The care of nurses in the Family Health Strategy: practices and theoretical foundation

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence

BACKGROUND

Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses.

OBJECTIVES

To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified.

SELECTION CRITERIA

We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification.

DATA COLLECTION AND ANALYSIS

For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population.

MAIN RESULTS

The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations.

AUTHORS' CONCLUSIONS

This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.

Nursing consultation in the Family Health Strategy and the nurse's perception: Grounded Theory

OBJECTIVES

to understand the experience of nurses with nursing consultations in the context of the Family Health Strategy and propose a representative model.

METHODS

qualitative research using Grounded Theory, with 14 nurses working through non-directive interviews. For data analysis, three stages were used: open, axial and selective coding, which originated phenomena, themes, categories and subcategories, which supported the construction of the central category and, consequently, the theoretical model.

RESULTS

the interrelation of phenomena emerged from the essence of the nurse's experience, revealing the central category: From nursing education to the practice of Nursing Consultation, unveiling learning, challenges and autonomy as intervening components. Final Considerations: the nurse's experience is positive and, despite numerous challenges in daily life, the nurse has been performing it based on comprehensive care. New studies may add new understandings that enable the expansion of working conditions, valuing the nursing consultation.

Nurse’s competences in promoting women’s health in light of the Galway Consensus

ABSTRACT Objectives: to identify nurses’ competences in promoting women’s health. Methods: descriptive study with a qualitative approach that adopted the Galway Consensus as a theoretical-methodological framework. Data collection was performed through semi-structured interviews. Results: most of the Galway Consensus’ competence domains were present in the nurses’ interventions related to health promotion in women’s care. “Assessment of needs” and “Implementation” were the most highlighted domains, followed by “Leadership” and “Impact assessment”. The domain “Defending/Advocating Rights” was not identified. Final Considerations: within the nurses’ work with women, some of the Galway Consensus domains of competencies for health promotion were present. However, there is a need, in the context of continuous health education, to expand strategies and enhance the development and application of these health promotion competences.

Challenges Faced by Nurses in the Provision of Health Care to Men in Primary Care, Brazil

Introduction:

The provision of primary care to men by nurses has been relevant, but there are challenges to be overcome.

Objective:

To analyze the challenges faced by Brazilian nurses in the provision of primary care to men.

Methods:

This was a qualitative descriptive study carried out by including 40 nurses working in the Family Health Strategy of a Basic Health Unit in Northeastern Brazil. Individual in-depth interviews were carried out and analyzed using the Discourse of the Collective Subject (CSD) method, supported by the Praxis Intervention Theory for Nursing in Collective Health – Tipesc.

Results:

The challenges faced by nurses in the provision of care to men originate in the academy and are transposed into professional practice, manifesting as limitations in the work process, lack of a specific health agenda, difficulties in raising male adherence, and professional demotivation.

Conclusion:

These challenges significantly affect the development and promotion of men’s health, resulting in the maintenance of the indicators of male morbidity and mortality in Brazil.

Suffering and defense mechanisms: an analysis of the work of Primary Health Care nurses

OBJECTIVE

To analyze the suffering and coping strategies of nurses working in Primary Health Care considering the psychodynamics of their work.

METHODS

Descriptive study with a qualitative approach, carried out with 11 nurses working in Primary Health Care. Data were collected through semi-structured interviews, systematized, and interpreted using Bardin's content analysis method applied to recurrent themes.

RESULTS

The suffering factors related to work in Primary Health Care are difficulties with management, the fragile structure of the health support network, and conflicts with the users. Defensive strategies to minimize these difficulties are the support of hierarchical superiors, the empowerment of the community and users, and communication between team members.

FINAL CONSIDERATIONS

It is important that there be changes in the organization of this line of work to improve the workers' health.

Situational analysis and reflections on the introduction of advanced practice nurses in Brazilian primary healthcare

BACKGROUND

The shortage of doctors and their unequal distribution serve as challenges to advancing primary healthcare (PHC) and achieving effective universal healthcare coverage in Brazil. In an effort to use nurses' potential more efficiently, the country is investigating the introduction of the advanced practice nurse (APN) into PHC. This paper presents a situational analysis of the practices of Brazilian nurses based on the following components: regulation, practice, and education.

METHODS

This is a national multi-method study with triangulated data from a documentary study, a scoping review, and an exploratory study. The regulation component involved the analysis of official normative documents on the regulation of nursing education and nurses' scope of practice. The practice component aimed to identify the practices performed by nurses in Brazilian PHC based on primary studies. The education component intended to identify the practices taught in nursing training based on a survey and interviews with directors of undergraduate nursing programs.

RESULTS

Federal legislation in Brazil authorizes nursing graduates to perform a set of advanced practices as part of the PHC nurse's daily routine. They can request and interpret complementary tests and prescribe medication. However, in the local context, municipalities define the scope of this assistance based on technical norms or nursing protocols. Furthermore, this study indicates that undergraduate nursing programs do not fully prepare students to adequately execute these tasks.

CONCLUSIONS

In the context of Brazilian PHC, advanced practices have already been implemented and respond to main healthcare demands. Therefore, it is unnecessary to introduce the APN as a new professional category. Upon detecting deficiencies in the training process, the current education model should undergo reforms that seek to incorporate the skills compatible with the regulated advanced practices and in-service training for practicing nurses. Regarding the introduction of APN along international lines, this article presents recommendations that may support the operationalization of a Brazilian APN model.

HEALTH-DISEASE-CARE PROCESS IN OLDER ADULTS LIVING IN RURAL AREAS: PERSPECTIVE OF CULTURALLY COHERENT CARE

ABSTRACT Objective: to understand the health-disease-care process of the older adult living in rural areas. Method: a qualitative research study from the perspective of Madeleine Leininger's Theory of Diversity and Universality of Cultural Care, carried out with the participation of 19 older adults living in the rural area of a municipality in southern Brazil. Data collection took place in July and August 2018 by means of semi-structured interviews and simple observation. And data analysis was performed following Laurence Bardin's Content Analysis proposal. Results: the conceptions of health and disease of the older adult living in rural areas are mainly related to the ability and inability to perform the activities of daily living and work, especially with the land and animals. We highlight the care practices of older adults living in rural areas with regard to the use of medications, food consumption and the practice of physical exercise. In addition, the notion about their health condition and the capacity for self-management and adaptation to the challenges of the health-disease-care process. Conclusion: the health-disease-care process of older adults living in rural areas is influenced by social and cultural factors of the context in which they are inserted. This suggests the planning, implementation, development, evaluation and (re)formulation of health policies, programs and actions focused on providing culturally congruent care, which encompasses more than the singularities of the rural area, in the sense of dichotomy in relation to the urban area.

Adaptive problems arising out of the progenitor's abandonment after Zika Congenital Syndrome

OBJECTIVE

to reveal the adaptive problems of the woman abandoned by the child's parent after Congenital Zika Syndrome, in the light of Roy's Adaptation Model.

METHOD

a qualitative, descriptive study, based on Roy's Adaptation Model, developed with six women abandoned by their child's parent after Zika Congenital Syndrome diagnosis, through interview and Content Analysis technique.

RESULTS

adaptive problems appeared in nutrition, activity, rest, and protection patterns, due to limitations in self-care; self-concept, related to dissatisfaction with body image and personal being; in the role of transition role, through difficulties in taking over new roles and in interdependence, related to changes in affective needs.

FINAL CONSIDERATIONS

the overload of care for children with Congenital Zika Syndrome, added to the challenges of the abandoned woman by her child's parent, led to adaptive problems, showing their main difficulties of coping.

Analysis of the correlation of socioeconomic, sanitary, and demographic factors with homicide deaths - Bahia, Brazil, 2013-2015

OBJECTIVE

To analyze the correlation of socioeconomic, sanitary, and demographic factors with homicides in Bahia, from 2013 to 2015.

METHODS

Ecological study, using data from the Information System on Mortality and from the Superintendence of Economic and Social Studies. The depending variable is the corrected homicide rate. Explanatory variables were categorized in four axes. Simple and multiple negative binomial regression models were used.

RESULTS

Positive associations were found between homicides and the Index of Economy and Finances (IEF), the Human Development Index, the Gini Index, population density, and legal intervention death rates (LIDR). The variables Index of Education Levels (IEL), rates of death with undetermined intentions (RDUI), and the proportion of ill-defined causes (IDC) presented a negative association with the homicide rates.

CONCLUSION

The specific features of the context of each community, in addition to broader socioeconomic municipal factors, directly interfere in life conditions and increase the risk of dying by homicide.