives is highlighted in discussions,which included the need to establish a profile of health needs that are peculiar to the territory of the family health team.
[...] the knowledge of how is the territory where the facility is located, if it has basic sanitation, transportation, and how they will get to the unit [...] (GF1e)
The importance of this view of the specific population’shealth problems converges with the Ministry of Health’srecommendations to advocate: the delimitation of the assisted population, the detection of customer needs and the establishment of epidemiological, demographic and social profile of the population in order to promote health35.
In identifying the populationhealth problems, undergraduates stressed that it is necessary to value popular knowledge and listen to what users have to say about their needs.
[...]the nurse comes with characteristics of knowing how to listen to, respect and work with popular knowledge and not discriminate against it, not disrespect it [...] (GF2d)
The expansion of intervention means in public health needs to be co-constructed with the community involved14 and thus, the FHS may constitute a meeting-place between health professionals and the population12.
Educational groups and health monitoring characterize the collective care
Different conceptions of shares of collective careappeared. The first was characterized in the work of educational groups and Ministry of Healthprograms.
[...] if I can form a hypertensive, diabeticsgroup, it’s collectively caring for people. (GF1c)
[...] group actions, collective care inbasic care [...] are the campaign itself of the programs offered by the Federal Government [...] (GF1e)
This conception seems to have influence from encouraging SUS government policies to working with educational groups, mainly to enhance the understanding of the user about their health needs and contributing to changesin lifestyle36,37. Generally, the topics covered in these groups are focused on disease prevention, which requires an expanded perspective on the health-disease-care in order to use the group space to also address social, cultural and historical issues36.
Another conception of collective care concerns health monitoring, as monitoring and analyzing epidemiological and environmental data of the specific population’sterritory, the family health team would plan collective actions to be developed.
[...] tem um número grande de hipertensos naquela comunidade: param e organizam feiras para falar sobre o que é hipertensão, ou se há muita criança ociosa: então fazem jogos, brincadeiras [...] (GF2i)
[...] there is a large number of hypertensive patients in the community: stop and organize fairs to talk about what is hypertension, or if there are a lot of idle child then play games [...](GF2i)
[...] it’s to look at the data [...] gathering trash somewhere, gathering rubbish [...] then I need to do some kind of collective action related to this. (GF2b)
The main assumption of health monitoring is territoriality, as it is based on the territorial context that one can define health needs and set priorities, considering the specificities of each community38. The discussions generated this concept,in the statements that in order to identify health needs it is necessary to look at information related to social reality and community health. However, the collective actions to meet identified needs almost always refer to the use of educational technologies. In this sense, the conceptions of the undergraduates seem to reflect the reality of health practices that need to advancethe combination of caring techniques, exceeding the structured line of the disease to new lines of care and incorporating into group actions elements that encourage the social demand for better living conditions and health36.
Undergraduates reported that collective actions are decided and planned in team meetings and that the public participates in such actions, with much swapping of knowledge and experiences.
[...] collective actions [...] are born within the scope of teamwork [...] the strategies are defined [...] it is establishedin group [...] (GF2j)
Collective care coversprofessionals, user to user, putting prevention and health promotion things for several people. (GF1g)
The FHSseeks to discusses health issues to reach a consensus on the necessary intervention actions39, and this is reported by undergraduates as actions of collective care.
Regarding the participation of users, the exchange relationship between professionals and them were brought to the discussion. This exchange requires an approach that considers the user as the bearer of knowledge, including beliefs and values, differingfrom technical knowledge and needing to be valued in collective actions40.
The conceptions of the students regardingcollective care advance in the sense of incorporating participatory approaches in relation to the public served, although the FHS also needs to broaden the list of technologies to attend the collective.
A limitation to be studied is how to incorporate the use of health technologies aimed at mobilizing society and bringing health professionals to build partnerships with social actors (users), seeking social participation and the construction of key intersectoral actions in achieving the expanded concept of health40.
CONCLUSION
The content analysis of the two focus groups conducted with nursing undergraduatesproduced four thematic categories. The first, comprehensive care and overcoming the preventive model, brought the notion of comprehensiveness in primary care, with the expectation that the actions of promotion and prevention go together with the treatment and rehabilitation, which may mean overcoming the preventive model in the training process of study participants. In the second category, family health is the highlight of SUS, the undergraduates valued the family health strategy in care production, defending it as the SUS most important policy and the main way to solve the health problems of the community.
The third category: family health,approximation in the living and health contextof the population, showed family health as a possible approximation in the actual context of people, being relevant to establishing the profile of the needs of public health. The fourth and final category, educational groups and health monitoring characterize collectivecare, addressed the perspective of nursing undergraduates in primary care that collective care is based on the activities of educational groups and on the practice of public health monitoring, monitoring epidemiological and environmental data with a view to developing actions aimed at the needs of the community.
It can be argued that the formation process of the study participants is providing learning experiences that are leading to the formulation of concepts and critical positions on collective care in the basic healthcare context, however, it is also apparent the need to overcome other conceptions still idealized in this same reality.
A limitation of this study is the fact that it does not allow generalizations, as it addresses the prospect of some participants in the Undergraduate Nursing Programme. But, on the other hand, showing student conceptions of the collective care in primary health care, the presented results enable reflections on the strengths and weaknesses of public health teaching in nursing education.
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