Esta investigação sobre o trabalho da enfermeira, na atenção básica em saúde, tem como questão central a especificidade desse trabalho e, como objeto de estudo, as competências gerais e específicas da enfermeira e sua contribuição para a construção do Sistema Único de Saúde (SUS) e para a constituição das Funções Essenciais de Saúde Pública (FESP), com os objetivos: 1) identificar e analisar as competências gerais e específicas requeridas da enfermeira para atuação na saúde pública, a partir do trabalho realizado na rede básica de saúde; 2) compreender como essas competências estão contribuindo para o desempenho das FESP, considerando-se a forma como estão sendo construídas no atual estágio de implementação do SUS. A determinação dos locais do estudo e da escolha dos sujeitos deu-se em função da utilização da Técnica Delphi como método de investigação. Foram selecionados dois grupos de participantes: um de 131 enfermeiras que atuam na rede básica do Município de Porto Alegre, e, outro, de 144 especialistas, enfermeiras que ocupam cargos na Secretaria de Saúde do Município de Porto Alegre e docentes de enfermagem em saúde publica/ comunitária/coletiva das escolas de enfermagem do estado do Rio Grande do Sul. O projeto foi aprovado pelo Comitê de Ética da Escola de Enfermagem de Ribeirão Preto/USP. Aceitaram participar da pesquisa, e assinaram o termo de consentimento informado, 52 enfermeiras e 57 especialistas. Para a coleta de dados utilizamos três questionários. O primeiro solicitou que as participantes indicassem três competências gerais e três especificas necessárias para o trabalho da enfermeira na atenção básica. Essas foram reunidas em uma listagem para cada grupo, que foi compilada, resultando em 84 competências, 44 gerais e 40 específicas no grupo das enfermeiras e 93 no grupo de especialistas, 49 gerais e 44 especificas. O segundo questionário foi composto dessas duas listagens adicionadas de uma escala de Likert, com valores de 1 (discordo muito) a 5 (concordo muito). Devido à estabilidade das respostas em torno do escore 5, foi adotado como critério de consenso, para a análise quantitativa, o percentual de 75% para os escores 4 ou 5, resultando em 17 competências gerais e 8 específicas no grupo de enfermeiras e 19 competências gerais e 9 específicas, no grupo das especialistas. Essas competências foram classificadas em áreas de domínio: valores profissionais; comunicação; trabalho em equipe; gerência; orientada a comunidade; promoção da saúde; resolução de problemas; atenção à saúde; educacional; em ciências básicas da saúde publica. Na análise qualitativa, foram discutidos os motivos pelos quais as competências são necessárias para o trabalho da enfermeira na atenção básica, frente ao percurso da enfermagem na implantação do SUS, aos preceitos da atenção primária, aos conteúdos da atenção básica, aos enunciados de competências existentes na literatura e a como estas competências estão contribuindo para o desempenho das FESP na realidade estudada. As competências específicas refletiram atividades tradicionalmente desempenhadas pela enfermeira, a sua posição na equipe de enfermagem, a especificidade da atenção prestada por essa profissional e a necessidade de seu desenvolvimento na profissão. / This study on nursing work in primary health care focuses on the specific nature of this work and investigates nurses’ general and specific competencies, as well as their contribution to the construction of the Single Health System (SUS) in Brazil and to the constitution of the Essential Public Health Functions (EPHF). The objectives were: 1) to identify and analyze general and specific competencies required for public health nursing practice, based on primary health care practice, and 2) to understand how these competencies are contributing to the performance of the EPHF, considering how they are being developed in the current implementation stage of the SUS. Places of study and subjects were determined according to the Delphi Technique, which was the method of study. Two groups of participants were selected: one with 131 nurses who work in the primary health care system of Porto Alegre, and another with 141 specialists, who were nurses working at the Porto Alegre Health Secretariat and public/community health faculty at nursing schools in the state of Rio Grande do Sul. The research project was approved by the Ribeirão Preto College of Nursing/USP Ethics Committee. Fifty-two nurses and fifty-seven specialists accepted to participate in the study and signed an informed consent term. Three questionnaires were developed for data collection. The first asked participants to indicate three general and three specific competencies nurses need to work in primary health care. These competencies were joined in a list for each group and then compiled into 84 competencies, 44 of which were general and 40 specific, for the nursing group and 93, 49 of which were general and 44 specific, for the specialist group. The second questionnaire was composed of these two lists with a Likert scale from 1 (completely disagree) to 5 (completely agree). In quantitative analysis, due to the stability of answers around score 5, 75% was adopted as a consensus criterion for scores 4 or 5, which resulted in 17 general and 8 specific competencies for the nursing group and 19 general and 9 specific competencies for the specialist group. These competencies were classified into action areas: professional values, communication, team work, management, community oriented, health promotion, problem solution, health care, educational, in basic public health sciences. In qualitative analysis, we discussed the reasons why these competencies are necessary for nursing work in primary health care, in view of the trajectory of nursing in the implantation of the SUS, the principles and concepts of primary health care, what literature says about competencies and how these competencies are contributing to the performance of EPHF in the reality that was studied. Specific competencies reflected traditional nursing activities, the specific nature of nursing care and the need for nurses’ development in the profession. / Esta investigación sobre el trabajo de la Enfermera en la atención básica de salud tiene como cuestión central la especificidad de este trabajo y como objeto de estudio las competencias generales e específicas de la enfermera y su contribución a la construcción del Sistema Único de Salud (SUS) y a la constitución de las Funciones Esenciales de Salud Pública (FESP). Los objetivos fueron: 1) identificar y analizar las competencias generales e específicas requeridas de la enfermera para actuación en la salud pública, a partir del trabajo realizado en la red básica de salud, y 2) comprender como estas competencias están contribuyendo al desempeño de las FESP, considerando la forma como están siendo construidas en el SUS. Para la determinación de los locales de estudio y la elección de los sujetos se utilizó la Técnica Delphi como método de investigación. Fueron seleccionados dos grupos de participantes: uno de 131 enfermeras que actúan en la red básica del Municipio de Porto Alegre, y otro de 144 especialistas, enfermeras que ocupan cargos en la Secretaría de Salud del Municipio de Porto Alegre y docentes de enfermería en salud publica/comunitaria/colectiva de las escuelas de enfermería del estado de Rio Grande do Sul. El proyecto fue aprobado por el Comité de Ética de la Escuela de Enfermería de Ribeirão Preto/USP. 52 enfermeras y 57 especialistas aceptaron participar de la investigación y firmaron el término de consentimiento informado. La recopilación de datos fue realizada por medio de tres cuestionarios. En el primer se solicitó que las participantes indicaran tres competencias generales y tres específicas necesarias para el trabajo de la enfermera en la atención básica. Estas fueran reunidas en una lista para cada grupo, que fue compilada, resultando en 84 competencias, 44 generales y 40 específicas, en el grupo de enfermeras y 93, 49 generales y 44 específicas, en el grupo de especialistas. El segundo fue compuesto de estas dos relaciones, además de una escala Likert con valores de 1 (muy en desacuerdo) a 5 (muy de acuerdo). Debido a la estabilidad de las respuestas en torno del escore 5, fue adoptado como criterio de consenso para el análisis cuantitativa el porcentual de 75% para los escores 4 o 5, resultando en 17 competencias generales y 8 específicas en el grupo de enfermeras y 19 competencias generales y 9 específicas en el grupo de especialistas. Estas competencias fueran clasificadas en áreas de dominio: valores profesionales, comunicación, trabajo en equipo, gerencia, orientada a la comunidad, promoción de la salud, resolución de problemas, atención a la salud, educacional, en ciencias básicas de la salud pública. En el análisis cualitativo, fueron discutidos los motivos por los cuales las competencias son necesarias para el trabajo de la enfermera en la atención básica, ante el trayecto de la enfermería en la implantación del SUS, los preceptos de la atención primaria, los contenidos de la atención básica, los enunciados de competencias existentes en la literatura y como estas están contribuyendo al desempeño de las FESP en la realidad estudiada. Las competencias específicas reflejaran actividades tradicionalmente desarrolladas por la enfermera, su posición en el equipo de enfermería, la especificidad de la atención prestada por esa profesional y la necesidad de su desarrollo en la profesión.

Introducción: La Atención Primaria de Salud (APS) es la asistencia sanitaria esencial accesible a todos los individuos y comunidades. Uno de los desafíos de la APS renovada es el fortalecimiento de competencias de los equipos de APS. Las competencias son los conocimientos, habilidades y actitudes, que se manifiestan cuando se ejecuta una tarea y están relacionadas con el desempeño exitoso de esta. Uno de los grupos vulnerables afectado por la falta de competencias adecuadas para abordar sus problemas de salud es la población indígena. Por ello, es fundamental conocer las competencias que estas comunidades consideran importantes, de manera que se pueda capacitar al personal sanitario en base a estos hallazgos. Objetivo: Sintetizar la evidencia reportada en la literatura sobre las competencias del personal sanitario en APS renovada, desde el punto de vista de la población indígena y del personal sanitario. Métodos: Revisión sistemática cualitativa de la literatura publicada durante el periodo 2005 – actualidad. Se realizó la búsqueda electrónica en bases de datos y se identificaron 24 estudios que evaluaban las percepciones del personal de salud y la población indígena sobre las competencias del personal sanitario para trabajar con comunidades indígenas. Se extrajeron y sintetizaron los datos utilizando la síntesis temática como metodología de síntesis cualitativa. La confianza de los hallazgos se evaluó utilizando el enfoque GRADE – CERQual. Resultados: Se analizaron 24 estudios, de los cuales 23 procedían de países de ingresos altos y 1 de ingresos medios. Se identificaron las competencias del personal sanitario clasificándolas en conocimientos, habilidades y actitudes. Entre los hallazgos relacionados a los conocimientos se evidenciaron temas como la formación cultural insuficiente y la estigmatización por parte del personal de salud. En cuanto a las habilidades se mencionó la barrera del idioma, la adaptación del lenguaje, la atención orientada a las características individuales, el tiempo de consulta, la aceptación de creencias y la inclusión de la fuerza laboral aborigen. Las actitudes más valoradas fueron la amabilidad, el respeto, la presencia de un ambiente de apoyo y el interés en aprender sobre la cultura aborigen. Conclusiones: Las competencias son elementos fundamentales de los Equipos de Atención primaria de la salud, sobre todo en el abordaje de los problemas de salud de las comunidades aborígenes, puesto que permiten una mayor aceptación por parte de estas. Esta revisión muestra extractos de estudios primarios sobre aquellas competencias que ayudan al proveedor de salud a lograr un mayor entendimiento acerca de las necesidades de la población indígena. / Introduction: Primary Health Care (PHC) is essential healthcare accessible to all individuals and communities. One of the challenges of the renewed PHC is the strengthening of competencies of PHC teams. Competencies are the knowledge, skills, and attitudes that are manifested when a task is performed and are related to its successful performance. One of the vulnerable groups affected by the lack of adequate skills to address their health problems is the indigenous population. Therefore, it is essential to know the competencies that these communities consider important so that health personnel can be trained based on these findings. Objective: To synthesize the evidence reported in the literature on the competencies of health personnel in renewed PHC, from the point of view of the indigenous population and health personnel. Methods: Qualitative systematic review of the literature published during the period 2005 - present. An electronic search was carried out in databases and 24 studies were identified that evaluated the perceptions of health personnel and the indigenous population about the competencies of health personnel to work with indigenous communities. Data were extracted and synthesized using thematic synthesis as a qualitative synthesis methodology. The confidence of the findings was assessed using the GRADE - CERQual approach. Results: 24 studies were analyzed, of which 23 were from high-income countries and 1 from middle-income countries. The competencies of health personnel were identified by classifying them in knowledge, skills and attitudes. Among the findings related to knowledge, issues such as insufficient cultural training and stigmatization by health personnel were evidenced. Regarding skills, the language barrier, language adaptation, attention oriented to individual characteristics, consultation time, acceptance of beliefs and inclusion of the Aboriginal workforce were mentioned. The most valued attitudes were kindness, respect, the presence of a supportive environment and an interest in learning about Aboriginal culture. Conclusions: Competencies are fundamental elements of Primary Health Care Teams, especially in addressing the health problems of aboriginal communities, since they allow greater acceptance by them. This review shows excerpts from primary studies on those competencies that help the health provider to achieve a greater understanding about the needs of the indigenous population. / Tesis

Hintergrund / Ziel der Studie: Im Bereich der Tabakentwöhnung existieren mittlerweile zahlreiche erprobte therapeutische Maßnahmen und Medikamente. Dennoch ist die Inanspruchnahme vorhandener Entwöhnungsangebote sehr dürftig. Es besteht die begründete Hoffnung, dass durch eine stärkere Einbeziehung der Hausärzte in den Bereich der Tabakentwöhnung eine Versorgungslücke geschlossen werden könnte. Die Studie soll Durchführbarkeit und Erfolg einer solchen Ausweitung des Anbieterkreises von Tabakentwöhnungsmaßnahmen im Hausarztbereich untersuchen. Unterschiedliche bereits vorhandene Therapieansätze werden hierbei hinsichtlich Effektivität und Effizienz in der allgemeinärztlichen Routineversorgung miteinander verglichen. Methoden: In Phase I der Studie werden bundesweit Patienten in mehr als 800 Arztpraxen an einem Stichtag per Fragebogen zu ihrer Gesundheit und ihrem Rauchverhalten befragt. In Phase II werden die in Phase I identifizierten entwöhnungswilligen Raucher in ausgewählten Arztpraxen für die Intervention rekrutiert und randomisiert vier Gruppen mit (idealerweise) jeweils 250 Personen zugeteilt: einer Bupropion SR (Zyban®)-Gruppe, einer Nikotinersatzmittel-Gruppe, einer Verhaltenstherapie-Gruppe und einer Kontrollgruppe. Die Behandlung erfolgt jeweils durch die Ärzte in ihren Praxen unter Supervision und mit Unterstützung durch Studienmonitore. Erwartete Ergebnisse: In Abhängigkeit von Merkmalen des Arztes und seiner Praxis auf der einen Seite sowie Merkmalen der betroffenen Patienten auf der anderen, sollte die Akzeptanz, Durchführbarkeit und Wirksamkeit der ausgewählten Therapieansätze unterschiedlich ausfallen. Insgesamt sollte jedoch jede Therapiebedingung gegenüber der Kontrollbedingung hinsichtlich ihrer Effektivität überlegen sein. Im 6-Monats Follow-up sollte die Zyban-Gruppe gegenüber allen anderen Gruppen die höchste Abstinenzquote aufweisen. Schlussfolgerung: Die Ergebnisse sollten Hinweise auf Möglichkeiten einer bedarfsgerechten, optimierten Allokation vorhandener Maßnahmen zur Tabakentwöhnung in der allgemeinärztlichen Versorgung liefern. / Background / aim of the study: Although a number of efficacious smoking cessation measures and medications do exist, only a small number of smokers (tobacco users) make use of them. A stronger engagement of general practitioners (GPs) in the field of smoking cessation might help to improve health care in this important area. The study will investigate feasibility and effectiveness of different readily available smoking cessation measures under routine conditions in primary health care practices. Method: In phase I of the study patients' health status and tobacco consumption are assessed by means of questionnaires provided on a nationwide appointed date in more than 800 general practices in Germany. In phase II selected practices offer smoking cessation treatments to identified smokers. Participants recruited will be randomly assigned to four groups ideally consisting of 250 subjects each: A bupropion SR (Zyban©) condition, a nicotine replacement therapy (NRT) group, a cognitive-behavioural treatment (CBT) group and a control condition. Treatments will be conducted by GPs in their practices under supervision of study monitors offering therapeutical and organisational support. Expected results: Acceptance, feasibility, and effectiveness of smoking cessation treatments offered will differ depending on GP and patient characteristics. Overall, success-rates (while success is primarily defined as abstinence from tobacco use) should be higher in all therapeutic conditions as compared to controls. In the 6-month follow-up abstinence rates are expected to be highest in the bupropion SR group. Conclusion: Results should yield indications for an improved allocation of available smoking cessation measures in primary care.

Bakgrunn og hensikt: For mennesker som blir akutt/kritisk syk blir livet oftest endret på kort tid fra å værevelfungerende i hverdagen til innleggelse i intensivavdeling hvor selveste livet kan stå på spill. Tradisjonelt settblir intensivpasienter tatt vare på gjennom medisinsk kunnskap og et naturvitenskapelig kunnskapsparadigme. Åvære akutt/kritisk syk innebærer å få spesielle opplevelser og erfaringer som går ut over hverdagserfaringene, oghvordan disse erfaringene trer fram i situasjonen. Denne kunnskapen pasientene bærer i seg er ikke bareindividuell og privat kunnskap, den representerer også en form for viten som trenger å forskes fram og løftes inni det offentlige rom både folkehelsevitenskapelig og sykepleievitenskaplig, nettopp fordi den omhandler viktigeforutsetninger for at pasientene skal bli sett og møtt også eksistensielt. Denne kunnskapen representerer en annenontologi og epistemologi enn den naturvitenskapelige kunnskapen og representerer derfor et annetkunnskapsperspektiv, også når det gjelder kunnskapsformidlingen i en klinisk veiledningssammenheng. Avhandlingens overordnede mål er å øke forståelsen av det å være alvorlig syk og hvordan kunnskap ut fraerfaringer har betydning i kunnskapsformidling i en intensivkontekst. Data og metoder: Avhandlingen har en kvalitativ tilnærming. I delstudie I ble det gjort en review avartikler for å se på stress relatert til kropp, rom og relasjon. I delstudie II ble det gjennomført intervju medtidligere intensivpasienter om opplevelsen av kropp, kraft og bevegelse under kritisk sykdom. I delstudie III bletidligere intensivpasienter intervjuet angående deres opplevelse av kroppsnærværet til pårørende under kritisksykdom. I delstudie IV ble det gjort observasjoner med påfølgende intervjuer av intensivsykepleiere om deresformidling av erfart og fortolket kunnskap i en klinisk veiledningssituasjon. I alle fire delstudiene benyttes detfenomenologisk-hermeneutiske analyser. Funn: I delstudie I kommer det fram at pasientene opplever stress knyttet til kropp, rom og relasjon.Kroppen påvirkes gjennom søvnavbrudd, smerter, angst og pasientene mister kontrollen over kropp og situasjon.Stress knyttet til rom framkommer gjennom at rommet blir et speil av situasjonen ved at den både representererlivet, men også redselen for døden. Gjennom det horisontale leie opplever pasientene at situasjonen utgjør enform for makt og de selv settes i avmakt. Relasjonelt stress framkommer oftest knyttet til sammenhenger hvordet utføres observasjoner, stell og behandling. Travelhet og organisering i avdelingen påvirker det relasjonellesamværet i form av stress. I delstudie II opplever intensivpasientene at kropp kraft og bevegelse trer fram bådegjennom ”tapet” av kroppen, hvordan de handterer situasjonen og hvordan de gjenerobrer kropp, kraft ogbevegelse. De opplever kraftløshet og bevegelsesbergrensninger. Dette innvirker på avhengigheten til andre ogskaper konflikter til pårørende. Pasientene handterer det kroppslige tapet gjennom mobilisering av familiengjennom å involvere dem. Samtidig blir de selvbeskyttende og utestenger familiesammenhengene. Kampen forlivet håndterer de gjennom galgenhumoren og skriket om hjelp som siste nødrop. Gjenerobringen av kroppen erknyttet til små framskritt, gjennom personalets motivasjon og gjennom drømmen om å utrette noe i livet. Idelstudie III opplever pasientene konflikt mellom nærheten og distanse til pårørende. De kjenner seg utestengt,samtidig som de bekreftes med gaver. Pasientene opplever det konfliktfylt når de sammenligner pårørendesreaksjoner og egen situasjon. De er redd at fellesskapet med pårørende skal opphøre, samtidig må de begrensesamværet. Å ikke kunne kommunisere med pårørende i kroppsnærværet oppleves motsetningsfullt. I delstudieIV formidler sykepleierne kunnskap til intensivstudentene gjennom meningsskapende kunnskapsbevegelser. Deformidler inntrykk fra situasjonen for å skape oversikt, de formidler kunnskap om fenomenene som framtrer ogde formidler hvordan de kan hjelpe kroppens egne prosesser. De vurderer og formidler også pasienteneskroppslige uttrykk og hvordan disse kan forstås og imøtekommes. Sykepleierne er også opptatt å formidlekunnskap for at studentene skal utvikle og få egne erfaringer i kroppen. Konklusjon: Gjennom fire delstudier løfter avhandlingen fram kunnskap som står i klar kontrast til dennaturvitenskapelige kunnskapen. Pasientene utsettes for store opplevelsesmessige belastninger i situasjonen somakutt/kritisk syke som setter de i en avmaktssituasjon ved at sykepleierne ikke fanger opp og handterer kroppensegen kunnskap i situasjonen. Pasientene befinner seg ofte i en eksistensiell situasjon som er preget avmarginalitet og eksistensiell væren. Pasientene viser at de har forutsetninger for å mestre situasjonen, menhjelpes lite til slik mestring. Intensivsykepleierne formidler ulikt faglig innhold til studentene for å skapeerfaringer og forståelse i situasjonen. Erfaringskunnskapen fra intensivkonteksten må derfor sees som et viktigkunnskapssupplement til folkehelsearbeidet. / Background and purpose: Acute/critically ill patients have had their life-conditions severely altered from awell-functioning everyday situation to a situation in which they struggle to survive. Traditionally the knowledgeparadigmfrom natural sciences together with medical expertise constitutes the framework for treatment. To beacute/critically ill involves experiences and events and phenomena typical to the situation. The patients’embodied knowledge is not limited to the personal and private sphere, it refers to highly relevant preconditionsfor visibility and reception, also on an existential level; it represents knowledge which needs to be researchedand discussed openly within the public health and nursing sciences. This knowledge represents a differentontology and epistemology from the natural sciences and thus a different perspective, also with regards toclinical tutoring. The dissertation’s primary target is to increase the knowledge about how critical illness isexperienced and how experience based knowledge is significant to teaching in an intensive care context. Data and methods: The dissertation is based on qualitative methods. Sub-study I includes reviews ofarticles on stress in a perspective of body, space and relationship. Sub-study II contains interviews with formerICU patients relating to their experience of body, strength and movement during critical illness. Sub-study III isbased on former ICU patients’ experience of the physical presence of their significant others during criticalillness. Sub-study IV contains observations and interviews of ICU nurses on how they teach experience basedand interpretation based knowledge in clinical tutoring. Phenomenological-hermeneutic analysis method isapplied to all four sub-studies. Findings: Sub-study I describes how patients experience stress in a perspective of body, space andrelation. The body is influenced by sleep deprivation, pain and anxiety. Patients experience loss of control withtheir bodies as well as with the situation. The room mirrors the situation patients are in, creating stress by itsrepresentation of life as well as fear of dying. The patient’s horizontal position reflects disproportionate powerinducing a sense of disempowerment. Relational stress situations usually appear in contexts involvingobservation, care or treatment. The organizational structure and activity on the ward affects stress levels. In substudyII the ICU patients experience how power and movement is affected by a sense of loss of body, how theymanage to respond to the situation and how they eventually reclaim the body, power and movement. Theyexperience disempowerment and limitations to movement. This causes dependency and creates conflicts withtheir significant others, especially with regards to proximity and distance. The patients address their loss of bodyby drawing on resources from their significant others, yet refrain from allowing themselves involvement infamily matters. The struggle for survival is characterised by gallows humour and the cry for help as their finalcry. Reclaiming the body happens stepwise with the aid of staff combined with a need to achieve. Sub-study IIIdescribes problems related to proximity to, and distance from, the significant others. A sense of exclusion iscontradicted by being showered with gifts. It is unsettling for patients to have their situation compared to theirsignificant others’. They fear the loss of community with loved ones, yet they need to limit visits fromsignificant others. The lack of ability to communicate when others are physically present is unsettling. Sub-studyIV describes how ICU nurses tutor students in practise by demonstrating knowledge in meaningful actions. Theyconvey their impressions of situations to provide an overview, convey knowledge of observable phenomena, andteach skills to assist the body’s own processes. They also assess and evaluate physical expressions in the patientand how these can be read and addressed. Nurses are also concerned with conveying embodied knowledge totheir students. Conclusion: In four sub-studies this dissertation highlights a form of knowledge which clearly contraststhat of the natural sciences. During acute critical illness patients experience severe stress and disempowermentcaused by a lack of response and action from nurses who are unable to interpret the body’s own knowledge inthe situation. Patients are often facing life and death questions characterised by marginality and existentiality.Patients demonstrate ability to cope with the situation, but are rarely assisted with coping. Intensive care nursesdisseminate a variety of professional skills and knowledge to their students in order to provide comprehensionand understanding of situations. Experience based knowledge from an intensive care context thus becomes asignificant supplementary factor in the public health perspective

La constatazione che in ambito sanitario il prodotto finale dei processi terapeutico-assistenziali, ovvero il miglioramento delle condizioni di salute dei cittadini, non possa essere definito soltanto in termini puramente economici e in un contesto in cui gli aspetti monetari costituiscono il perno intorno al quale si muovono tutte le strategie politiche, sociali ed economiche nazionali ed europee, costituisce il primum movens di questo progetto di ricerca. L’Azienda Sanitaria rappresenta, infatti, un locus in cui si embricano e sovrappongono le esigenze di numerose categorie di stakeholders (politici, fornitori, utenti e lavoratori) che, pur calati in un ambiente che possiede caratteristiche aziendali indissociabili da valutazioni finanziarie, non possono considerarsi esaurite nelle sole dimensioni economico-monetarie. Il valore finale dei processi di output di un’Azienda Sanitaria, sinteticamente riassumibile nel concetto di “soddisfacimento dei bisogni di salute della popolazione” riconosce, fra le componenti intrinseche del processo produttivo, cogenti sollecitazioni di carattere etico che presuppongono il rispetto di garanzie di equità, legittimità e imparzialità, irrinunciabili nella costruzione del prodotto finale. Questo lavoro di ricerca concentra, quindi, la propria attenzione sul processo di creazione di valore nell’Azienda Sanitaria, a partire dalle suggestioni bibliografiche inerenti le principali variabili economiche e organizzative, per giungere a indagare le corrispondenze derivanti dalle componenti intangibili. / The finding that the final product in the health-care therapeutic process, namely the improvement of citizens' health, can not only be defined in purely economic terms and in a context where the monetary aspects are the pivot around which move all the political strategies, social and economic national and European, it is the primary cause of this research project. The Health Service is, in fact, a locus where they overlap the needs of various categories of stakeholders (politicians, suppliers, users and workers) who, although dropped in an environment that has business features inseparable from financial ratings, were not exhausted only in the economic and monetary dimensions. The final value of the output processes of a company Health, succinctly summed up in the concept of "meeting the health needs of the population" recognizes, among the intrinsic components of the production process, mandatory stress ethical which require compliance with guarantees of fairness , legitimacy and impartiality, essential in the construction of the final product. This research focuses, therefore, its attention on the process of value creation in the Company Health, from bibliographical suggestions regarding the main economic and organizational variables, to come to investigate the matches resulting from intangible assets.

Introdução: A transformação dos perfis demográficos, epidemiológicos e as possibilidades da assistência têm feito dos Cuidados Paliativos um eixo importante para a reorganização dos serviços e sistemas de saúde, a fim de promover tanto quanto possível e até o fim da vida o bem estar e a qualidade de vida das pessoas. Os Cuidados Paliativos são ações ativas e integrais a pacientes com doença progressiva e irreversível. Esta pauta ainda é negligenciada na agenda de saúde em boa parte dos países, sendo preciso pesquisas que contribuam para a melhor gestão da clínica e serviços frente a estas novas demandas. Considerando tal cenário e a capilaridade da atenção domiciliária na Atenção Básica, com a Estratégia Saúde da Família, pergunta-se: haveria entre os pacientes acamados, atendidos pela Saúde da Família, usuários que requerem Cuidados Paliativos? Com o propósito de iniciar a resposta para esta questão, apontando as dimensões da demanda por Cuidados Paliativos e sua relação com a Atenção Primária à Saúde no Sistema Único de Saúde, desenvolveu-se a presente pesquisa que identificou pacientes elegíveis para Cuidados Paliativos entre os atendidos pelo Programa de Dispensação de Insumos para Incontinência Urinária/Fecal da Secretaria Municipal de Saúde do Município de São Paulo. Objetivos: Identificar e caracterizar os usuários elegíveis para Cuidados Paliativos, dentre os atendidos pelo Programa de Dispensação de Insumos para Incontinência Urinária/Fecal em uma Supervisão Técnica de Saúde de São Paulo e discutir a incorporação dos Cuidados Paliativos na Atenção Primária à Saúde. Método: Pesquisa exploratória, descritiva, documental. Realizada nas Unidades de Saúde com Estratégia Saúde da Família, na região de Parelheiros do município de São Paulo, SP, Brasil. Com base na relação dos usuários cadastrados no Programa Dispensação de Insumos para Incontinência, mês base abril de 2012, selecionaram-se os registros que foram revisados para a coleta de dados clínicos, sociais e demográficos. Destes registros, foram selecionados os prontuários nas Unidades e a Escala de Performance de Karnofsky foi aplicada, identificando a indicação para cuidados paliativos destes pacientes. Resultados: Dentre os 180 registros cadastrados no Programa de Dispensação, concentrados nas Unidades localizadas nas áreas de maior urbanização, foi possível acesso a 160 registros. Predominaram os quadros crônico-degenerativos (46,26%), incluindo: AVC; doença de Alzheimer; doença de Parkinson; e Demências. A idade dos pacientes variou de 4 a 98 anos, com predomínio dos homens entre os jovens e das mulheres depois dos 60 anos. Aplicou-se a Escala de Performance de Karnofsky em 141 prontuários. A maioria dos casos (98,28%) alcançou pontuação abaixo de 70%, sendo elegíveis para Cuidados Paliativos, com incapacidade ou pelo menos necessidade frequente de ajuda, assistência médica e cuidados especiais. Conclusões: A Estratégia Saúde da Família confronta-se com as demandas de usuários que necessitam de Cuidados Paliativos. A inclusão dos Cuidados Paliativos na Atenção Primária à Saúde implica a organização de redes de cuidados continuados em que as equipes de Saúde da Família executariam ações segundo a resolubilidade prevista, nas Políticas de Saúde, para a Atenção Básica. / Introduction: The transformation of demographic, epidemiological profiles and possibilities of assistance have transformed Palliative Care as an important axis for the (re) organization of health systems and services in order to promote as much as possible welfare and quality until the end of life. Palliative care is active integral actions to patients with progressive and irreversible disease. This subject is still neglected in health agendas in most countries, requiring research that may contribute to better management of clinical services and confront these new demands. Given this scenario and the capillarity of homecare in Primary Health Care with Family Health Strategy, the question arises: is there between \'bedridden\' patients, attended by Family Health Strategy, those who require palliative care? In order to start up the answer to this question, indicating the dimensions of the demand for palliative care and its relationship with the Primary Health Care, this research was developed in order to identify patients eligible for palliative care among those attended by the Dispensing Supplies Program for Urinary/Fecal Incontinence of the Municipal Health Secretary of São Paulo. Objectives: To identify and characterize eligible users for Palliative Care, among those attended by Dispensing Supplies Program for Urinary/Fecal Incontinence in Technical Health Supervision in the city of São Paulo, and discuss the incorporation of Palliative Care in Primary Health Care. Method: Exploratory, descriptive and documental research, developed in Health Units with Family Health Strategy in Parelheiros region of the city of São Paulo, SP, Brazil. From the list of users registered in the Program Dispensing Supplies for Incontinence, month base April 2012, we selected the records and collected clinical, social and demographic data. Karnofsky Performance Status was applied, identifying the indication for palliative care of these patients. Results: Among the 180 records registered in the Dispensation Program, the majority from units located in areas of greater urbanization, we could access 160 records. In these cases prevailed chronic degenerative diseases (46.26%) including: stroke, Alzheimer\'s disease, Parkinson\'s disease and Dementia. The patients\' ages ranged from 4 to 98 years, with a predominance of men among youth and women after the age of 60. We applied the Karnofsky Performance Status was applied in 141 records. Most cases (98.28%) had performance below 70%, being eligible for Palliative Care, implying disabled or at least frequent help needing, medical assistance and care. Conclusions: The Family Health Strategy is faced with the demands of users who require palliative care. The inclusion of palliative care in primary care involves the organization of continuous care networks where teams of Family Health Strategy would perform actions according to the solvability provided in Health Policy for Primary Health Care.

Introdução: A transformação dos perfis demográficos, epidemiológicos e as possibilidades da assistência têm feito dos Cuidados Paliativos um eixo importante para a reorganização dos serviços e sistemas de saúde, a fim de promover tanto quanto possível e até o fim da vida o bem estar e a qualidade de vida das pessoas. Os Cuidados Paliativos são ações ativas e integrais a pacientes com doença progressiva e irreversível. Esta pauta ainda é negligenciada na agenda de saúde em boa parte dos países, sendo preciso pesquisas que contribuam para a melhor gestão da clínica e serviços frente a estas novas demandas. Considerando tal cenário e a capilaridade da atenção domiciliária na Atenção Básica, com a Estratégia Saúde da Família, pergunta-se: haveria entre os pacientes acamados, atendidos pela Saúde da Família, usuários que requerem Cuidados Paliativos? Com o propósito de iniciar a resposta para esta questão, apontando as dimensões da demanda por Cuidados Paliativos e sua relação com a Atenção Primária à Saúde no Sistema Único de Saúde, desenvolveu-se a presente pesquisa que identificou pacientes elegíveis para Cuidados Paliativos entre os atendidos pelo Programa de Dispensação de Insumos para Incontinência Urinária/Fecal da Secretaria Municipal de Saúde do Município de São Paulo. Objetivos: Identificar e caracterizar os usuários elegíveis para Cuidados Paliativos, dentre os atendidos pelo Programa de Dispensação de Insumos para Incontinência Urinária/Fecal em uma Supervisão Técnica de Saúde de São Paulo e discutir a incorporação dos Cuidados Paliativos na Atenção Primária à Saúde. Método: Pesquisa exploratória, descritiva, documental. Realizada nas Unidades de Saúde com Estratégia Saúde da Família, na região de Parelheiros do município de São Paulo, SP, Brasil. Com base na relação dos usuários cadastrados no Programa Dispensação de Insumos para Incontinência, mês base abril de 2012, selecionaram-se os registros que foram revisados para a coleta de dados clínicos, sociais e demográficos. Destes registros, foram selecionados os prontuários nas Unidades e a Escala de Performance de Karnofsky foi aplicada, identificando a indicação para cuidados paliativos destes pacientes. Resultados: Dentre os 180 registros cadastrados no Programa de Dispensação, concentrados nas Unidades localizadas nas áreas de maior urbanização, foi possível acesso a 160 registros. Predominaram os quadros crônico-degenerativos (46,26%), incluindo: AVC; doença de Alzheimer; doença de Parkinson; e Demências. A idade dos pacientes variou de 4 a 98 anos, com predomínio dos homens entre os jovens e das mulheres depois dos 60 anos. Aplicou-se a Escala de Performance de Karnofsky em 141 prontuários. A maioria dos casos (98,28%) alcançou pontuação abaixo de 70%, sendo elegíveis para Cuidados Paliativos, com incapacidade ou pelo menos necessidade frequente de ajuda, assistência médica e cuidados especiais. Conclusões: A Estratégia Saúde da Família confronta-se com as demandas de usuários que necessitam de Cuidados Paliativos. A inclusão dos Cuidados Paliativos na Atenção Primária à Saúde implica a organização de redes de cuidados continuados em que as equipes de Saúde da Família executariam ações segundo a resolubilidade prevista, nas Políticas de Saúde, para a Atenção Básica. / Introduction: The transformation of demographic, epidemiological profiles and possibilities of assistance have transformed Palliative Care as an important axis for the (re) organization of health systems and services in order to promote as much as possible welfare and quality until the end of life. Palliative care is active integral actions to patients with progressive and irreversible disease. This subject is still neglected in health agendas in most countries, requiring research that may contribute to better management of clinical services and confront these new demands. Given this scenario and the capillarity of homecare in Primary Health Care with Family Health Strategy, the question arises: is there between \'bedridden\' patients, attended by Family Health Strategy, those who require palliative care? In order to start up the answer to this question, indicating the dimensions of the demand for palliative care and its relationship with the Primary Health Care, this research was developed in order to identify patients eligible for palliative care among those attended by the Dispensing Supplies Program for Urinary/Fecal Incontinence of the Municipal Health Secretary of São Paulo. Objectives: To identify and characterize eligible users for Palliative Care, among those attended by Dispensing Supplies Program for Urinary/Fecal Incontinence in Technical Health Supervision in the city of São Paulo, and discuss the incorporation of Palliative Care in Primary Health Care. Method: Exploratory, descriptive and documental research, developed in Health Units with Family Health Strategy in Parelheiros region of the city of São Paulo, SP, Brazil. From the list of users registered in the Program Dispensing Supplies for Incontinence, month base April 2012, we selected the records and collected clinical, social and demographic data. Karnofsky Performance Status was applied, identifying the indication for palliative care of these patients. Results: Among the 180 records registered in the Dispensation Program, the majority from units located in areas of greater urbanization, we could access 160 records. In these cases prevailed chronic degenerative diseases (46.26%) including: stroke, Alzheimer\'s disease, Parkinson\'s disease and Dementia. The patients\' ages ranged from 4 to 98 years, with a predominance of men among youth and women after the age of 60. We applied the Karnofsky Performance Status was applied in 141 records. Most cases (98.28%) had performance below 70%, being eligible for Palliative Care, implying disabled or at least frequent help needing, medical assistance and care. Conclusions: The Family Health Strategy is faced with the demands of users who require palliative care. The inclusion of palliative care in primary care involves the organization of continuous care networks where teams of Family Health Strategy would perform actions according to the solvability provided in Health Policy for Primary Health Care.

Thesis (PhD)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: Rationale: Critical questions have been raised about the overcrowding of primary care services, such as community health centres (CHCs) and clinics in predominantly Xhosa-occupied areas in the Western and Eastern Cape, with clients who present with minor health ailments. Suggestions have been made about the integration and the use of the indigenous health knowledge (IHK) carried by older Xhosa women in the services as a strategy for managing minor health ailments, and as a way of encouraging appropriate health-seeking behaviour. Preliminary studies have reinforced the need for the revival of the IHK that currently is lying dormant within communities. The studies affirm that such knowledge could be an asset if integrated into, and valued by, the Western biomedical model, and could play a major role in contributing towards alleviating the problem of overcrowding in primary care (PC) services. Aim: This study primarily explored and described the IHK carried by older Xhosa women and used in the management of health problems in their home situation. Secondary recommendations were made to key stakeholders regarding the use, retainment and integration of the IHK into PC services. Method: This ethnographic, feminist and emancipatory study used qualitative methods of data collection. Thirty-six (36) older Xhosa women were purposefully selected to participate in four FGDs, to explore the IHK that they used for managing health problems in their home situation. Sixteen (16) in-depth interviews were conducted with the elite older Xhosa women and their family members to validate the findings from the four FGDs. The process of analysis and interpretation was informed by an inductive process of a combination of narrative analysis and the analysis of narratives strategies. Findings: The findings showed that the older Xhosa women possess IHK regarding the management of minor health problems within the home situation. Assessment, treatment strategies and medications were identified. Functionality and observation are mainly used to diagnose and manage illness. This approach also includes monitoring the progress, severity and recovery from illness in the patient. The findings further demonstrated that older Xhosa women were also managing illnesses that could be classified as major. They could clearly distinguish between what was health and what was illness in their village. Distance from health care services had an impact on the health-seeking behaviour of the older Xhosa women, with those closer to health care services wanting all illnesses, even those that could be classified as minor health ailments, to be managed by the health service, and those who were farther away from the hospital appearing to manage complex illnesses, and only referring clients with those illnesses to external health care services quite late. The findings further showed communication and attitudinal problems that existed between the clients and health care providers. Conclusion: Many studies have already challenged the manner in which PHC was implemented in developing countries, as it appeared to focus on the curative approach to disease and left out disease prevention and health promotion. It is within this area that the older Xhosa women appear to express the greatest concern for the health of their homes and villages. The older Xhosa women in the Eastern Cape appear to be struggling with problems of broken family units, and are left behind to struggle to keep the home together, as they lack the necessary resources to do the hard work involved with producing food and building the home and village. In the light of the promise of National Health Insurance and the revitalisation of PHC, the study proposes that the two major national health policies should take cognisance of the IHK utilised by the older Xhosa women, and that there should be a clear plan as to how the knowledge can be supported within a health care systems approach. A rural health model is proposed by the study to do this. / AFRIKAANSE OPSOMMING: Rasionaal: Daar word kritiese vrae gestel oor die toeloop van mense met geringe ongesteldhede by primêre-sorg(PS)-dienste, soos gemeenskapgesondheidsentrums (GGS) en klinieke, hoofsaaklik in Xhosa-woongebiede in die Wes- en Oos-Kaap. Voorstelle is geopper dat ouer Xhosa-vroue se inheemse gesondheidskennis (IGK) by die dienste geïntegreer en benut moet word as ’n strategie om minder ernstige gesondheidsprobleme te bestuur en om mense aan te moedig om toepaslike keuses oor gesondheidshulp te maak. Voorlopige navorsing het die nodigheid bevestig dat die kundigheid wat tans onbenut in gemeenskappe lê, herontgin behoort te word. Die navorsing bevestig dat sulke kennis ’n bate kan wees indien dit as ’n gewaardeerde element by die Westerse biomediese model ingeskakel word en dat dit ’n groot rol kan speel om die druk op PS-sentrums te verlig. Doelstelling:Hierdie navorsing ondersoek en beskryf hoofsaaklik die IGK waaroor ouer Xhosa-vroue beskik en wat in die hantering van gesondheidsprobleme in hul tuisomgewing aangewend word. Aanvullende aanbevelings rakende die gebruik, behoud en integrasie van IGK by PS-dienste is aan bepalende belanghebbers voorgelê. Metode: Kwalitatiewe data-insamelingsmetodes is in hierdie etnografiese, feministiese en bevrydingsgerigte navorsing gebruik. Ses-en-dertig ouer Xhosa-vroue is spesifiek uitgesoek vir deelname aan vier fokusgroepbesprekings (FGB’s) om hul hantering van gesondheidsprobleme in hul tuisomgewing aan die hand van hul IGK te ondersoek. Sestien indringende onderhoude is met die elite- ouer Xhosa-vroue en hul gesinslede gevoer om die bevindings van die vier besprekings te bevestig. Die proses van ontleding en vertolking is gerig deur ’n induktiewe proses wat ’n kombinasie van narratiewe ontleding en die ontleding van narratiewe strategieë behels het. Bevindings: Die bevindings wys dat ouer Xhosa-vroue IGK het rakende die hantering van minder ernstige gesondheidsprobleme in die tuisomgewing. Evalueringsmetodes, behandelingstrategieë en medikasie is uitgewys. Kwale word hoofsaaklik volgens funksionaliteit en waarneming gediagnoseer en hanteer. Die werkwyse sluit in dat pasiënte se vordering, die erns van hul siekte en hul herstel gemoniteer word. Die bevindings wys verder dat ouer Xhosa-vroue ook siektetoestande hanteer wat as ernstig geklassifiseer kan word. Hulle kan duidelik tussen gesondheid en siekte in hul gemeenskap onderskei. Die afstand vanaf gesondheidsorgdienste speel ’n rol in die gedrag van ouer Xhosa-vroue wat keuses oor gesondheidshulp betref; diegene wat na aan ʼn gesondheidsorgsentrum woon, verkies dat die gesondheidsdienste alle siektes - selfs dié wat as minder ernstige gesondheidskwale geklassifiseer kan word - moet hanteer, terwyl diegene wat verder van ’n hospitaal woon, klaarblyklik self komplekse siektetoestande behandel en eers op ’n gevorderde stadium sulke kliënte na eksterne gesondheidsorgdienste verwys. Die bevindings het ook probleme rakende kommunikasie en houdingsingesteldheid tussen kliënte en gesondheidsdiensverskaffers uitgewys. Gevolgtrekking: Verskeie ondersoeke het al die manier waarop PG-sorg in ontwikkelende lande toegepas word, bevraagteken, aangesien die benadering oënskynlik op genesing fokus terwyl dit siektevoorkoming en gesondheidsvoorligting verontagsaam. Dis oor hierdie aspek dat die ouer Xhosa-vroue skynbaar die grootste kommer oor die welstand van hul huishoudings en gemeenskappe het. Die ouer Xhosa-vroue in die Oos-Kaap het klaarblyklik met dieselfde probleme van gebroke gesinne as dié in die Wes-Kaap te kampe, en word dikwels alleen agtergelaat om die huishouding te laat oorleef. Hulle kry swaar om sonder die nodige hulpbronne die harde werk te doen om voedsel te produseer en om huishoudings en die gemeenskap op te bou. In die lig van die vooruitsigte wat nasionale gesondheidsversekering en vernuwing van die PGS inhou, stel hierdie navorsingsprojek voor dat bogenoemde twee hoofelemente van die nasionale gesondheidsorgbeleid aandag skenk aan die IGK wat ouer Xhosa-vroue toepas, asook dat ’n duidelike plan uitgewerk word oor hoe hierdie kennis binne die benadering tot gesondheidsorg ondersteun kan word. Die navorsings stel ’n model vir plattelandse gesondheidsorg voor om dié doelstellings te verwesenlik.

In western countries such as Australia, the U.S. and the U.K., the women’s prison population has increased exponentially over the past decade, far outstripping the rate of growth in male imprisonment. The majority of women in prison are the mothers of dependent children. Subsequently, increasing numbers of children are being separated from their mothers; many displaced from home and effectively left parentless. Despite a growing body of knowledge since the 1960s, and growing numbers of children affected, little is known about these children, particularly older children and adolescents. This study examines the impact of maternal imprisonment on 20 young people, aged between 10 and 18 years, whose mothers were incarcerated in the two women’s prisons in Victoria (Australia). Data was gathered directly from young people themselves, as well as from their mothers and a small cohort of professionals, after the mother’s release from prison. To answer the research question, the study sought retrospective and predominantly qualitative data on children’s lives before, during and after their mother’s imprisonment. The data was analysed in a variety of ways, initially through the development of case studies and then across cases using thematic content analysis, drawing on themes emerging from the data and a priori categories gleaned from earlier research. The study shows that maternal incarceration has a significant impact on the lives of adolescents, and that it is uncommon for children to have secure care arrangements in place at the time of their mother’s imprisonment. For children to be displaced from home is also common, although most maintain some contact with their mother over the course of her imprisonment. While the majority of children return home to live with their mother, this is largely influenced by the child’s pre-prison placement and their visiting patterns during the imprisonment. Interestingly, although many young people are not satisfied with their care arrangements, particularly those who are cared for by their fathers, and cope with difficulties by internalising them, most do not report persistent adverse effects. The study provides new and challenging ideas. It describes the important role played by care planning in children’s reaction to maternal incarceration; this has not previously been examined. The findings also illustrate the poor coping mechanisms employed by children and discuss the range of social factors which affect this coping. Finally, factors influential in actual family reunifications are described and examined; very few studies, and none in Australia, have previously sought this data. The study provides a description of family reunification pathways, and highlights the importance of pre-prison placement and children’s visiting. The study findings stress that the impact of a mother’s imprisonment begins before sentencing and continues beyond her release. Yet research to date has focused predominantly on the period of a mother’s imprisonment. Overall, the study finds that limited formal or informal attention is given by adults involved to children’s needs. They are little seen or acknowledged at any point during their mother’s contact with the adult criminal justice process. From her arrest, through sentencing, imprisonment and planning for release, they are not considered to be participants in the proceedings.

Diss. (sammanfattning) Göteborg : Göteborgs universitet, 2007. / Härtill 4 uppsatser.