Research Article
Production of Interprofessional Care for the Person
with Oncological Disease: A Study on the Patient’s
Perspective
Rocío Andrea Cornejo Quintana1, Isabel Cristina dos Santos Souza2, Jéssica Miranda Pereira3,
Raphaella Alves Pires4, Raquel Stefanni Garcia Sales Lima5, Magno Conceição das Mercês6 and
Marcio Costa de Souza7*
Author Affiliations
1Psychologist, Specialist in Oncology, Brazil
2Social Worker, Specialist in Oncology, Brazil
3Pharmaceutical, Specialist in Oncology, Brazil
4Psychologist, Specialist in Oncology, Brazil
5Nutricionist, Specialist in Oncology, Brazil
6Assistant Professor, PhD in Heath Science,Brazil
7Assistant Professor, PhD in Human Medicine and Health, Brazil
Received: July 27, 2020 | Published: August 07, 2020
Corresponding author: Marcio Costa de Souza, Assistant Professor, PhD in Human Medicine and Health, Brazil
DOI: 10.26717/BJSTR.2020.29.004797
Introduction: This study aimed to analyze the perception of people with
Oncological diseases about interprofessional care, in a public hospital in Salvador de
Bahia - Brazil. It was adopted a phenomenological qualitative research approach, in
which a semi-structured interview, a field log and medical records were used. Also,
fourteen patients hospitalized participated in the study.
Development:
Through the Analysis of the interviews, there were identified
categories of meaning linked to human interaction, such as the team-patient relationship,
affective work, live care network and negative impacts of interprofessional care.
Conclusion:
It was observed the primary role that Oncology patients gave to human
contact with the team, so it is essential that the interprofessional team pay attention of
the subjectivity and feelings of the patient, at the moment of meeting and during the
assistance to them. Measures could be taken, considering humanized care.
Keywords: Interprofessional Care; Oncology ; Health; Cancer
The concept of Care refers to all actions and interventions that
aim to restore or generate autonomy, hope, freedom of choice,
human relations, and the meaning of life. The production of care
refers to the daily life, the place of events, manifestations, details,
and situations, related to the dimension of details that are part of
life [1]. Care is bound to an inexhaustible integrality, since it will
always be possible to add new aspects of the subject’s existence, and
it will only be possible to exist in front of an intersubjective flow, in
which people, instrumented with certain human knowledge and
qualities, get close to each other [2]. Considering that the subject
in need of care is a human being in its corporal and subjective
comprehensiveness, interprofessional teamwork becomes essential
in order to consider the completeness of the individual for care production in the hospital environment. In this way, nutritionists,
psychologists, nurses, social workers, doctors, pharmacists, and
other professionals, must act as a team to consider the subject as
a whole, so that he can have access to humanized actions which
contemplate all his needs [3].
Regarding Oncology Care, this type of care is linked to the
complexity and severity of this disease since the person with cancer
needs to be treated with highly specialized techniques. At this point,
the patient is at risk of having a significant emotional impact, mood
swings, psychic and physical suffering, and thoughts about the
finitude of life [4]. When dealing with hospitalization for neoplasms
in Brazil, in 2016, 767,954 hospitalizations were conferred and
in Bahia 46,958 [5]. The neoplasia proper and the complications
resulting from cancer treatment make hospitalizations frequent
and prolonged, causing the patient to suffer feelings of suffering and
forsakenness [6]. This course of illness causes cancer patient care
to have a connotation directed at the concept of integral healthcare,
within which the team and patient should be active participants [7].
Nevertheless, it can be perceived that there is a paucity of studies
that address the patient’s perception of interprofessional care. Due
to these issues, this research aimed to analyze the perception of
people with Oncological diseases about interprofessional care in a
large hospital in Salvador, Bahia, Brazil.
This study was developed through a qualitative exploratory
and phenomenological approach. The study participants were
patients with an oncologic disease, hospitalized for at least 5 days.
The number of participants was defined by the saturation criterion
of the answers, totaling 14 participants. The study setting was
an oncology center of the public health system (SUS) of a large
philanthropic hospital in the city of Salvador, Brazil. In addition to
the various specialties in the health field, this hospital also acts as a
High Complexity Oncology Unit (UNACON) in the state of Bahia. On
the production of data, we used a semi-structured interview, which
aims to capture the subjects’ point of view, leaving the researcher
and participants of the study free to discuss the proposed theme
[8]. As guideline for the interview, a semi-structured script was
developed and divided into four topics: Identification of the health
care team; Perception of the function of each professional mentioned
in the previous item; Perception of the interaction between health
professionals and the communication of the interprofessional team
with the patient and; Benefits/losses in the care relations between
the health team/patient.
During the interviews, a tape recorder (Motorola G3) was used
as a way of guaranteeing the trustworthiness of the testimonies,
with due secrecy, thus recording questions and answers. Also, a field
diary was used, which was elaborated by the researcher during the
course of the study, following the semi-structured interview script
guidelines. Finally, the documentary analysis became fundamental
as a tool to complement the production of data, in which the
medical records of the users were used. For the data collection, an
active search of the profile of the hospitalized patients was done
via medical records and afterwards the viability of the interview
was discussed with the health team. Concerning this, contact with
the hospitalized people was initiated, the research was presented
and they were invited to participate. The term of free and informed
consent was also presented, emphasizing the guarantee of
anonymity and free choice to leave the research at any time. After
the participants’ consent, the researcher read aloud each question
from the semi-structured interview and left a reading copy for the
patient. After the response was issued, the following question was
asked, in a comfortable place.
The data analysis method was the Institutional Analysis of
Lourau [9] which understands the field as something inherent
to the researcher, inseparable; therefore, there is an intersection
of implications for all who are involved in this search. Thus, it is
necessary to map the existential territories before the sights and
situations placed in the reality of the working world. In order to
systematize the data for their analysis, the following steps were
performed: the data was initially ordered by mapping all the
obtained information (transcription of the recordings, re-reading
of the material, organization of the recordings, the data of the field
diary, and the documentary sources). Therefore, the classification
of the data and the identification of analyzers was carried out and
the empirical categories – which were identified through exhaustive
reading – of the collected information were elaborated. Finally,
empirical data was coupled with the theoretical references of the
research and documents, thus promoting a relationship between
concrete and abstract, general, and singular, theory and practice.
In this research we had 14 participants. Of them, 8 were males
and 6 females; 8 stated to be married and 6 were single; 9 came
from Salvador and 5 from the countryside of the state of Bahia; 4
followed an oncological treatment with no possibility of cure and 3
palliative Care as main treatment. We identified several meanings
of interprofessional care production from the patients’ perspective
through the spontaneous speech of the participants. Within
these, the implications of the care relationships and the ways of
care and communication between patient-staff and vice versa
were highlighted, emphasizing the quality of these interactions,
which had a significant influence on the care processes with the
oncological patient.
Team-User Relationship
In this meaning, we highlighted the relevance that some
participants gave to the construction of a relationship between
the health team and the cancer patient, thinking of it as a health
promotion device. The relationship between team and user is
functional and healthy when the team is able to perceive the person with cancer as a unique individual, confirming their existence as a
human being [10]. By the statements of interviewees 6 and 7 it can
be noticed that they reported the presence of the relationship as
part of the production of care between the patient and the heath
team:
They talk with us, talk, pay attention, sometimes they play. Yes,
they play, and then we forget the problems that we are feeling, right?!
Then the pain that we are feeling are going away the psychologist,
always, she is always there, every day, right? Every day she has to
see me, she worries about me, and my doctor also.
welcomed by everyone, everyone treats me well no one has
ever treated me wrong neither when I call look, there is something
here wait, I come back in a moment, quickly they come back I got
it. I will talk, they come I will be back I go and come back here and
fix it right away without discretion. One is well treated and treat the
other well all the same.
The discourse of these interviewees showed a notion of
functionality on the team-patient relationship, in which both parts
were participants. That is, individuals with cancer disease were able
to express themselves as human beings with feelings and needs, and
in return, being listened to and welcomed by health professionals.
In the day-to-day life of the oncologic ward, it was noticed that
patients asked and talked more if they were more involved in their
own treatment when they were recognized as individuals by the
interprofessional team. A simple “Hello, good morning, how are
you?” on the part of the team, listening to the patient, made the
difference for the patient to feel more at ease and often even happy,
creating a relationship of trust with the professionals. A study
about those human interactions [11] indicated that cancer patients
revealed their desire to be recognized as individuals by the health
professionals, characterizing a relationship as functional when
the professionals made eye contact with them, sitting down and
remembering their names instead of just standing there by their
side. Other studies pointed out that the notion of oncology care
could be fulfilled when a relationship between the health team and
the patient exists. Therefore, the team needed to be open to the
possibility of relating to them, to be available in that relationship,
attentive and empathetic, identifying the desires and needs of those
being cared for [10-13].
On the other hand, two interviewees brought the notion of what
a non-functional relationship would be if it happened:
The loss would be mistrust, not being sure of what I am doing,
which way I am walking, where I’m going, right? What direction
am I taking? If there was no such interaction, I would not know
the direction I am taking in this treatment. According to that
interviewee, mistrust could reach him as a symptom of malaise in
the meeting with the interprofessional team, generating doubts
and uncertainties regarding his care. Through the experience with
some patients it can be noticed that the distrust tended to increase
when the health team didn’t include the patient as a participant in
the planning of their own treatment, not giving space to express
themselves, thus opening a breach for fantasies and unanswered
questions. According to Orlandi [14], when a being meets another,
they are predisposed to be in a subjective condition of alertness,
aiming to achieve in this meeting what they evaluate as beneficial
to their health. However, due to this expectation, it is to be expected
that they could experience well-being or malaise, symptoms of
trust and/or distrust, depending on each situation in their singular
feeling. Given the complexity of human subjectivity, it is up to the
interprofessional staff to be attentive to the feeling of trust or
distrust in the interaction with the person with cancer, aiming to
reduce the disturbances that may generate distrust in the quality
of care.
Affective Work
Affective work is one of the lines of care that belongs to the
integral assistance with the patient, regarding immaterial work.
That is, affective work produces immaterial health effects, such as
feelings, sensation of well-being, knowledge, among others [15].
In the intersubjective meeting with the patient, affective work has
the capacity of interaction through emerging affections, where the
health worker perceives himself and feels the other, building a fluid
care relationship produced through the meetings between health
workers and patients [16].
Well, because when the doctor arrives with small talk... when
the doctor arrives and treats well, he gives a little life or many years
of life to us, when he treats well, he gives years of life, many years
for us. When he treats poorly (non-verbal expression of cutting
with the hand*) he kills, kills us. And the ones here, they treat us
very well I do not say the person, I do not say the person, talking
to the doctor, they treat us well, know how to laugh, play, “how are
you? How are you?” With their heart full of love
ah, generally well. I do not worry. Attention to the patient, love
for the patient, respect for the patient, dedication to the patient.
So, the doctor, picking up the client and giving love, affection, spirit,
makes the patient feel loved. Some nurses have an excellent level
Those patients denoted the presence and importance of
affection in the health team’s work, as a tool that generated life
and love. When the worker is in body and soul in his relationship
with the other, aware of the influence of his affections in this
encounter, the profits could be perceived, because the patients
tend to manifest the benefits of the presence of affective work. In
the hospital routine of the researchers, more than once the scene
of some patient praising the affective work of a professional had
been witnessed, highlighting how feeling welcomed and loved
was a health generator to them. This not only contributed to the
mood of the patient, but to the production of care. Franco and
Merhy [17] indicated that one of the main potential questions of affective work was its capacity to produce life, an issue that is a part
of the main goal of any interprofessional health team, making the
presence of affective work coherent in their professional practices.
Still, the interviewees highlighted the immaterial results that
were being developed in the meeting with the team, pointing out
that that aspect was being worked properly, provoking in them a
sense of well-being. On the other hand, interviewee 1 brought the
destructive capacity that inadequate affective care can bring when
it is permeated by indifference. Thinking about this, the meaning of
care involving indifference was found in other interviews
There are nurses there are also people who destroy, but that is
very natural, people who are out of tune, there is no way. A person
out of tune is, that hurt, disheartened, closed heart person.
Oh, with me everything is fine. I keep quiet if they come in and
say something. Sometimes they pass sulky and I do not know why,
then I have to take it because they are angry? I am not, I am not
going to make such a move. Then the person arrives “everything
fine mister XX?”, I answer “everything”.
Those interviewees alluded to the absence of affective
work, where the professionals take care without perceiving the
subjectivity and needs of the patient, which can cause unwanted
effects in the care, such as communication noises, dysfunctional
feelings, breakdown in the patient-team bond and even the
sensation of “dying”. Thinking about this, those difficulties (not
looking at patients, not presenting themselves, treating them
inappropriately, emitting feelings that do not fit with a professional
health environment, such as anger or disgust) often could bring
immeasurable damages to those being cared of. Merhy and
collaborators [18] indicated that when the professional was
not really present in the meeting with the patient, acting in a
protocolized way, canceling the subjective difference of the person
in need of care, eventually the possibilities of dialogue between
patient-team might be reduced, decreasing the patient’s chance of
using the care that the team can offer.
Live Network
The concept of a living network came from the moment when
no one cannot longer think about health in a linear way, since
thinking about health production involves several actors and
systems, constantly influencing themselves in a complex network
of care [19]. Therewith, thinking about health is considering the
constant interaction between patient, family, team, infrastructure,
relationships, frictions, affections, supra- and subsystems.
The techniques. So that is fantastic, because you know to who
it is directed. “My name is so-and-so and I will be staying with
you, you and you” so then she is your bridge of support and the
connection to the rest. Let us say, if by chance... I know that it is
not the time to clean the bathroom, but the bathroom is vomited,
then you say, “ah but the bathroom is like that” and incredible as
it seems she goes, you understood? Oh, she goes there, she sorts
of... reverses the... depending on the case. Then she arrives with the
cleaning and exchange people, the mediation of the communication,
that is perfect
I say, “I’m at the square” and she says “Hi! There is medication”,
but she has no obligation, is not part of hers. If she does it by herself
because as a patient you know you have the rules to follow as well.
You know you have medication, you know you have to be on the
bed. Right? I know I can come and go, but not like I do, I spend all
afternoon sitting, and “do you have medication for me?” “not only
be at the end of the day” So it is up to me to be here and not to her to
call me, understand? So that is, I think it is an extra affection.
That we complain, but what is good, is to send the message
back, right? Then I sent for her and I talked to the nurse, to send to
the kitchen staff. I think it is. What the... that is useful, right? I do not
know, what I told you. I cannot tell if they are overworked or not, I
do not know, but uhh, I think it works.
That interviewee brought several aspects that coincided with
the construction of a living network of care, which seemed to be a
part of the processes of care for her. Those statements emphasized
the importance of effective individual-team and interprofessional
communication and interaction, resulting in positive effects on
her overall health. In addition, she placed herself as an active and
responsible element in the care for herself and others, because she
remained as an active participant in the procedures and still payed
attention to the subjectivity of the health professional, thus building
a relationship of mutual care. All those thoughts and actions were
parts of her construction of health reality, constituting a network
of care. During the routine of the studied ward, the live network
was seen in a shy manner, probably due to the different rules that
surrounded the hospital environment, which often cause both the
team and the patient not even able to think about the fluidity of
care activities. On the other hand, when the network was sighted,
care becomed dynamic, creative, uniting professionals and patients
pursuing health.
Thinking about the possibility of dynamism in health care, that
interviewee stated the ability of some professionals who had left
the conventional care protocols to promote health, an action that
she called “unexpected”. This activity is called by several authors
as living work [19,20], in which professionals have the opportunity
to develop a free-activity, in the sense of allowing the construction
of personalized health processes, unique to each professional,
creative, giving openness to the subjectivity and individuality of all
actors in the process.
Negative Impacts on Care
Regarding Bioethics applied to healthcare [21], negative attitudes to oncological care can be considered as those attitudes and
procedures that damage the principles of autonomy, beneficence,
non-maleficence, and justice. Although most of the interviewees
did not mention negative impacts in their care experience, some of
the subjects exposed the following experiences.
She came in here, did not say good night to anyone and the
second time also the same thing.
It bothered me because everyone was awake. No, why does she
enter here as if there were, that there was no one, as a dog, you
understand?
Then I called a person an hour later I did not want to keep
calling. Oh, “what does this woman want?” I got it, I asked. To be it
is, it is. Because she ran her hand, it was dirty with feces, then the
girl came and I said, “can you change it?’’ and it took her a while to
change me.
There was a doctor who told me I was not going to take chemo,
so that harmed me [...] that the drugs were going to be thrown away.
That it would be useless. For me it was a moment of sadness... that I
thought it would be no use fighting for anything else. Only God was
going to fight for me.
I was on one side, with feces, she asked me to get up and sit
down... it embarrassed me, I even got cry. It was such a disrespect,
so disrespectful of her. I went to the infirmary to report that I had a
hygiene problem and “look at this old man, he doesn’t get up to go
to the toilet”. I had to hire a person, because this was not possible,
every day to come to take care of me, accompany me, so as not to
feel bad. So, whoever, whatever class, must be respected.
The interviewees mentioned above were in extended
hospitalization for more than twenty days and their oncology
treatments were made jointly with the palliative care team.
Regarding this, respect for the patient is fundamental, since it is
not possible for the health team fully understand the subjective
experiences of the patients, it is noticed that the patient with an
oncological disease is going through a difficult time. Within the
characterization of oncological patients who need palliative care
[22], it is known that they require an intensification of technical
procedures that aim the relief of symptoms and care of bio-psychosocio-
spiritual aspects.
Thinking about the bias of the “Health Technologies”
mentioned by Franco and Merhy [17], the technologies that should
be strengthened in this context are the so-called “light-hard”
and “light” technologies. In “light-hard” technologies, the team
would focus on technical knowledge, effective communication
on the treatment, flow of procedures and decision making.
“Light” technologies, on the other hand, lay the emphasis on the
professional-individual relationship, considering the creation of
bonds of trust and affectivity, fundamental attributions for palliative
care workers [23]. Given what was said by the participants, it can
be seen that the care that was being provided was not related to
their needs, which was a failure in the exercise of bioethics and
in the execution of technologies, such as not identifying the need
of technical procedures, inadequate communication and lack of
perception of the subjectivity in the relationship with the patient.
The patients even mention feelings of “embarrassment”, “sadness”
and “disrespect” in the interaction with the health team members.
Those situations have a common point, in which subjective care
surrounds. This way of care stands out because it is a humanized
and integral act based on political action and ethics, passing through
technique, that produce new possibilities of feelings. However, in
the experience of those people, this format of care production is not
being offered in their daily lives. As a reflection regarding negative
impacts, participant 9 said when someone works with dedication,
well even with their problems, they work naturally, better, they
do it better, faster, more dedicated. When you do not bury your
problems, you tell others, it creates problems for them and for the
patient. We highlighted the perception of the interviewee on how
the subjectivity of the worker himself influences the way on how
he will care the patient. On this influence, Pfaff [24] indicated that
the empathy that the interprofessional team can offer in contact
with the person with an oncological disease starts to reduce when
they are exposed to psychic suffering. This can be alleviated from
the professionals’ ability to perceive themselves, exercise selfcontrol,
as well as hospitals’ actions that aim at the promotion of
the workers’ health in this context. By analyzing the interviewee’s
utterance, we interpreted it as an invitation to the self-reflection
of each health team member. A call to self-perception, aiming the
mental health of the worker himself as something to be taken care
of, for their sake and consequently the sake of the patient. Thus,
ideally, actions that offer health and well-being for all who are
involved in the process should always be constructed.
In view of the variety of meanings that can be attributed to
the process of interprofessional health care, this study found the
leading role that patients attribute to the human contact with the
team, the positive connotation to the moment when the professional
built a singular and creative care relationship with them, in which
both can expose their subjectivities through the smallest gestures
of everyday life, feelings and affections, thus conforming what we
can call care. However, it can be seen that the desired care was
not always provided, identifying discrepancies in the approaches
of the different members of the interprofessional team, observing
moments of depersonalization and disqualification of the subject.
Within health technologies, it is noticed how the light technologies
play a fundamental role in the integral and humanized care of
the person with an oncological condition, and in this research,
it stands out clearly. The moment of the health-worker/patient
meeting can produce life or discomfort, which will depend on how the meeting participants interact and affect each other. Therefore,
the interprofessional team has a duty to be alert to the subjectivity
and the processes of subjectivation of the patient, and more than
that, be aware that their contact with the individual is a generator
of subjectivity and health. In this perspective, the reflection on
strategies that can establish forms of care that meet the health
needs and the way in which the health and disease process is
thought, has provoked a (re)thinking of the operational protocols
and the educational actions within the Brazilian health units, in
order to equip the team regarding the meaning of the production
of subjective care linked to the technical treatment in Oncology.
However, perhaps the most basic changes that could be made to
achieve integral health should begin with a new look at the training
of the health workers and the construction of spaces of ongoing
education, in which the logic of the work process should be based
on micropolicies. This could strengthen attitudinal competencies in
caring for and operating with potency and quality in the daily life
of people who have an oncological disease. This study showed the
possibility to bring perspectives of the care production in Oncology.
However, the elaboration of studies aiming to reach the perception
of several focus groups that participate of this context, whether
health workers, support team members, family, among others, may
be of high relevance.
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