THE OPI NI ON OF NURSES REGARDI NG THE W ORK THEY PERFORM W I TH FAMI LI ES
I N THE FAMI LY HEALTH PROGRAM
1Raqu el Gu sm ão Oliv eir a2 Sonia Silv a Mar con3
Oliv eir a RG, Mar con SS. Th e opin ion of n u r ses r egar din g t h e w or k t h ey per f or m w it h f am ilies in t h e f am ily healt h pr ogr am . Rev Lat ino- am Enfer m agem 2 0 0 7 m aio- j unho; 1 5 ( 3 ) : 4 3 1 - 8 .
This st udy aim ed t o lear n t he nur ses’ opinion concer ning t he w or k t hey per for m w it h fam ilies in t he cont ex t of t he Fam ily Healt h Pr ogr am and w hich ar e t he necessar y com pet ences t o accom plish it . This is an ex plor at or y - descr ipt iv e st udy , of qualit at iv e nat ur e, car r ied out w it h 20 nur ses w ho w or ked at a Fam ily Healt h Cent er . The dat a w er e collect ed t hr ough a sem i- st r uct ur ed int er v iew and t he Bar din’s r efer ent ial w as used for t he analysis of cont ent . The r esult s r evealed t hat t he w or k w it h fam ilies is st r uct ur ed based on t he act ions and r elat ionships ex ist ent bet w een t he pr ofessionals and t he fam ilies, because t he est ablishm ent and m aint enance of such r elat ions int er fer e in t he qualit y of t he assist ance. Regar ding t he necessar y com pet ences, t he im por t ance of t he scient ific t echnical know ledge ( know - how ) and especially t he abilit y t o r elat e w it h t he fam ilies and w it h ot her t eam m em ber s ar e em phasized. I n addit ion, com m it m ent , inv olv em ent and et hical post ur e w er e nam ed, w hich ar e aspect s easily r eached w hen a per son lik es w hat ( s) he does.
DESCRI PTORS: nur se’s r ole; fam ily healt h; fam ily nur sing; fam ily healt h pr ogr am
OPI NI ÓN DE ENFERMEROS CON RELACI ÓN A LO QUE SI GNI FI CA TRABAJAR CON
FAMI LI AS DENTRO DEL PROGRAMA SALUD DE LA FAMI LI A
El obj et iv o de est e est udio fue conocer la opinión de enfer m er os sobr e lo que significa el t r abaj o con fam ilias dent r o del cont ex t o del Pr ogr am a Salud de la Fam ilia ( PSF) y cuales son las com pet encias r equer idas par a est e t ipo de t r abaj o. Es un est udio ex plor at or io descr ipt iv o, de t ipo cualit at iv o, desar r ollado con v eint e enfer m er os que t r abaj an en un PSF. Fue ut ilizada par a la r ecolección de dat os, la ent r evist a sem i est r uct ur ada, y par a el análisis de cont enido de las ent r evist as el fundam ent o t eór ico de Bar din. Los r esult ados dem ost r ar on que el t r abaj o r ealizado con las fam ilias se est r uct ur a a par t ir de acciones y r elaciones de los pr ofesionales con las m ism as, pues al est ablecer y m ant ener r elaciones con la fam ilia se int er fier e en la calidad de la asist encia. Con r elación a las com pet encias se r esalt ó, sobr e la im por t ancia del conocim ient o t écnico cient ífico ( saber -h acer ) y en esp ecial d el sab er r elacion ar se ( sab er - ser ) con las f am ilias y con los m iem b r os d el eq u ip o, dem ost r an do com pr om iso, in v olu cr am ien t o y post u r a ét ica; aspect os m ás fácilm en t e con segu idos cu an do se gust a de lo que se hace.
DESCRI PTORES: r ol de la enfer m er a; salud de la fam ilia; enfer m er ía de la fam ília; pr ogr am a salud de la fam ilia
OPI N I ÃO DE EN FERMEI ROS ACERCA DO QUE É TRABALHAR COM FAMÍ LI AS
NO PROGRAMA SAÚDE DA FAMÍ LI A
O obj et ivo dest e est udo foi conhecer a opinião de enfer m eir os acer ca do que é o t r abalho com fam ília n o con t ex t o do Pr ogr am a Saú de da Fam ília ( PSF) e qu ais as com pet ên cias n ecessár ias par a esse t r abalh o. Tr at a- se d e est u d o ex p lor at ór io- d escr it iv o, d e n at u r eza q u alit at iv a, d esen v olv id o j u n t o a v in t e en f er m eir os qu e at u am em u m PSF. Ut ilizou - se par a a colet a de dados a en t r ev ist a sem i- est r u t u r ada e par a an álise do con t eú d o d os d iscu r sos, o r ef er en cial d e Bar d in . Os r esu lt ad os r ev elar am q u e o t r ab alh o com f am ílias é est r ut ur ado a par t ir de ações e r elações dos pr ofissionais j unt o às fam ílias, pois est abelecer e m ant er r elações com a fam ília int er fer e na qualidade da assist ência. Em r elação às com pet ências, for am r essalt adas a im por t ância do con h ecim en t o t écn ico- cien t ífico ( saber - fazer ) e pr in cipalm en t e do saber se r elacion ar ( saber - ser ) com as fam ílias e com os m em br os da equipe, dem onst r ando com pr om et im ent o, envolvim ent o e post ur a ét ica, aspect os esses m ais facilm ent e alcançados quando se gost a do que se faz.
DESCRI TORES: papel do pr ofissional de enfer m agem ; saúde da fam ília; enfer m agem fam iliar ; pr ogr am a saúde da fam ília
1 St udy ext ract ed fr om Mast er Thesis; 2 RN, M.Sc in Healt h Sciences, e- m ail: calolive@hot m ail.com ; 3 RN, PhD in Nur sing Philosophy, Pr ofessor St at e
Univer sit y of Mar ingá, Br azil, e- m ail: ssm ar com @.uem .br
I NTRODUCTI ON
I
n r ecen t decades, t h e academ y h as t ak en in cr easin g in t er est in t h e fam ily t h em e, r esu lt in g int he gr eat er inclusion of specific cont ent s in subj ect s
from different know ledge ar eas. I n healt h, an incr ease
has been obser v ed in t he num ber of st udies, as w ell
as in clinical pract ice direct ed at t he fam ily( 1), st r ongly
driven by t he em ergence of t he Fam ily Healt h Pr ogram
( FHP) . Now ad ay s, t h is p r og r am is con sid er ed m or e
as a st r at egy t o r edir ect t he healt h car e m odel.
Accor din g t o t h e FHP, t h e f am ily sh ou ld be
consider ed in it s socioeconom ic and cult ur al cont ex t
an d ack n ow led g ed as a sp ace f or in t er act ion s an d
conflict s t hat dir ect ly influence people’s healt h. What
fam ily car e is concer ned, t his st r at egy believ es t hat
t he int egr al appr oach needs t o include, am ong ot her
issues, t he concept ion of m an as a social subj ect w ho
is capable of out lining his ow n dev elopm ent pr oj ect s
a n d t h a t ca r e sh o u l d f o cu s o n a n i n d i v i d u a l w i t h
r elat ions, as opposed t o t he biological indiv idual( 2).
Hence, pr ofessionals w or k ing in t his st r at egy
m ust adopt differ ent iat ed at t it udes, based on r espect ,
e t h i cs a n d co m m i t m e n t t o t h e f a m i l i e s t h e y a r e
responsible for, by creat ing bonds of t r ust and affect ion
an d b y t ak in g p ar t in t h e con st r u ct ion of h ealt h ier
env ir onm ent s in t he fam ily space( 2).
I n p r a ct i ce , t h e st r a t e g y h a s f a ce d so m e
difficult ies t o sust ain FHP t eam pr ofessionals’ act ions,
as it s t heor et ical fr am ew or k has not been consider ed
easy t o read and it s pract ical applicat ion st ill represent s
a challenge for act ive t eam s( 2). How ev er, w e believe
t hat t he m ain problem derives from t he fact t hat t he
m arket does not offer a sat isfact ory quant it y of qualified
professionals wit h t he profile t o work in t his new m odel,
as n ei t h er p r o f essi o n al ed u cat i o n n o r p r o f essi o n al
t r aining has decr eased t his gap.
Wit h r espect t o nur ses, alt hough nur sing and
t he fam ily have alw ays been close, as care is inherent
i n b o t h , t h e r e a l i t y o f w o r k i n g w i t h f a m i l i e s h a s
b a si ca l l y co v e r e d o r i e n t a t i o n a n d t h e se a r ch f o r
infor m at ion, m ainly in t heor et ical st udies( 3).
Th e r e f o r e , a m o n g o t h e r r e a so n s, n u r si n g
w or k w it h fam ilies has been consider ed a challenge,
w hich r equir es pr ofessionals t o lear n how t o t hink of
t he fam ily; t o st ar t developing a differ ent iat ed pr act ice
in t he healt h and disease cont ext , est ablished on t he
basis of t he fam ily’s ow n r ealit y; and t o cont r ibut e t o
t he const r uct ion of nur sing k now ledge in t he ar ea.
Fr o m t h e p e r sp e ct i v e o f t h e t h e r a p e u t i c
a p p r o a c h , t o r e f e r t o w o r k a s f a m i l y c a r e , t h e
p r o f e s s i o n a l n e e d s k n o w l e d g e a b o u t t h e f a m i l y
u n i v e r se , a s ca r e d e l i v e r y i m p l i e s t h e a b i l i t y t o
u n d e r s t a n d a n d a d e q u a t e l y a t t e n d t o t h e o t h e r
p er so n ’ s n eed s. Sci en t i f i c r esear ch h as ap p o i n t ed
som e char act er ist ics of fam ily w or k , focusing on t he
w orld of it s int eract ions, as t hese sust ain and m aint ain
t h e f a m i l y co r e . Th i s p r e su p p o se s p r o f e ssi o n a l s’
k n o w l e d g e o f f a m i l y, f a m i l y h e a l t h a n d f a m i l y
int er act ion concept s( 4 ).
Sev er al act ions t he pr ofessionals pr oduce in
t he cont ext of t he FHP, ( fam ily r egist er s, fr equent hom e
visit s at t im es of changes in t he phases of t he fam ily
cy cle and in case of acut e or chr onic diseases) fav or
int er act ion and bonding w it h t he fam ily. I n pr act ice,
h ow ev er, p r of ession als of t en b eliev e t h at t h ey ar e
deliv er in g car e t o t h e fam ily, ev en w h en t h eir w or k
p r o ce ss d o e s n o t d i f f e r f r o m t h e i n d i v i d u a l ca r e
pr ocess. I n t h is case, w h at is act u ally h appen in g is
car e deliv er y t o an indiv idual w it h r elat iv es, inst ead
of care t o t he fam ily as a unit . And, how ever, t here is
a d if f er en ce b et w een car e d eliv er y t o an in d iv id u al
w ho belongs t o a fam ily and car e t o t he act ual fam ily,
w hen care has it s ow n charact erist ics and is developed
on t he basis of t he univ er se of fam ily r elat ions( 4).
This confusion is ev en obser v ed in scient ific
research, as som e st udies( 5- 6) affir m , for exam ple, t hat
FHP nur ses focus t heir car e on t he fam ily and do not
m anage t o dem onst r at e t his w hen t hey descr ibe t he
act iv it ies t h ey per f or m . Th is is specif ically t h e case
for hom e visit s w hich, alt hough indicat ed as a fam
ily-o r i e n t e d a ct i v i t y, a r e m a d e i n t h ily-o se ca se s w h e n
pat ient s need special pr ocedur es( 5- 6).
I n t he FHP scenar io, fam ilies ar e addr essed
i n d i f f er en t w a y s: f a m i l y / i n d i v i d u a l , f a m i l y / h o m e,
f am ily / in div idu al/ h om e, f am ily / com m u n it y, f am ily /
social r isk and fam ily / fam ily, but t her e ex ist s neit her
m ut ual dialogue nor com plem ent ar iness in t his w hole
d i v er si t y, w h i ch m ak es i t d i f f i cu l t t o ach i ev e car e
int egr alit y and pr oduces com pr ehension difficult ies in
p lan n in g , in car e, in p r of ession al ed u cat ion ad v ice,
b e s i d e s c a u s i n g f r u s t r a t i o n s d u e t o u n a t t e n d e d
ex pect at ion s( 7 ).
I t sh ou ld b e u n d er lin ed t h at t h e FHP w en t
t hr ough m om ent s of r efor m ulat ion, t r ials, ex pansion
and t hat , now adays, it has r eached t he age of facing
ch allen ges, an oppor t u n it y t h at dem an ds t ar get s t o
be r econsider ed and cour ses t o be r eadj ust ed( 8). This
m ay be t he appr opr iat e t im e t o r econsider or, bet t er,
d elim it sp aces, con cep t s an d p r act ices ab ou t w or k
w it h fam ilies. And, as t his w or k is new and, w hat is
n ew m en t alit y an d n ew k n ow led g e f r om n u r ses or
an y ot h er pr of ession als.
Resear ch in d icat es t h at t h e FHP in t en sif ied
an d ex pan ded n u r ses’ act iv it ies in n u r sin g car e an d
educat ion as w ell as in healt h ser vice m anagem ent(
9-1 0 )
a n d , a l s o , t h a t n u r s e s ’ a c t i o n s h a v e b e e n
ch ar act er ized as b ein g com p at ib le w it h t h e h ealt h
su r v e i l l a n ce m o d e l , r e p r e se n t e d b y p r o g r a m a n d
su r v eillan ce act ion s t h at , alt h ou g h d ir ect ed at t h e
com m u n it y ’s h ealt h p r ob lem s, ar e p lan n ed w it h ou t
t heir par t icipat ion( 11).
Thus, focusing on healt h and fam ily car e, in
t his st udy, w e aim t o exam ine nur ses’ opinions about
w ork w it h fam ilies in t he cont ext of t he FHP, defining
t he follow ing st udy obj ect iv es:
- ident ify w hat it m eans t o w ork w it h fam ilies accor ding
t o FHP nur ses fr om Mar ingá, PR;
- ident ify w hat com pet encies FHP nur ses fr om Mar ingá,
PR believe are necessary t o w ork w it h fam ilies in t he
cont ext of t he FHP.
STUDY DESI GN
Th i s d escr i p t i v e, ex p l o r at o r y st u d y w i t h a
qualit at ive appr oach w as car r ied out in Mar ingá – PR
and inv olved nur ses w or k ing in t he cit y’s FHP.
The FHP w as im plant ed in Mar ingá in 1999,
init ially w it h 7 t eam s. At t he t im e of st udy, 62 t eam s
w er e dist r ibut ed am ong t he 23 basic healt h unit s ( 20
in t he urban zone, 2 in t he dist rict s and 1 in t he rural
area) , dist ribut ed am ong 5 r egional healt h unit s, w hich
a t t e n d e d t o 6 9 . 9 6 0 f a m i l i e s, i . e . a p o p u l a t i o n a l
cov er age of 8 1 % .
St udy par t icipant s w er e 20 nur ses, w ho w er e
sor t ed, based on a list w it h t he nam es of t he 62 FHP
nur ses, dist r ibut ed per BHU. The int ent w as t o m ap
t h e 2 0 BHU l o ca t ed i n t h e u r b a n zo n e, r a n d o m l y
select in g on e n u r ses f r om each BHU, in depen den t ly
fr om t he num ber of FHP t eam s allocat ed t her e. Dat a
for t he or iginal st udy w er e collect ed bet w een Febr uar y
and August 2004, t hr ough t hr ee differ ent t echniques:
sem ist r uct ur ed int er v iew s, obser v at ion of hom e v isit s
and pat ient file analy sis.
I n t his paper, w e hav e only used dat a fr om
in t er v iew s t h at w er e pr ev iou sly sch edu led by ph on e
and based on a t w o- par t scr ipt : t he fir st w it h obj ect ive
quest ions t o ident ify sociodem ographic charact erist ics;
t he second w it h eight open quest ions about t he concept
of fam ily and fam ily healt h and fam ily w or k pr act ice,
w h i ch i n cl u d ed a q u ot at i on an d d escr i p t i on of t h e
p e r f o r m e d a c t i v i t i e s a n d t h e k n o w n a n d u s e d
t echniques and inst rum ent s. All int erview s w ere t aped
w it h t he infor m ant s’ consent .
The obt ained dat a w er e pr ocessed accor ding
t o Bar din’s cont ent analy sis( 12). Aft er t r anscr ibing t he
t apes, t he m at er ial w as r ead, st ar t ing t he pr elim inar y
an aly sis an d ex p lor at ion of d at a. Nex t , d at a w er e
sy st em at ically or ganized and gr ouped in unit s, w hich
a l l o w e d f o r t h e e x a c t d e s c r i p t i o n o f r e l e v a n t
ch ar act er ist ics.
Th e n , ca t e g o r i e s w e r e e st a b l i sh e d , w h i ch
consist ed in isolat ing discourse elem ent s and im posing
a cer t ain or gan izat ion on t h e m essages, ex am in in g
w hat each of t hem holds in com m on w it h t he ot her
( act iv it ies t h at in v olv e an d t h at d o n ot in v olv e t h e
fam ily gr oup) or, also, isolat ing t hem accor ding t o t he
p r e v i o u sl y p r o p o se d t h e m e s ( f a m i l y co n ce p t a n d
p er f or m ed act iv it ies) . Nex t , b ased on t h e ob t ain ed
dat a, infer ences w er e m ade, using av ailable m at er ial
on t h e FHP an d scien t if ic st u d ies on w or k in g w it h
fam ilies as a t heor et ical r efer ence fr am ew or k , in t he
at t em pt t o reach conclusions about t he charact erist ics
of w ork w it h fam ilies in t he FHP.
The st udy com plied w it h t he et hical pr ecept s
f o r r e s e a r c h i n v o l v i n g h u m a n b e i n g s , r u l e d b y
Re so l u t i o n No 1 9 6 / 9 6 , a n d w a s a p p r o v e d b y t h e
Resear ch Et hics Com m it t ee of Mar ingá St at e Univer sit y
( Opinion 1 5 9 / 2 0 0 3 ) .
RESULTS AND DI SCUSSI ON
Get t ing t o k now t he nur ses under st udy
All nur ses in t his st udy w er e w om en, m ost ly
young ( 45% up t o 29 year s and 35% bet w een 30 and
39 year s) , half of t hem gr aduat ed for bet w een 5 and
1 4 y ear s an d 4 5 % f o r l ess t h an f o u r y ear s. Mo st
par t icipant s ( 65% ) had t ak en a specializat ion cour se,
m ost of w hom in an ar ea com plem ent ar y t o t heir w or k
( fam ily healt h and collect iv e healt h) .
As to work in the FHP, m ost nurses (75% ) were
hired through a public selection process and have worked
in the FHP for 3- 4 years. Sixty percent have worked in
the sam e team since the beginning. The hiring form was
considered t o be a fact or t hat st rongly influenced t he
professionals’ perm anence, qualification and perform ance,
in view of t he need t o adhere t o and incorporat e new
v alues and exer cise new healt h pr act ices. Mor eov er,
precarious cont ract s have been indicat ed as fact ors of
M o s t p a r t i c i p a n t s ( 7 5 % ) m e n t i o n a n
i n t r o d u ct o r y t r a i n i n g f o r t h e FHP a n d a l l o f t h em
r eceiv ed at least 1 ( one) t r aining in a specific ar ea.
How ever, only 15% r epor t t hat t he t raining was dir ect ly
r elat ed t o t he fam ily and FHP st r uct ur e ( sensit izat ion
and cover age ar ea) . The Minist r y of Healt h st im ulat es
t h e p er m an en t ed u cat ion p r ocess, w h ich sh ou ld b e
con ceiv ed as a con st an t p r ocess of p r om ot ion an d
com pr ehensive developm ent and placed in t he cont ext
of t he t eam . I t should be focused on cir cum st ances
and pr oblem s in t heir w or k pr ocess, in a cr it ical and
cr ea t i v e w ay, t r a n sf o r m i n g t h e w o r k p r o cess a n d
g u i d i n g t h e m t o w a r d s t h e c o n s t a n t q u a l i t y
im pr ov em ent of healt h act ions and ser v ices( 14).
I n view of t he lack of fam ily- or ient ed cont ent s
a n d t h e e m p h a si s o n d i se a se - o r i e n t e d t e ch n i ca l
co n t e n t s, t h e a u x i l i a r y / i n d i v i d u a l / u n i p r o f e ssi o n a l
m odel is st ill pr edom in an t in h ealt h ser v ices, w h ich
m akes it difficult t o pract ice FHP principles. Considering
t h is aspect an d t h e scar cit y of pr of ession als w it h a
pr ofile for FHP w or k in t he j ob m ar ket , it is ext r em ely
i m p o r t a n t t o d e v e l o p a n d i m p l e m e n t c o n s i s t e n t
per m anent educat ion pr ogr am s, aim ed at effect iv ely
su p p or t in g t h e w or k of FHP t eam s in t h e cit ies b y
ov er com ing t he pr oblem s t hey face in daily w or k .
What it m eans t o w ork w it h fam ilies
The nur ses in t his st udy consider t hat w or k
w it h f am ilies is ch ar act er ized b y t h e p r of ession als’
act ions and r elat ions w it h t he fam ilies.
Act i on s in v olv e ev er y t h i n g t h at is d on e in
d ai l y r eal i t y. Ob t ai n i n g a f am i l y d i ag n osi s i s m ost
fr equ en t ly r ecogn ized as par t of t h e r ealit y of w or k
w it h fam ilies.
The t eam ar r ives at t he fam ily, r eaches a diagnosis,
su r v ey s p r ob lem s, n ot on ly r elat ed t o d isease, ev er y t h in g
involving t he fam ily... ( N- 18) .
For you t o w or k w it h fam ilies, fir st , you have t o know
t hat fam ily.... ( N- 11) .
The t est im onies ar e dir ect ly r elat ed w it h t he
FHP m odel an d t h e pr of ession als’ t ask s, w h ich ar e:
under st anding t he fam ily in an int egr al and sy st em ic
way, as a space for individual and gr oup developm ent
t hat is dynam ic and subj ect t o cr ises; get t ing t o know
t h e r ealit y of t h e f am ilies t h ey ar e r esp on sib le f or,
p a r t i c u l a r l y t h e i r s o c i a l , e c o n o m i c , c u l t u r a l ,
dem ogr aphic and epidem iological char act er ist ics and
ident ify t he m ost com m on healt h pr oblem s and r isk
si t u a t i o n s t h a t p o p u l a t i o n i s e x p o se d t o , a m o n g
ot h er s( 2 ).
D e l i v e r i n g c a r e t o t h e f a m i l y i s a n o t h e r
char act er ist ic t hat is fr equent ly m ent ioned as par t of
fam ily w or k. This car e is based on t hr ee point s: focus,
a c t i v i t i e s a n d s t r u c t u r e . So m e n u r s e s e x p l i c i t l y
m ent ion t hat t he focus of car e is t he fam ily, alt hough
t hey adopt indiv idual or indiv idual- r elat ed car e as a
r ef er en ce f or f am ily w or k .
For m e, w or king w it h fam ilies m eans looking at each
individual separ at ely... ( N- 20) .
... I ndividual car e... ( N- 4) .
FHP act ions ar e configur ed on t he basis of an
int egral approach of t he fam ily. I nt egral care includes,
am o n g o t h er asp ect s, co n cei v i n g m an as a so ci al
su b j ect cap ab l e o f o u t l i n i n g h i s o w n d ev el o p m en t
pr oj ect s. Thus, t he focus of car e should be an individual
w it h relat ions, as opposed t o t he biological individual( 2).
Th e p r e d o m i n a n t h e a l t h m o d e l i n Br a zi l ,
ch ar act er ized b y in d iv id u al, cu r at iv e an d ex clu d in g
car e, cr eat ed a lar ge dist ance bet w een healt h t eam s
a n d t h e p o p u l a t i o n , a n d a l s o m a r k s h e a l t h
p r of ession als’ ed u cat ion ; an d , d esp it e all ef f or t s t o
change t his realit y, t he old m odel st ill exert s a st rong
influence on t he nur ses’ t est im onies and act ions.
How ever, it should be r em inded t hat , alone,
t he pr inciples and bases of t he FHP cannot r espond t o
t he goal of inv er t ing t he aux iliar y m odel, as such a
ch an g e r eq u ir es m u ch b r oad er act ion s t h an f am ily
h ealt h t eam s’ in t er v en t ion capacit y, n o m at t er h ow
w ell p r ep ar ed t h ey ar e. I n ot h er w or d s, st r u ct u r al
ch a n g es a r e n eed ed , r el a t ed t o t h e en v i r o n m en t ,
econ om y, agr icu lt u r al policy, social w or k , edu cat ion
and leisur e( 15).
Wit h r espect t o t he second aspect of car e
-act i v i t i es – t h ese ar e i n t er p r et ed as au x i l i ar y an d
m a n i f e st e d i n t h e f i r st p l a ce t h r o u g h p r e v e n t i v e
guidelines. These act ivit ies m ark t he realit y of Brazilian
nur sing w or k w it h fam ilies. This m ak es it necessar y
t o st im u lat e a m or e adv an ced pr act ice, con sider in g
t he needs and healt h st at es of individuals in t he fam ily
as w ell as it s f u n ct ion in g , st r u ct u r e an d f u n ct ion s.
Hen ce, t h e assessm en t an d car e w ill f ocu s on each
indiv idual’s healt h as w ell as t hat of t he fam ily as a
w h ole.
What t he t hir d aspect of car e is concer ned
-st r uct ur e – t he nur ses r efer r ed t o t he need for act ivit y
planning and t o t he fact t hat act ivit ies ar e per for m ed
by a m ult ipr ofessional t eam .
A c c o r d i n g t o t h e FH P m a n u a l( 2 ), a c t i o n
p lan n in g is r elat ed t o t h e cap acit y t o d iag n ose t h e
local realit y, as w ell as t o elaborat e and evaluat e w ork
i n t er d i sci p l i n a r y w o r k i n v o l v es p r o f essi o n a l s f r o m
d i f f e r e n t a r e a s , a n d s h a r i n g k n o w l e d g e a n d
infor m at ion in favor of t eam w or k, so as t o achieve a
gr eat er im pact on t he differ ent fact or s t hat int er fer e
in t h e h ealt h - disease pr ocess an d con t r ibu t e t o t h e
i m p l e m e n t a t i o n o f a m o r e i n t e g r a l a n d p r o b l e m
-solv in g ap p r oach .
Wit h r espect t o t he second char act er ist ic of
fam ily w or k t he nur ses appoint ed – t he pr ofessional’s
r elat ion w it h t h e fam ilies – t w o cat egor ies cou ld be
i d e n t i f i e d : e st a b l i sh i n g r e l a t i o n s a n d m a i n t a i n i n g
r elat ions w it h t he fam ily.
According t o t he nurses, est ablishing relat ions
w it h t he fam ily is necessar y for t heir w or k t o ev olv e
w ell.
Having a good bond t o feel confidence... ( N- 5) .
You have t o get involved in ever yt hing t o w or k w it h
fam ilies... ( N- 7) .
You have t o conquer t he fam ily w it h a view t o giving
advice... ( N- 11) .
But t he concer n cannot be lim it ed t o bonding,
as m aint aining t he r elat ion w it h t he fam ily is j ust as
or ev en m or e n ecessar y. For ex am p le, a r esp ect f u l
r e l a t i o n n e e d s t o b e m a i n t a i n e d f o r c a r e t o b e
ef f ect iv e.
Ther e has t o be r espect , et hics... ( N- 11) .
Ther e has t o be r espect and confidence. ( N- 1) .
I t has t o be a relat ionship of confidence and friendship.
( N- 4) .
The per spect iv e of t he r elat ionship r est s on
t h e t r iad of w elcom in g, list en in g an d r espon sibilit y,
as a pr ocess t hat st ar t s in t he pr ofessional’s int er nal
ex er cise w it h h im - / h er self. Welcom in g an d list en in g
favor bonding and ar e t r anslat ed in t he pr ofessional’s
w illingness t o get involved and est ablish a relat ionship
of t r ust and fr iendship. Responsibilit y is ev idenced at
t he m om ent t he nur se int ends t o r espect t he fam ily
and be et hical in his/ her r elat ions.
I t can be per ceived t hat t he dynam ics of t he
FHP f av or s t h e est ab lish m en t of n ew r elat ion s an d
ch a n g e s i n t h e w o r k p r o ce ss, b u t i t n e e d s t o b e
u n d e r st o o d t h a t t h e m e a n i n g o f w e l co m i n g g o e s
b e y o n d m e r e l y t r e a t i n g s o m e b o d y w e l l . I t
pr esupposes r espect , int er est and r esponsibilit y, not
o n l y f o r p r o f e s s i o n a l a c t i o n s , b u t a l s o f o r t h e
populat ion’s pr oblem s and needs( 16).
I t is int er est ing t hat t he nur ses appoint som e
benefit s of w ork w it h fam ilies, w hich are perceived in
t h e r el at i o n al sp h er e, su ch as: easi er Access an d
accep t an ce of t h e ad v ice g iv en . Th is, in t u r n , h as
b e n e f i t e d p r o f e ssi o n a l p r a ct i ce , a s t h e i n t i m a cy,
confidence and bonds est ablished w it h t he fam ily favor
car e qualit y, r esult ing, am ong ot her aspect s, in great er
gr at if icat ion .
Alt h ou gh t h e r elat ion sh ips w it h t h e f am ilies
ar e per ceiv ed as posit iv e for t h e ev olu t ion of w or k ,
t h ey ar e also per ceiv ed as a ch allen ge, as k n ow in g
how t o r elat e w it h ot her s is one of t he com pet encies
needed t o w or k w it h fam ilies, as illust r at ed below .
Com pet encies needed for w or k in t he FHP
The nur ses’ opinion about t he com pet encies
n eeded t o w or k w it h f am ilies, in t h e con t ex t of t h e
FHP, g av e r i se t o t w o ca t e g o r i e s: k n o w - h o w a n d
k n ow in g - h ow - t o- b e.
Th e k n ow - h ow cat egor y in v olv es k n ow ledge
and act ions r elat ed t o t he t echnical ar ea, w hich can
b e d et a i l ed o r d escr i b ed( 1 7 ), a n d co v er s t ech n i ca l
( t echnical- scient ific k now ledge – pr ocedur es or ient ed
t o w a r d s t h e p a t i e n t ’ s p h y s i c a l p r o b l e m s ) a n d
or ganizat ional or m et hodical com pet encies ( t eam w or k
and planning)( 17).
The com pet encies t hey m ent ioned ar e in line
w it h t he w or k pr oposal configur ed by t he FHP, w hich
est ab lish es t ask s b ased on k n ow led g e an d act ion s
f o r t h e e n t i r e t e a m a n d s p e c i f i c a l l y f o r e a c h
p r of ession al. Tech n ical- scien t if ic k n ow led g e cen t er s
on k n ow - h ow an d p r oced u r es or ien t ed t ow ar d s t h e
pat ient ’s phy sical pr oblem s( 2).
W i t h i n t h e c o n c e p t i o n o f t h e FH P, i t i s
f u n d a m e n t a l t o u n d e r s t a n d h e a l t h a s s o c i a l
p r od u ct ion , as a con st r u ct iv e p r ocess a g r ou p can
conquer in it s daily r ealit y. Thus, pr ofessionals r efer
t o t he nur se’s capacit y t o deal w it h t he com m unit y ’s
social p r ob lem s as a com p et en ce n eed ed f or w or k ,
as show n by t he follow ing declar at ions.
Yo u n e e d t r a i n i n g t o b e a b l e t o d e a l w i t h t h e
com m unit y’s pr oblem s ... ( N- 8) .
A ver y lar ge social view ( N- 9) .
Being aw ar e t hat you ar e going t o w or k w it h social
problem s...( N- 13) .
The FHP r ecom m ends t hat t he pr ofessionals
get t o k n ow t h e f act or s ( social, polit ical, econ om ic,
env ir onm ent al, cult ur al and indiv idual) t hat int er fer e
w i t h t h e r e sp e ct i v e co m m u n i t y ’ s q u a l i t y o f l i f e ;
ar t iculat e w it h ot her social sect or s ( or ganized social
m ov em ent s) ; st im ulat e t he com m unit y ’s par t icipat ion
i n t h e p l an n i n g , ex ecu t i o n an d assessm en t o f t h e
Fam ily Healt h Unit ’s act ions and est ablish int egr at ed
act i o n s i n f av o r o f t h e p o p u l at i o n ’s q u al i t y o f l i f e
Th er ef o r e, t ea m p r o f essi o n a l s n eed t o b e
p r e p a r e d t o so l v e t h e co m m u n i t y ’ s m a i n h e a l t h
p r ob lem s, or g an izin g t h eir act iv it ies ar ou n d act ion
plan n in g ( h ealt h car e, pr om ot ion an d su r v eillan ce) ,
in t er disciplin ar y t eam w or k an d an in t egr al appr oach
of t he fam ily( 1). I t is highlight ed t hat act ion planning
r ef er s t o t h e capacit y t o diagn ose t h e local r ealit y,
elab or at e an d assess w or k p lan s t h at can p r od u ce
t he appr opr iat e im pact .
Team w or k is n eeded t o ach iev e t h e lar gest
possible im pact on t he differ ent fact or s int er fer ing in
t he healt h- disease pr ocess and t he int egr al appr oach
of t he fam ily. I t m eans appr oaching t he fam ily in it s
so ci o e co n o m i c a n d cu l t u r a l co n t e x t , i n h e a l t h o r
disease sit uat ions, based on t he v aluat ion of aspect s
relat ed t o t he fam ily’s dynam ics, funct ioning, funct ions,
dev elopm ent and t o it s social, cult ur al, dem ogr aphic
an d epidem iological ch ar act er ist ics( 2 ).
Ther efor e, fam ily healt h m ust be under st ood
in t h e con t ex t of t h e r elat ion sh ip s an d in t er act ion s
am on g it s h ealt h y an d sick m em ber s, dim en sion in g
t h e in f lu en ce t h e in d iv id u al’s h ealt h ex er t s on t h e
fam ily gr oup and v ice- v er sa( 4). Thus, for w or k t o be
called fam ily car e, t he pr ofessional needs k now ledge
abou t t h e ‘fam ily ’ u n iv er se, as car e deliv er y im plies
t he capacit y t o under st and and adequat ely at t end t o
ot h er people’s n eeds.
Ther efor e, for oper at ional and com m unicat ion
goals, t he pr ofessional or t eam t hat int ends t o w or k
needs his/ her/ it s ow n definit ion of fam ily as, in a way,
t his indicat es t he ext ent of t he look and int ent t o w or k
w it h t he fam ilies and can influence t he pr ofessional’s
b e h a v i o r, st r e n g t h e n i n g o r st i m u l a t i n g b e h a v i o r.
Mor eov er, t h e p r of ession al or t eam w or k s w it h t h e
w hole or w it h t he part s( 3).
I n t h e d e f i n i t i o n o f f a m i l y, t h e n u r s e s
consider ed t he t ypes, com ponent s and at t r ibut ions of
t he fam ily. As t o fam ily t y pes, t he em phasis on t he
social aspect st ood ou t , w h ich can be at t r ibu t ed t o
t he nurses’ w ork pract ice in t he FHP, w ho select ed t he
fam ily and t he hom e spher e as car e foci and, in t his
envir onm ent , t he pr ofessionals get t o know / r ecognize
t he realit y of t he fam ily’s life, w hich is alm ost alw ays
per m eat ed by t h e f igh t f or bet t er liv in g con dit ion s,
a l so a l l o w i n g f o r a b r o a d e r u n d e r st a n d i n g o f t h e
h ealt h - d isease p r ocess.
I n t h e p r e s e n t e d d e f i n i t i o n s o f f a m i l y,
psy chological, biological and legal aspect s w er e also
highlight ed( 18).
I t is the set of persons who live together in the sam e
place, under the sam e roof, with or without blood relationship. (N-19).
I t is each per son’s w or ld, t he r elat ionships, w hom he
consider s as fam ily. ( N- 16) .
Fam ily is fat her , m ot her and childr en. ( N- 3) .
Ther e ar e var ious t ypes ... fost er childr en. ( N- 9) .
Th e n u r ses ack n ow led g e a r an g e of f am ily
c o m p o s i t i o n s( 1 8 ), e m p h a s i z i n g a l t e r n a t i v e f a m i l y
ch ar act er ist ics.
I t doesn’t have t o be fat her, m ot her and children, it can
include br ot her s, colleagues... ( N- 17) .
Of t he ex t ended fam ily.
Fam ily is... father, m other, grandparents, relatives (N-6).
Of t he incom plet e fam ily.
...m ot her , childr en, aunt , it has changed a lot ( N- 17) .
And also of t he fam ily nucleus.
Fam ily is m ot her , fat her w ho t akes car e of t he childr en
( N- 10) .
Th e em ph asis on t h e alt er n at iv e fam ily can
b e r elat ed t o t h e ack n ow led g em en t of t h e m u lt ip le
char act er ist ics of t he fam ilies t he nur se r elat es w it h
in d aily w or k . I n a w ay, f am ily r elat ion sh ip s h av e
w eak en ed ov er t i m e an d , am i d st t u r b u l en ces, t h e
fam ily at t em pt s t o get r eor ganized, r eact ing t o and,
at t h e sam e t im e, adapt in g t o ex t er n al con dit ion in g
fact or s, fin din g n ew w ay s of st r u ct u r in g w h ich , in a
way, r econst it ut e it , w it hout a dom inant pat t er n( 19).
Finally, in defining t he fam ily, t he nurses also
r efer r ed t o it s at t r ibut ions, t he m ain of w hich is car e
for it s m em ber s.
I t is one helping t he ot her , it is par t ner ship, lov e,
affect ion, fr iendship, com panionship... ( N- 3) .
... m ot her , fat her w ho t akes car e of t he childr en, or
m ot her w ho has som e t im e, t eaches t he child ( N- 10) .
... it is t he base for ever yt hing, educat ion, suppor t ,
m ut ual help...( N- 15) .
Fam ily is w ho t akes car e, it ’s one per son t aking car e of
t he ot her... ( N- 11) .
The funct ion t he fam ily is at t r ibut ed can var y
ov er t im e an d d ep en d in g on t h e cu lt u r e. How ev er,
hist orically, it s funct ion has been t o achieve econom ic
survival, offer prot ect ion, t ransm it values and religion,
educat e t he childr en and y oung people( 18).
Fam ily car e is ch ar act er ized b y act ion s an d
int eract ions present in t he fam ily core and is direct ed
at each of it s m em ber s, w it h a v iew t o feeding and
st r engt hening t heir gr ow t h, dev elopm ent , healt h and
w ell- b ein g . I t can b e r ecog n ized t h r ou g h cou n t less
at t r ibut es, especially : pr esence, pr ot ect ion, inclusion,
or ient at ion and educat ion( 20).
I t should be highlight ed t hat half of t he nur ses
expr essed difficult ies t o define fam ily, r efer r ing t o t he
Now adays, it is ver y com plicat ed for you t o say w hat a
fam ily is, t her e ar e var ious t ypes of fam ily t oday, var ious fam ily
organizat ions... ( N- 9) .
Now adays, it is difficult t o say w hat fam ily is... (
N-12) .
This difficult y can part ially be j ust ified by t he
v er y m ean in gf u l f am ily ch an ges t h at h av e occu r r ed
in r ecen t y ear s, accor din g t o t h e specificit y of each
g r o u p o r s o c i a l c l a s s . An o t h e r d i f f i c u l t y c a n b e
at t r ibut ed t o FHP pract ice, w hich r uns int o t he absence
of a t heor et ical- pr act ical fr am ew or k t hat sust ains and
g u i d e s t h e i n t e r - r e l a t i o n a l ( t o t h e d e t r i m e n t o f
t echnical) act ions by each m em ber and t he t eam as
a w hole, in t heir int eract ion w it h t he fam ilies, respect ing
t heir dev elopm ent cy cles and t he differ ent m om ent s
and char act er ist ics of t heir liv ing ex per ience.
Th ese r esu lt s lead t o r ef lect ion s ab ou t t h e
nur ses’ need t o t ake int o account t his r ealit y of change
an d d iv er sit y in t h e f am ily, an d t o seek t h eor et ical
su ppor t bey on d t h e lim it s of t h e FHP, so t h at t h eir
w ork w it h fam ilies can be effect ive and achieve bet t er
r esu lt s.
The cat egor y know ing- how - t o- be r efer s t o t he
n u r se s’ b e h a v i o r a l ch a r a ct e r i st i cs, w h i ch ca n b e
under st ood as t he capacit y t o r elat e w it h ot her s and
w i t h o n esel f. Th e m o st em p h a si zed co m p et en ci es
acknow ledged as necessar y for w or k in t he FHP w er e
r elat ed w it h k n ow in g - h ow - t o- b e, w h ich cor r ob or at e
discussions about pr ofessional com pet ency in nur sing
and hav e pr iv ileged a br oader focus, ov er com ing t he
em inent ly t echnical view and valuing et hics and hum an
r elat ions( 2 1 ).
I n t h i s c a t e g o r y, t h e m o s t f r e q u e n t l y
m en t ion ed ch ar act er ist ic w as “ t o lik e w h at y ou do”.
The choice of t he profession presupposes affinit y w it h
or a cert ain apt it ude for t he area, w hile t he choice of
w or k in v olv es m u ch m or e, in clu des t h e n eed t o get
in t o t h e lab or m ar k et , t h e op p or t u n it ies f ou n d an d
t he need for per sonal and fam ily sust enance, w hich
oft en m ak es pr ofession als ch oose w or k t h ey do n ot
lik e t hat m uch.
N e v e r t h e l e s s , t h e n u r s e s s e e m t o h a v e
v isualized t hat t heir pr ofessional com pet ency cannot
b e s o l e l y a n d e x c l u s i v e l y a d a p t e d t o m a r k e t
i m p o si t i o n s, i n a co n t e x t o f co m p e t i t i v e n e ss a n d
p r od u ct iv it y, b u t sh ou ld g o b ey on d t h e em p loy er ’s
dem ands and aggr egat e per sonal v alues t hat pr ov ide
int er nal sat isfact ion( 21).
First, profile to work with fam ilies. I f he doesn’t like to get
into the house and get into a dirty place, see dirty people in a bad
m ood, weakened patients, see people be m istreated, if you don’t have
this profile, love for the profession... I n the first place love for the
profession, you like to be a nurse and you like fam ily health, it’s no
use, the nurse won’t m anage to cope with it, no (N-3).
Com m it m ent , involvem ent and et hical at t it ude
were ot her charact erist ics m ent ioned as com pet encies
needed t o work wit h fam ilies: Being very com m it t ed and
responsible for what you assum ed (N-14); I f I see their need I end
up getting involved with them and let him get involved with m e
(N-17); I t has to be very ethical, because we enter the house, m ainly the
nurse; there has to exist a bond, knowing how to listen, having the
right attitude and training...(N-8).
Th ese ch ar act er ist ics seem t o be con n ect ed
w it h t he w ay nur sing w or k is configur ed in t he FHP,
m ai n l y w i t h t h e r esp o n si b i l i t i es t h ey r ecei v e. Th e
nur ses’ involvem ent and com m it m ent w it h w or k have
t o occur cr it ically, cr eat ing spaces t o m odify and r enew
t heir act ions, so as t o effect iv ely guar ant ee t he r ight
t o h ealt h . Th ey can be iden t if ied on t h e basis of a
cr it ical at t it ude and const ant inquir ies about t he goal
of nur sing w or k ( w hy ar e t o w hom car e is deliver ed) ,
f o r w h a t ( i n w h a t w a y i n o r d e r t o co n t r i b u t e t o
m aint ain, m odify or t r ansfor m ) , w it h w hat ( r esour ces,
est ablished pow er s, w or k inst r um ent s) or, also, w hat
i d e o l o g y g u i d e s t h e m i n p r o f e ssi o n a l a n d so ci a l
r elat ions inside t he healt h pr oduct ion pr ocess( 15).
I t should be highlight ed t hat involvem ent and
r esponsibilit y do not only r efer t o t he w or k pr act ice
( pr ofessional conduct and per for m ed pr ocedur es) , but
m ainly t o t he people involved in professional pract ice.
Thus, in t he relat ion w it h people, an et hical post ure is
essent ial t o st ar t bonding and achiev e effect iv e car e
and int egralit y. Each professional, int ernally m ot ivat ed
b y h i s/ h e r e t h i ca l - p h i l o so p h i ca l p r i n ci p l e s, i s t h e
person w ho relat es w it h a t eam and w it h t he fam ilies,
in or der t o get t o know , plan and advise for t he sake
of pr ev en t ion .
CONCLUSI ON
The gr oup of nur ses in t his st udy, w ho w or ked
in t he FHP in Mar ingá, PR, consider s t hat w or k w it h
f am ilies is st r u ct u r ed on t h e basis of pr of ession als’
act ion s an d r elat ion s w it h t h ese f am ilies, w h ich ar e
u n der st ood on t h e basis of t h e social aspect , gr ou p
v ar iet y and fam ily car e. Alt hough t he act ions inv olv e
ev er y t h in g t h at is d on e in d aily p r act ice, t h e m ost
fr equent ly r ecognized char act er ist ics of t his w or k ar e
t h e a c h i e v e m e n t o f t h e f a m i l y d i a g n o s i s a n d
a ssi st a n ce , co n si d e r i n g t h e f o cu s, a ct i v i t i e s a n d
p r a c t i c e , t h e a c t i v i t i e s , w h i c h a r e a u x i l i a r y a n d
m anifest ed in t he first place t hrough pr event ive advice,
are st ill direct ed at individuals, especially people w it h
a healt h pr oblem ; w it h r espect t o t he car e st r uct ur e,
t h e gr ou p h igh ligh t s t h e n eed t o plan act iv it ies an d
t he fact t hat t hey ar e car r ied out by a m ult ipr ofessional
t eam .
The pr ofessionals also consider t hat t his j ob
r equ ir es est ablish in g an d m ain t ain in g r elat ion s w it h
t h e f am i l y an d t h at t h i s i s t h e b ase f o r t h e g o o d
developm ent of t he w or k, as facilit at ing access t o t he
f am ily an d it s accep t an ce of w h at t h e h ealt h t eam
proposes int erferes in t he qualit y of t he delivered care.
W i t h r e s p e c t t o t h e p r o f e s s i o n a l s ’
com pet en cies t o w or k w it h f am ilies, t h e im por t an ce
o f t ech n i ca l - sci en t i f i c k n o w l ed g e ( k n o w - h o w ) w a s
h i g h l i g h t e d , t r a n s l a t e d b y t h e r e c o g n i t i o n a n d
appr opr iat e appr oach of t he healt h pr oblem and t he
social asp ect s in v olv ed on t h e b asis of t eam w or k
and, m ainly, of know ing how t o r elat e ( know ing-
how-t o - b e) w i how-t h how-t h e f am i l i es an d w i how-t h how-t eam m em b er s,
d e m o n st r a t i n g co m m i t m e n t , i n v o l v e m e n t a n d a n
et hical at t it ude, aspect s t hat ar e achieved m or e easily
w hen people lik es w hat t hey do.
The nur ses’ em phasis on k now ing- how - t o- be
show s t hat t he FHP has been a favor able scenar io for
c r i t i c a l a n d r e f l e x i v e d i s c u s s i o n w i t h a v i e w t o
o v er co m i n g t h e t ech n i ci st , b i o m ed i cal h eal t h car e
m odel. How ever, t his requires cit ies t o be m ore daring
in per m anent educat ion of t hese pr ofessionals, so as
t o t r ain t hem for daily m anagem ent and also t o lead
t o new pr act ices and v alues.
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