O objeto deste estudo foram as relações estabelecidas entre os trabalhadores e os usuários do serviço de saúde sob a perspectiva do trabalhador no contexto de uma unidade da Estratégia Saúde da Família situada na cidade de Franca, SP. Para isso foram utilizados os referenciais teóricos dos processos de trabalho em saúde, da micropolítica do processo de trabalho e da produção de subjetividade. Sabemos que o trabalho em saúde implica um espaço relacional, ou seja, para que exista esse trabalho, deve existir o outro, compreendido como alguém que possui necessidades de cuidado, e é no encontro com esse outro que há a produção de um ato de saúde. Diante dessa temática, a pesquisa teve por objetivo geral mapear e analisar as relações entre profissionais e usuários da Estratégia Saúde da Família na produção de atendimentos sob a ótica dos trabalhadores. Para responder aos objetivos do estudo, foram necessários procedimentos investigativos mais abertos e inventivos, um olhar vibrátil, sensível aos movimentos e que conseguisse captar as vibrações. Portanto, para atender a essa finalidade de estudar os processos de produção de subjetividade nas relações entre profissionais e usuários da ESF, a pesquisa fez uma aproximação ao método cartográfico, que diz respeito às estratégias das formações do desejo no campo social, aos seus movimentos e suas conexões que podem surgir de diversos lugares. O cartógrafo faz um mergulho nos afetos e sempre busca elementos para compor e complementar suas cartografias. Aqui o conhecimento é dado em processo, sendo inseparável do movimento da vida e dos afetos que a acompanham. Nesse mesmo movimento o estudo adotou a pesquisa- intervenção, que parte do princípio de que o processo de conhecer e fazer, pesquisar e intervir são inseparáveis. Aqui, as metas e os caminhos são traçados ao longo do processo a ser pesquisado, tendo como norte seu objeto e objetivo. Para a produção dos dados, foi importante estabelecer algumas ferramentas, dentre elas a observação participante, o uso do diário de bordo e a entrevista semiestruturada. Além dessas ferramentas, o estudo também contou com uma primeira fase, a exploração de campo, o que permitiu um rico diálogo com a realidade. Diante do cenário estudado, pude observar que o que mais se destaca nas relações é ainda a prevalência do modelo hegemônico de saúde, do cuidado centrado em técnicas procedimentais e protocolos em detrimento das tecnologias leves, relacionais, que possibilitam e ampliam um cuidado mais integral e de produção de vida. No estudo, também percebemos a existência de algumas instituições que estão presentes no momento do encontro trabalhador-usuário e que perpassam esse primeiro, dentre elas a instituição saúde, a enfermagem e a assistência social que, no caso, dão-se por uma faceta do controle, do seguimento de regras, e estão intensamente presentes nas relações estudadas. Por outro lado também pude captar alguns momentos em que os trabalhadores conseguiram realizar um cuidado mais ampliado, exercendo uma escuta empática e deixando para segundo plano as tecnologias duras e leve-duras, experimentando um pouco mais das tecnologias relacionais, de comunicação e escuta, colocando o usuário em evidência e tentando realizar um cuidado usuário-centrado e em suas reais necessidades. A perspectiva do estudo era a produção de vida e autonomia do usuário nos encontros. Algumas questões foram compreendidas e outras não devido à complexidade do tema ao se tratar das relações. A pesquisa também explorou apenas a perspectiva do trabalhador, ficando desconhecida a perspectiva do usuário, por isso a necessidade de novos estudos que caminhem por esse universo relacional por meio de um olhar vibrátil que consiga enxergar o que se passa entre as forças presentes nesses encontros / The object of this study were the relations between workers and users of the health service under the worker\'s perspective in the context of a Family Health Strategy (ESF) unit in the city of Franca, SP. For this, the theoretical references of the work process in health, the micropolitics of the work process and the subjectivity production were used. We know that the work in health involves a relational space, in other words, for this work, there must be another one, this one, understood as someone who has care needs, and it is in the encounter with this other one that there is the production of an act of health. On this thematic, the research aimed to map and to analyze the relationships between professionals and users of the ESF in the care production from the workers\' perspective. To respond the study objectives, more open and inventive investigative procedures were needed; one vibratable look, sensitive to movements that could pick up the vibrations. Therefore, to meet this purpose, of studying the subjectivity production processes in relations between professionals and users of the ESF, the research made an approach to the cartographic method, that regards to the strategies of desire formations in the social field, their movements and their connections that can arise from several places. The cartographer dives into the affections and always seeks elements to compose and complement its cartography. Here, the knowledge is given in the process, being inseparable from the movement of life and its affections. In this same movement, the study adopted the intervention research that assumes that the process of knowing and doing, and of researching and intervening, are inseparable. Thus, the goals and the paths are traced throughout the process to be searched, with its object and purpose as north. It was important to establish some tools for the data production, among them, the participative observation, the use of the on board diary and the semi-structured interview. In addition to these tools the study also included a first phase which was the field exploration, which allowed a rich dialogue with reality. Given the scenario studied, I could see that what stands out the most in relationships is still the prevalence of a hegemonic model of health care centered on technical and procedural protocols to the detriment of lightweight relational technologies, which enables and expands a more comprehensive care and of production of life. In the study we also realize that some institutions are present in the worker-user encounter, running through this first, among them, there are the institution health, nursing and social assistance that in the case emerge by a control facet of following rules and are intensely present in the studied relations. On the other hand, I could also capture moments in which workers managed to realize a broader care acting for an empathic listening and to leave in the background the hard and soft-hard technologies, experimenting relational technologies a little more, communication and listening, putting the user in evidence and trying to accomplish an user-centered care based in their real needs. The study perspective was the production of life and user autonomy in encounters. Some questions were understood and others not due to the issue\'s complexity when dealing with relations. The research also explored the worker\'s perspective only, being unknown the user\'s perspective, therefore, new studies are needed to walk this relational universe through a vibratable look that can see what goes on between the forces presents in those encounters

Wu Yan Fei. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2003. / Includes bibliographical references (leaves 161-189). / Abstracts in English and Chinese. / Chapter 1. --- BACKGROUND --- p.1 / Chapter 1.1 --- Hong Kong health care system --- p.1 / Chapter 1.2 --- Medication compliance and treatment responses --- p.2 / Chapter 1.3 --- Definition of compliance --- p.5 / Chapter 1.3.1 --- Compliance --- p.5 / Chapter 1.3.2 --- Adherence --- p.6 / Chapter 1.3.3 --- Concordance --- p.7 / Chapter 1.4 --- Definitions of satisfactory compliance --- p.9 / Chapter 1.5 --- Importance of compliance --- p.10 / Chapter 1.6 --- Non-compliance as a behavioral disease --- p.12 / Chapter 1.6.1 --- Disease manifestation (Patterns of non-compliance) --- p.12 / Chapter 1.6.2 --- Prevalence/Epidemiology (Rate of non-compliance) --- p.14 / Chapter 1.6.3 --- Diagnosis (Detecting non-compliance) --- p.15 / Chapter 1.6.3.1 --- Direct methods --- p.16 / Chapter 1.6.3.1.1 --- Use of biological fluids --- p.17 / Chapter 1.6.3.1.2 --- Biological surrogate (Drug) markers --- p.18 / Chapter 1.6.3.1.3 --- Pharmacological indicators --- p.20 / Chapter 1.6.3.2 --- Indirect methods --- p.22 / Chapter 1.6.3.2.1 --- Self-report / Direct questioning --- p.24 / Chapter 1.6.3.2.2 --- Pill counts --- p.25 / Chapter 1.6.3.2.3 --- Diaries --- p.27 / Chapter 1.6.3.2.4 --- Electronic monitoring --- p.27 / Chapter 1.6.3.2.5 --- Physician estimates --- p.31 / Chapter 1.6.3.2.6 --- Outcome measurement and clinical judgment --- p.32 / Chapter 1.6.3.2.7 --- Presence of side effects --- p.33 / Chapter 1.6.3.2.8 --- Keeping of appointments --- p.34 / Chapter 1.6.3.2.9 --- Prescription refill rates --- p.34 / Chapter 1.6.3.3 --- Direct observation --- p.35 / Chapter 1.6.3.4 --- The ideal detection method --- p.36 / Chapter 1.6.4 --- Risk factors (Related factors of non-compliance) --- p.37 / Chapter 1 .6.4.1 --- Patient related factors --- p.37 / Chapter 1.6.4.1.1 --- Understanding and comprehension --- p.37 / Chapter 1.6.4.1.2 --- Health beliefs --- p.39 / Chapter 1.6.4.1.3 --- Socio-demographic factors --- p.44 / Chapter 1.6.4.1.4 --- Forgetfulness --- p.45 / Chapter 1.6.4.2 --- Illness --- p.46 / Chapter 1.6.4.3 --- Therapeutic regimen --- p.46 / Chapter 1 .6.4.4 --- Patient-practitioner relationship --- p.48 / Chapter 1.6.5 --- Treatment (Interventions) --- p.50 / Chapter 1.6.5.1 --- Education --- p.51 / Chapter 1.6.5.2 --- Dosing regimen planning --- p.55 / Chapter 1.6.5.3 --- Clinic scheduling --- p.57 / Chapter 1.6.5.4 --- Communication --- p.57 / Chapter 1.6.6 --- Intelligent non-compliance --- p.60 / Chapter 1.6.7 --- Overview of problems with compliance studies --- p.63 / Chapter 1.6.7.1 --- Complex and not effective --- p.64 / Chapter 1.6.7.2 --- Lack theoretical framework --- p.64 / Chapter 1.6.7.3 --- Fragmented studies --- p.65 / Chapter 1.6.7.4 --- Lack high quality compliance study --- p.66 / Chapter 1.6.7.5 --- Without long term follow up --- p.67 / Chapter 1.6.7.6 --- Correlation between compliance and desired therapeutic outcomes --- p.68 / Chapter 2 --- HYPOTHESIS AND OBJECTIVES --- p.71 / Chapter 3 --- METHODS --- p.75 / Chapter 3.1 --- Study design --- p.76 / Chapter 3.2 --- Outcome measures --- p.80 / Chapter 3.3 --- Statistical analysis --- p.81 / Chapter 3.4 --- Power analysis --- p.82 / Chapter 4. --- RESULTS --- p.85 / Chapter 4.1 --- Patient demographics --- p.85 / Chapter 4.2 --- Clinic attended and drug usage --- p.85 / Chapter 4.3 --- Non-compliant rates and its patterns --- p.86 / Chapter 4.4 --- Reasons for non-compliance --- p.86 / Chapter 4.5 --- Relationship between drug class and medication compliance --- p.86 / Chapter 4.6 --- Relationship between dosage frequency and medication compliance --- p.87 / Chapter 4.7 --- Clinical characteristics of compliant and non-compliant patients --- p.87 / Chapter 4.8 --- Comparison of non-compliant patients identified at baseline during the second reassessment --- p.88 / Chapter 4.9 --- Effects of pharmacist's telephone intervention on tertiary outcomes --- p.88 / Chapter 4.9.1 --- Medication compliance --- p.88 / Chapter 4.9.2 --- Blood pressure --- p.89 / Chapter 4.10 --- Effects of pharmacist's telephone intervention on secondary outcomes --- p.90 / Chapter 4.11 --- Primary end-points of compliant versus non-compliant patients --- p.91 / Chapter 4.12 --- Best predictors of mortality rate for the studied population --- p.92 / Chapter 4.13 --- Effects of pharmacist's telephone intervention on primary outcomes --- p.92 / Chapter 4.14 --- Clinical characteristics of non-compliant patients with / without second follow up --- p.93 / Chapter 4.15 --- Clinical outcomes of defaulted patients at the second visit --- p.93 / Chapter 5. --- DISCUSSION --- p.126 / Chapter 5.1 --- Study design --- p.126 / Chapter 5.2 --- Compliance assessment method --- p.126 / Chapter 5.3 --- Patient demographics and drug prescribing pattern --- p.128 / Chapter 5.4 --- Extent and pattern of non-compliance --- p.128 / Chapter 5.5 --- Reasons for non-compliance --- p.129 / Chapter 5.5.1 --- Lack of knowledge --- p.129 / Chapter 5.5.1.1 --- Dosing instructions --- p.129 / Chapter 5.5.1.2 --- Drug identification --- p.130 / Chapter 5.5.1.3 --- Storage --- p.131 / Chapter 5.5.2 --- Forgetfulness --- p.131 / Chapter 5.5.3 --- Problems with health beliefs --- p.132 / Chapter 5.5.3.1 --- Common myths or misconceptions --- p.132 / Chapter 5.5.4 --- Presence of side effects --- p.133 / Chapter 5.6 --- Predictability of non-compliance --- p.134 / Chapter 5.6.1 --- Socio-demographics --- p.134 / Chapter 5.6.2 --- Polypharmacy --- p.135 / Chapter 5.6.3 --- Dosing frequency --- p.137 / Chapter 5.6.3.1 --- "Little difference between daily, twice daily and thrice daily dosing." --- p.137 / Chapter 5.6.3.2 --- Importance of drug property in determining the impact of usual dosages --- p.138 / Chapter 5.6.3.3 --- The impact of missed dosage on clinical condition --- p.139 / Chapter 5.6.3.4 --- Practical issues regarding dosing frequency --- p.140 / Chapter 5.6.4 --- Drug Profiles --- p.141 / Chapter 5.7 --- Outcomes measure --- p.142 / Chapter 5.8 --- The role of pharmacist in chronic care --- p.147 / Chapter 5.9 --- The role of physician in chronic care --- p.155 / Chapter 5.10 --- Possible sources of bias and limitations --- p.156 / Chapter 5.11 --- Further studies --- p.156 / Chapter 5.12 --- Concluding remarks --- p.159 / Chapter 6. --- REFERENCES --- p.161 / Chapter 7. --- APPENDICES --- p.190

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Objetivou-se validar um modelo de comunicaÃÃo nÃo-verbal para o atendimento de enfermagem à clientela cega, segundo o referencial teÃrico de E.T. Hall (1986). Trata-se de um estudo metodolÃgico, desenvolvido no LabCom_SaÃde do Departamento de Enfermagem da UFC, no perÃodo de outubro de 2007 a junho de 2008. Foram selecionados 15 cegos e 15 enfermeiros para comporem cada grupo, treinado e nÃo-treinado e ambos tiveram as mesmas caracterÃsticas. Os cegos foram contatados por meio da AssociaÃÃo dos Cegos do Estado do Cearà e os enfermeiros a partir dos Centros AcadÃmicos. A fase de coleta de dados do grupo nÃo-treinado deu-se durante o mÃs de abril de 2008, por meio de consultas. Estas ocorreram dentro do LabCom_SaÃde e os dados foram coletados por meio de filmagens. O primeiro passo para a construÃÃo do modelo foram os estudos realizados acerca da teoria de Hall (1986). Subdividiu-se a consulta de enfermagem em quatro etapas denominadas etapas do cuidado. Em cada etapa de cuidado sÃo orientadas as aÃÃes do enfermeiro, descreve-se a aÃÃo e como deve ser desenvolvida tal aÃÃo. A etapa do cuidado 1 refere-se à organizaÃÃo do ambiente para desenvolver a Consulta de Enfermagem. Na etapa do cuidado 2 o enfermeiro deve receber o paciente na entrada do consultÃrio para introduzi-lo no ambiente onde serà realizada a consulta e deve cumprimentÃ-lo e informar a localizaÃÃo dos mÃveis e objetos. Jà a etapa do cuidado 3 aborda o desenvolvimento da CEnf propriamente dita. A etapa do cuidado 4 constitui-se a Ãltima etapa do modelo de comunicaÃÃo nÃo-verbal e enfoca a finalizaÃÃo da consulta e o encerramento da comunicaÃÃo com o paciente. ApÃs ser construÃdo, o referido modelo foi submetido à validaÃÃo aparente e de conteÃdo. Foi analisado por trÃs especialistas em comunicaÃÃo nÃo-verbal, por ser um nÃmero jà adotado em pesquisas anteriores. As sugestÃes incluÃdas no modelo se referiram à abrangÃncia, forma de apresentaÃÃo e representatividade do conteÃdo. Em seguida, iniciou-se a segunda etapa de validaÃÃo, por meio da qual o modelo foi submetido à testagem. Os enfermeiros e concludentes foram treinados de acordo tanto com as tÃcnicas de comunicaÃÃo pertinentes à utilizaÃÃo da comunicaÃÃo nÃo-verbal quanto em relaÃÃo à utilizaÃÃo do modelo com cegos. Quanto à coleta dos dados, foi realizada mediante o uso de trÃs cÃmeras filmadoras que registraram toda a consulta de enfermagem entre a enfermeira, o cego e o acompanhante, quando este estivesse presente. Para a anÃlise dos dados das filmagens foram escolhidos outros trÃs juÃzes, enfermeiros e estudantes do Programa de PÃs-GraduaÃÃo em Enfermagem, do nÃvel mestrado e doutorado, da UFC. Eles foram treinados em relaÃÃo à utilizaÃÃo do instrumento de anÃlise da comunicaÃÃo nÃo-verbal do enfermeiro-cego (CONVENCE) e do instrumento de validaÃÃo do modelo. Pelo fato deste estudo ser duplo cego, os juÃzes nÃo eram informados acerca de qual grupo, controle ou experimental, eram realizadas as anÃlises. Os dados coletados foram inseridos em planilha eletrÃnica com a utilizaÃÃo do programa SPSS, versÃo 14.0, e analisados em freqÃÃncia absoluta por meio de tabelas univariadas. Para se analisar a associaÃÃo entre as variÃveis e os enfermeiros nos grupos controle e experimental, foram empregados os testes qui-quadrado (&#967;2) e o mÃximo de verossimilhanÃa. Cumpriram-se as normas que regulamentam pesquisas em seres humanos, conforme a ResoluÃÃo 196/96 do MinistÃrio da SaÃde. Ao se comparar as aÃÃes da etapa do cuidado 1 entre o grupo treinado e nÃo-treinado, observa-se que o grupo treinado obteve resultado excelente (p<0,0001) em quatro dos cinco itens avaliados. Somente o item âtemperaturaâ apresentou proporÃÃo aproximadamente igual na escala. Na Tabela 3, ao se comparar as aÃÃes da etapa do cuidado 2 entre os grupos, observa-se que o treinado obteve resultado excelente (p<0,05) em todos os itens avaliados. Portanto, houve associaÃÃo estatisticamente significante em todas as aÃÃes. Em relaÃÃo aos resultados obtidos pela Tabela 4, observam-se resultados excelentes (p<0,05) em oito dos nove itens avaliados do grupo treinado em relaÃÃo ao grupo nÃo-treinado na etapa do cuidado 3. Apenas o item referente a âseguir o roteiro da CEnfâ ficou prÃximo ao valor do teste, ressaltando que esta aÃÃo obteve forte indicador de associaÃÃo. Os dados da Tabela 5 mostraram tambÃm resultados excelentes (p<0,05) do grupo treinado em relaÃÃo ao grupo nÃo-treinado nas trÃs das quatro aÃÃes desenvolvidas na etapa do cuidado 4. Conforme se percebe na Tabela 6, todos os itens contribuem para a confiabilidade interna do Modelo de ComunicaÃÃo NÃo-Verbal Enfermeiro-Cego. Conclui-se com este trabalho a necessidade de implementaÃÃo prÃtica tanto por parte dos enfermeiros como dos estudantes de enfermagem deste Modelo de ComunicaÃÃo NÃo-Verbal com o paciente cego para tornar o cuidado efetivo e afetivo, especialmente com aqueles que necessitam compreender e serem compreendidos em sua vida cotidiana. Confirma-se a hipÃtese de que o Modelo de ComunicaÃÃo NÃo-Verbal Enfermeiro-Cego à eficaz na consulta de enfermagem a pacientes cegos. / The goal was to validate a non-verbal communication model for nursing care delivery to blind clients, based on the reference framework by E.T. Hall (1986). This methodological research was developed at the LabCom_SaÃde research lab of the Nursing Department at Cearà Federal University between October 2007 and June 2008. Fifteen blind people and 15 nurses were selected for each group, i.e. trained and non-trained, both with the same characteristics. The blind were contacted through the Cearà State Association of the Blind (ACEC) and the nurses through the Academic Centers (CAs). In the non-trained group, data were collected in April 2008 through consultations. These took place inside the LabCom_SaÃde and data were collected through movie recordings. The studies carried out about Hallâs theory (1986) represented the first step to construct the model. The nursing consultation was subdivided in four phases, which were called care phases. In each phase, orientations are given for the nurseâs actions and the action is described, as well as how this action should take place. Care phase 1 refers to the organization of the environment to develop the Nursing Consultation (CEnf). In care phase 2, the nurse should receive the patient at the entry of the consultation room to introduce him/her into the environment where the consultation will take place, greet the patient and inform where furniture and objects are located. Care phase 3 addresses the development of the CEnf itself. Care phase 4 constitutes the final phase of the non-verbal communication model and focuses on how to end the consultation and close off communication with the patient. After its construction, the Model was submitted to face and content validation. It was analyzed by three specialists in non-verbal communication specialists, a number already adopted in earlier studies. The suggestions included in the model referred to range, presentation form and content representativeness. Next, the second validation phase started, through which the model was tested. The nurses and blind people were trained in terms of the communication techniques that are important in the use of non-verbal communication as well as the use of the Model with blind people. Data were collected with the help of three film cameras that recorded the entire nursing consultation among the nurse, the blind and the companion, if present. To analyze the movie data, three other judges were chosen, who were nurses and students from the Graduate Nursing Program at Cearà Federal University, masterâs and doctoral level. They were trained on how to use to nurse-blind non-verbal communication analysis instrument (CONVENCE) and the model validation instrument. As this was a double-blind study, the judges were not informed about which group â control or experimental - they were analyzing. The collected data were inserted in an electronic worksheet, using SPSS software, version 14.0, and analyzed as absolute frequencies through univariate table. To analyze the association between the variables and the nurses in the control and experimental groups, the chi-square (&#967;2) test and the maximum likelihood estimation were used. Guidelines for research involving human beings were complied with, in accordance with Resolution 196/96 by the Brazilian Ministry of Health. The comparison between care phase 1 actions in the trained and non-trained group showed that the trained group obtained excellent results (p<0.0001) on four of the five items under analysis. The only exception was the âtemperatureâ item, with an approximately equal proportion on the scale. Table 3 shows that, when comparing care phase 2 actions between the groups, the trained group obtained an excellent result (p<0.05) on all items under evaluation. Hence, statistically significant associations were found for all actions. As to the results obtained in Table 4, excellent results are observed (p<0.05) on eight of the nine items assessed for the trained group in comparison with the non-trained group in care phase 3. Only the item related to âfollowing the CEnf scriptâ remained close to the test value, highlighting that this action obtained a strong association score. Data in Table 5 also showed excellent results (p<0.05) for the trained group in comparison with the non-trained group for three of the four actions developed in care phase 4. As observed in Table 6, all items contributed to the internal reliability of the Nurse-Blind Non-Verbal Communication Model. Through this research, it is concluded that nurses and even nursing students need to implement this Non-Verbal Communication Model with a view to effective and affective care, especially for patients who need to understand and be understood in their daily life. The hypothesis is confirmed that the Nurse-Blind Non-Verbal Communication Model is effective in nursing consultations with blind patients.

A atenção primária à saúde constitui hoje área prioritária nas políticas de saúde em diversas partes do mundo, constituindo, no Brasil, elemento estratégico para a organização dos sistemas de atenção. A complexidade e especificidade das demandas e características do cuidado em saúde na atenção primária exige, contudo, renovados esforços conceituais e práticos no sentido da construção de processos comunicacionais e interativos entre médicos e pacientes que caminhem para além da anamnese tradicional, pautada por uma racionalidade estritamente biomédica Objetivo: identificar e compreender fundamentos e contribuições de quatro influentes correntes teóricas que, a partir da década de 90, vêm problematizando as interações e a comunicação entre médicos e pacientes na atenção primária à saúde: Medicina Centrada no Paciente, Medicina Baseada em Narrativa, Abordagem Integral (Comprehensive Care) e Integralidade da Atenção à Saúde. Metodologia: Levantamento e estudo interpretativo, apoiado na filosofia hermenêutica de Hans-Georg Gadamer e Paul Ricoeur, de produção bibliográfica indexada nas bases MEDLINE e LILACS de 1990 a 1999. Resultados: A Medicina Centrada no Paciente orienta-se, fundamentalmente, para a identificação de domínios específicos que devem ser integrados à anamnese médica tradicional para ampliar seu escopo prático, utiliza metodologia de pesquisa quantitativa como modo predominante de fundamentação de suas proposições e propõe inúmeras metodologias ativas de ensino-aprendizado. A Medicina Baseada em Narrativa detém-se no como construir narrativas ao longo do diálogo entre médicos e pacientes, utiliza a metodologia qualitativa como principal recurso de pesquisa e fundamentação de suas proposições e desenvolve diversas estratégias de ensino-aprendizado com utilização de textos literários e narrativos. A Abordagem Integral (Comprehensive Care) utiliza como referencial teórico o modelo biopsicossocial de abordagem do processo saúde-doença e busca desenvolver propostas de assistência integral à saúde de grupos populacionais prioritários do ponto de vista médico-sanitário. A integralidade privilegia a transformação da organização dos serviços e dos processos de trabalho em saúde como primeira instância para a qualificação dos processos comunicacionais entre médicos e pacientes. Não foram identificados nas tradições da Abordagem Integral (Comprehensive Care) e da Integralidade a discussão de estratégias de ensino-aprendizado de abordagens comunicacionais, o que é bastante enfatizado nas outras duas. Conclusão: As quatro tradições estudadas apresentam inovações e pressupostos teórico-práticos que se complementam. Mostra-se imprescindível estabelecer uma fusão de horizontes entre tais proposições de forma a qualificar os diálogos e processos de comunicação-interação estabelecidos entre médicos e pacientes no nível da atenção primária à saúde / The primary health care is currently a priority area in health policies in different parts of the world, being a strategic element to the care systems organization in Brazil. Nevertheless, the complexity and the specificity of demands and characteristics of healthcare in primary health care require conceptual and practical renewed efforts with respect to the construction of interactive and communicational processes between doctors and patients that go beyond the traditional anamnesis, regulated by a rationality strictly biomedics. Objective: identify and understand fundaments and contributions of four theoretical perspectives of relevance which have been problematizing, since the 90s, the interactions and the communication between doctors and patients in primary health care: Patient-Centered Medicine, Narrative Based Medicine, Comprehensive Care and Integrality in Healthcare. Methodology: Survey and interpretive study based on Hans-Georg Gadamers and Paul Ricoeurs philosophical hermeneutics of indexed bibliography in MEDLINE and LILACS from 1990 to 1999. Results: Patient-Centered Medicine is fundamentally guided towards the identification of specific domains that must be integrated with traditional medical anamnesis in order to broaden its practical scope. It uses quantitative research methodology as a predominant way of laying the foundations of its propositions, recommending various active teaching-learning methodologies. The Narrative Based Medicine withholds on \"how\" to construct narratives throughout the dialogue between doctors and patients. It applies a qualitative methodology as the major resource of research and of fundamenting its propositions, besides developing various teaching-learning strategies using literary and narrative texts. The Comprehensive Care uses the biopsychosocial model of addressing the health-disease process as a theoretical approach and aims at developing proposals for Integrality in Healthcare for population groups who have priority in terms of medical health care. Comprehensiveness privileges the transformation of services organization and of work processes in health as the first instance to the quality of communication processes between doctors and patients. In the traditions of Comprehensive Care and of Integrality in Healthcare, the discussion of teaching-learning strategies of communication approaches, which is quite emphasized in the other two approaches, was not identified. Conclusion: The four theoretical perspectives studied present innovations and theoretical-practical propositions that complement themselves. It is imperative to establish a \"fusion of horizons\" between such propositions for qualifying the dialogue and the communication-interaction processes established between doctors and patients at the primary health care level

A atenção primária à saúde constitui hoje área prioritária nas políticas de saúde em diversas partes do mundo, constituindo, no Brasil, elemento estratégico para a organização dos sistemas de atenção. A complexidade e especificidade das demandas e características do cuidado em saúde na atenção primária exige, contudo, renovados esforços conceituais e práticos no sentido da construção de processos comunicacionais e interativos entre médicos e pacientes que caminhem para além da anamnese tradicional, pautada por uma racionalidade estritamente biomédica Objetivo: identificar e compreender fundamentos e contribuições de quatro influentes correntes teóricas que, a partir da década de 90, vêm problematizando as interações e a comunicação entre médicos e pacientes na atenção primária à saúde: Medicina Centrada no Paciente, Medicina Baseada em Narrativa, Abordagem Integral (Comprehensive Care) e Integralidade da Atenção à Saúde. Metodologia: Levantamento e estudo interpretativo, apoiado na filosofia hermenêutica de Hans-Georg Gadamer e Paul Ricoeur, de produção bibliográfica indexada nas bases MEDLINE e LILACS de 1990 a 1999. Resultados: A Medicina Centrada no Paciente orienta-se, fundamentalmente, para a identificação de domínios específicos que devem ser integrados à anamnese médica tradicional para ampliar seu escopo prático, utiliza metodologia de pesquisa quantitativa como modo predominante de fundamentação de suas proposições e propõe inúmeras metodologias ativas de ensino-aprendizado. A Medicina Baseada em Narrativa detém-se no como construir narrativas ao longo do diálogo entre médicos e pacientes, utiliza a metodologia qualitativa como principal recurso de pesquisa e fundamentação de suas proposições e desenvolve diversas estratégias de ensino-aprendizado com utilização de textos literários e narrativos. A Abordagem Integral (Comprehensive Care) utiliza como referencial teórico o modelo biopsicossocial de abordagem do processo saúde-doença e busca desenvolver propostas de assistência integral à saúde de grupos populacionais prioritários do ponto de vista médico-sanitário. A integralidade privilegia a transformação da organização dos serviços e dos processos de trabalho em saúde como primeira instância para a qualificação dos processos comunicacionais entre médicos e pacientes. Não foram identificados nas tradições da Abordagem Integral (Comprehensive Care) e da Integralidade a discussão de estratégias de ensino-aprendizado de abordagens comunicacionais, o que é bastante enfatizado nas outras duas. Conclusão: As quatro tradições estudadas apresentam inovações e pressupostos teórico-práticos que se complementam. Mostra-se imprescindível estabelecer uma fusão de horizontes entre tais proposições de forma a qualificar os diálogos e processos de comunicação-interação estabelecidos entre médicos e pacientes no nível da atenção primária à saúde / The primary health care is currently a priority area in health policies in different parts of the world, being a strategic element to the care systems organization in Brazil. Nevertheless, the complexity and the specificity of demands and characteristics of healthcare in primary health care require conceptual and practical renewed efforts with respect to the construction of interactive and communicational processes between doctors and patients that go beyond the traditional anamnesis, regulated by a rationality strictly biomedics. Objective: identify and understand fundaments and contributions of four theoretical perspectives of relevance which have been problematizing, since the 90s, the interactions and the communication between doctors and patients in primary health care: Patient-Centered Medicine, Narrative Based Medicine, Comprehensive Care and Integrality in Healthcare. Methodology: Survey and interpretive study based on Hans-Georg Gadamers and Paul Ricoeurs philosophical hermeneutics of indexed bibliography in MEDLINE and LILACS from 1990 to 1999. Results: Patient-Centered Medicine is fundamentally guided towards the identification of specific domains that must be integrated with traditional medical anamnesis in order to broaden its practical scope. It uses quantitative research methodology as a predominant way of laying the foundations of its propositions, recommending various active teaching-learning methodologies. The Narrative Based Medicine withholds on \"how\" to construct narratives throughout the dialogue between doctors and patients. It applies a qualitative methodology as the major resource of research and of fundamenting its propositions, besides developing various teaching-learning strategies using literary and narrative texts. The Comprehensive Care uses the biopsychosocial model of addressing the health-disease process as a theoretical approach and aims at developing proposals for Integrality in Healthcare for population groups who have priority in terms of medical health care. Comprehensiveness privileges the transformation of services organization and of work processes in health as the first instance to the quality of communication processes between doctors and patients. In the traditions of Comprehensive Care and of Integrality in Healthcare, the discussion of teaching-learning strategies of communication approaches, which is quite emphasized in the other two approaches, was not identified. Conclusion: The four theoretical perspectives studied present innovations and theoretical-practical propositions that complement themselves. It is imperative to establish a \"fusion of horizons\" between such propositions for qualifying the dialogue and the communication-interaction processes established between doctors and patients at the primary health care level

"September 2002" Includes bibliographical references (leaves 301-318)

"September 2002" / Includes bibliographical references (leaves 301-318) / viii, 318 leaves : ill. (col.) ; 30 cm. / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / Thesis (Ph.D.)--University of Adelaide, Dept. of Clinical Nursing, 2003

This phenomenological study describes the lived experience of pain inflicted in the context of medically prescribed treatment, explores the meanings of such pain for patients who endured it and for nurses whose actions contributed to its generation, and presents a thematic description of the phenomenon of clinically inflicted pain. The study is informed by phenomenology, both in terms of its premises and orientation, and its research design and method. The participants in the study were 14 adult patients, admitted to hospital following burn injuries, or receiving intravenous chemotherapy upon diagnosis of cancer, and 20 nurses involved in their care. Data collection took place over a period of five months and included participant observation and compilation of field notes, and a total of 89 tape-recorded interviews (48 with patients and 41 with nurses). Through the process of hermeneutic interpretation a number of themes were identified and used to describe the phenomenon of clinically inflicted pain and the structure of the lived experience of the patients and nurses concerned. The phenomenon of clinically inflicted pain is described in terms of four related themes: 1) the hurt and painfulness of inflicted pain; 2) handing one's body over to others; 3) the expectation and experience of being wounded, and 4) restraining the body and the voice. These themes point to the embodied nature of pain experience and the extent to which the person is involved not only in the enduring of pain but also in its generation. The broader lifeworld of clinically inflicted pain involves patients in the experience of constituting such pain, often as punishment and almost always as something unavoidable, and in turn being constituted by their experiences in terms of losing and seeking to regain a sense of embodied self and of personal situation, and by changed experiences of lived space and lived time. Nurses who themselves helped to generate pain, frequently overlooked the patient's lived exerience and thus the essential nature of inflicted pain as painful, wounding, and demanding cooperation and composure from the patient. Instead, the pain frequently became invisible to nurses involved in its infliction, or when it could not be overlooked or ignored, it was perceived as inevitable, non-harmful, and even as beneficial to patients' recovery. The strategic responses that nurses adopted to pain infliction included detachment from the perceived impact and consequences of their own actions and objectification of the person in pain as a body-object on whom certain tasks had to be performed. An alternative to the strategy of detachment and objectification was involvement in a therapeutic partnership between the nurse and the patient, where shared control over pain infliction and relief helped to sustain trust in the relationship and preserve personal integrity of the patient and the nurse. The study points to dangers for both patients and nurses when clinically inflicted pain is ignored, overlooked, or treated with detachment. It also points a way toward nursing practice that is guided by thoughtfulness and sensitivity to patients' lived experience, and awareness of freedom and responsibility inherent in nursing actions, including those involved in inflicting and relieving pain. The study raises questions about nurses' knowledge, attitudes, and actions in relation to clinically inflicted pain, and highlights the need for nursing education and practice to consider the contribution of a phenomenological perspective to the understanding of human experience of pain, and the nursing role in its generation, prevention, and relief.

One of the most critical elements in empowering the patient, and ensuring concordance, is communication of the possible benefits and harms of different actions in health care. Risk assessment is a complex task due both to the different interpretations of the concept of risk, and the common lack of hard facts. Hormone, or hormone replacement, therapy (HT) is used by many women in, and after, the menopause. The benefits and possible harms associated with short and long term treatment with HT have been extensively discussed the last decade and the use of HT has decreased dramatically internationally the last few years. The aims of this thesis were to study the interaction between patient and physician when discussing risks and benefits of different treatment alternatives, and to suggest strategies to improve risk communication in clinical practice. The studies have focused on how risks and benefits with HT were communicated between women and physicians during firsttime consultations in 1999- 2000 on this subject (20 women, 5 gynaecologists), and through questionnaires how attitudes towards HT have changed between 1999 (n=1,760) and 2003 (n=1,733) among women entering the menopause (53-54 years). Through a qualitative analysis of the risk communication in the consultations a system was constructed to classify how risk is communicated in relation to benefits. This was used to assess and present differences in risk communication in the consultations. Different rhetorical strategies by the physicians were identified and the dominating tendency was a move from the woman’s current problems to the long-term effects of HT. The questionnaires showed a marked difference in attitudes towards HT between the years. In 2003 women perceived HT to be associated with higher risk and less benefits than in 1999. This correlated to a drastic reduction in the use of HT over the same period. Media was the most frequent source of information about HT during the last twelve months before the questionnaire in 2003. Possible explanations for the different attitudes towards HT between women entering the menopause and gynaecologist; how this difference might have influenced the results; and how they may have implications for future communication strategies are discussed. This thesis illustrates the importance of a deeper understanding in health care of the concept of risk in order to achieve an adequate communication of risk. This is important both in consultations and in campaigns to educate and inform the public. / Reprinted figure 1 on page 32 with permission from Science Ref # 05-17260-Revised. Copyright 2006 AAAS.

Omvårdnadsrelationen och omvårdnadsmötet är omvårdnadens livsrum. Ett vårdmöte med tolk inblandad borde ses som en interaktion mellan tre eller möjligen fler personer. Detta arbete syftar till att beskriva sjuksköterskors erfarenheter av relationerna i sådana möten. Sjuksköterskor med erfarenhet av tolkanvändning ombads att besvara en enkät innehållande kvantitativa och kvalitativa frågor. Utöver detta gjordes två semistrukturerade intervjuer. Svaren analyserades med öppen innehållsanalys. Tre huvudkategorier hittades: trygghet, tolkteknik och kulturella aspekter. Sju underkategorier hittades: anhöriga (relationen till anhöriga tar över), förluster (olika aspekter av relationen påverkas), normer (skilda normsystem försvårar relationen), profession (spänning mellan professionell och personlig relation mellan de olika parterna), färdighet (parternas färdighet påverkar relationens kvalité), telefontolk jämfört med fysisk tolk (olika sjuksköterskor har olika preferenser) samt tolkanskaffning (sjuksköterskorna väger in relationen när tolk ska anlitas). Relationerna mellan huvudkategorier och underkategorier beskrivs och deras innebörd diskuteras. Sjuksköterskor kan öka möjligheterna att uppnå en vårdgemenskap med patienten genom god förberedelse inför tolkningen liksom att hjälpa patienten uppnå skicklighet i att använda tolk. En professionell relation till tolken, karaktäriserad av omsorg, möjliggör också vårdgemenskap med patienten. / The caring relationship and the caring encounter are the life-space of caring. A caring encounter involving an interpreter should be seen as an interaction between three or possibly more persons. This paper seeks to describe nurses' experiences of the relationships in such encounters. Nurses with experience in using interpretation were asked to answer a survey comprising quantitative and qualitative questions. Additionally, two semi-structured interviews were conducted for clarification and depth. Answers were analyzed using manifest content analysis. Three main categories were found: security, interpreter technique, and cultural aspects. Seven sub-categories were found: relatives (the relationships with relatives take precedence), loss (different aspects of the relationship are affected), norms (different norm systems complicate the relationship), profession (a tension between professional and personal relationships), skill (the impact of the skills of the parties), telephone vs. physical interpreter (preferences vary among nurses), and acquisition of interpreters (the relationship is a factor when enlisting an interpreter). The interrelationships of the main categories and sub-categories are described and their meaning discussed. Nurses can increase the probability of achieving a caring connection by preparing well for interpretation as well as helping patients to gain proficiency in using an interpreter. A professional relationship, characterized by caring, with the interpreter will also facilitate a caring connection with the patient.