Artigos

Conteúdo (article):

The thinking and acting of health professionals on the coordination between the assistance levels of the health care network

Mireilly Cristiany Lucena Moura Hemetério. Instituto de Medicina Integral Prof. Fernando Figueira-IMIP, Secretaria Municipal de Saúde do Cabo de Santo Agostinho. mireilly17@yahoo.com.br . https://orcid.org/0000-0002-1593-1575

Lygia Carmen de Moraes Vanderlei. Instituto de Medicina Integral Prof. Fernando Figueira-IMIP.lygiacarmen@yahoo.com.br. https://orcid.org/0000-0002-3610-3699

Marina Ferreira de Medeiros Mendes. Instituto de Medicina Integral Prof. Fernando Figueira-IMIP, Universidade Federal Rural de Pernambuco (UFRPE). Marinamendes2004@gmail.com. https://orcid.org/0000-0002-5752-5217

Paulo Germano de Frias. Instituto de Medicina Integral Prof. Fernando Figueira-IMIP, pfrias@imip.org.br. https://orcid.org/0000-0003-4497-8898

Abstract
The study aims to understand the thinking and acting of health professionals about the coordination between levels of care. Qualitative researchan international multicenter study Equity-LAII. Audios were retrievedeleven interviews of doctors/nurses of two levels of care in Recife, 2014. A content analysis of the theoretical framework of coordination was performed in the light of the hermeneutic approach. Most professionals knew the duties of coordination, without identifying its execution. The primary care physician was not recognized as responsible for the clinic, nor for his role by the specialist physician, while the primary care physician resented it. Failures in the use/completion of reference/counter-reference mechanisms and organizational barriers emerged. The unavailability for the “conversation game” and “fusionality” was evidenced in the lack of recognition of authority in the authoritative character of the primary care physician by that of the specialized, feeling of less value for that and technicist and specialized posture in everyone\'s practice. The coordination in on professionals’view revealed the “there-to-be-understood” condition that needs to be launched in the “game of comprehension” to build dialogical practices focused on integral care.
Keywords: Clinical Management; Hermeneutics; Qualitative Research; Health Care levels

Introduction
The initial experiences of integrated health systems inducted the constitution of Healthcare Networks (HN) which spread in Western Europe and Canada.1 These initiatives sought to break the segmentation of national health systems and the fragmentation of the care process, as strategy of challenging inefficiency and low quality of care.2
Few countries have universal public systems, for instance, Spain and United Kingdom. These countries, with variations among themselves, privilege full access, equity, integration, regionalization and network hierarchization.1,3,4 In Brazil, in spite of undeniable improvements, the healthcare system still fragmented and focused on acute illnesses and acute-on-chronic illnesses, reaffirming the need for organization in HN. 5,6
The HNs are arrangements constituted by services and actions, with technological conformations and various assignments, complementarily organized. Among their main characteristics it is highlighted the sanitary accountability by continuous and integrate care; share of objectives; centralization of the health needs of the population, having Primary Healthcare (PH) as the center of communication and care ordainer; and horizontal relationships between the points of attention and multiprofessional care.7
In Brazil, difficulties for the implementation of HNs are related to scarce resources associated with the financial imbalance between the PH and the Specialized Care (SC); the availability; the training and links of professionals and the regional inequities.6,8 The PH, as the ordainer of longitudinal care, needs to share tasks between the physicians of its level of care, clinically responsible for the patient, and those from SC.5,9
The coordination refers to the harmonious connection between different services and levels of care, with synchronization of procedures addressed to the user, which are necessary to its continuous care, in obtaining common, free of conflicts and articulated goals. A better integration in HNs is linked to the higher success of care coordination, with organizational determinants, professionals and needs in user health, which influence collaboration and responsibility between PH and SC. 10-12
In order to investigate the coordination between levels of care, various approaches are available, such as the one used in a multicentric research to evaluate strategies of enhancement and quality of care in Latin American HNs (Equity-LA),13 which considers three types of coordination: information, clinical management and administrative management.14 However, analyses under theoretical perspective are unusual, as philosophical hermeneutics, which interprets the sense attributed by Being and science comprehension as a discourse, characterized by the search for intersubjective validation, based on the commitment with truth, which involves uncertainties and is produced in the subject-object relationship. 15-18
In this conception, truth is a hermeneutic experience which refers to the revelation in the junction between familiar and unknown, resulting from sociohistorical and cultural constructions (tradition, prejudices, horizon). 15,16 The assistance coordination would occur in a dialogical, intersubjective and reflexive relationship, characterized by “good practice”, 15,18 reached when two beings dialog agreeing about something, even without complying with each other’s perspective, but keeping themselves in touch with the other’s horizon. Thus, the construction of truth is an experience open to resignification, which demands mediation between technical-scientific knowledge and self-knowledge. 16,19
The comprehension of phenomena implies in reveal what is the sense attributed by the actors which compose them, identified by professionals as authority, which constitute and are constituted by health services, processes and by the others with which they are related. These, express the legality of the horizon of tradition of this knowledge engineered by assumptions and prejudices which characterize its action. 16,17,19 The objective of this article is to comprehend the thinking and acting of professionals about the coordination of assistance between levels of care.
Methods
This is an evaluative research of qualitative approach, whose theoretical references concerning coordination between levels of healthcare14 were articulated to those of philosophical hermeneutics. 15,19
The survey was a cutout from the qualitative strand of Equity-LA Research baseline,13 which analyzed the dimensions of information coordination (transfer of clinical and biopsychosocial information; coordination of clinical management (adequate patient follow-up, accessibility between levels and care coherence) and management coordination (established administrative circuits and access ordination). Eligibility criteria to select informers were: physicians and nurses acting for at least six months in PH and SC, the latter attending reference centers specialized in care of patients with chronic diseases and who agreed participating in the research.
In this study, audio records from eleven semi-structured interviews were used, by means of a script built from the theoretical framework of coordination, 14 which were applied to the physicians (three from PH and five from SC) and nurses (two from PH and one from SC) in Recife, in the years 2014 and 2015.
Empirical material was analyzed in order to comprehend meanings expressed in the participants’ discourse by means of hermeneutic interpretation, 15,19 considering the researcher as subject implied in the survey and that this action is done in a relational continuum, by means of interpretative dialog, yet the comprehensive totality cannot be fully reached by limits inherent to the methodological course in point, which hindered the intersubjectivity process of the actors that composed it.
A content analysis was performed, a systematic, comprehensive, interactive and cyclic process20 developed in three phases: 1) pre-analysis of material by re-listening of audio records from interviews, in order to perform discourse analysis of the actors, including paralinguistic characteristics, with registration of silence periods, laughter, and elements of analytic interest; 2) comprehensive reading of new transcriptions for approximating the totality of each report and its latent content; followed by organization of the material, identification of information and separation of discourses according to characteristics of the actors (age, gender, etc.); grammatical units (sentences or paragraphs); by temporal evolution of narrative or combination of many of these aspects. 3) elaboration of empirical categories or units of meaning, resulting from identification of patterns, data related to each other, corresponding to a given theme, created on a inductive manner resulting from the re-listening of audio records, from the interviews’ script or the combination of both (Figure1).
The analysis was performed in the first to third phase in each one of the interviews and comparatively between actors, by levels of attention, for establishing dissent, contradictions and emerging consensus. Finally, description and interpretation of results were performed, as well as establishment of relationships and development of explanations and/or hypothesis constituting the gadamerian theoretical framework, which made possible the attribution of meaning to the findings, enabling the comprehension/interpretation dynamics to occur.
The definition of the sample size was reached by saturation, which is related to convenience-pertinence criteria, and informs about quality and sufficiency of information, when its set presents completeness to achieve research objectives and expresses saturation, characterized by redundancy and absence of new aspects on discourses, evidencing its exhaustion. 20 The informants were presented by codes which assured confidentiality and origin of information.
The study followed ethical principles, according to Resolution nº 466/2012 of National Health Council and was approved by the Ethics and Research Committee of the Integrative Medicine Institute Prof. Fernando Figueira, permit number nº 2.057.958 in 11/05/2017, CAAE 63439416.0.0000.5201.
Results
The sample was composed by 11 informants, ten women and one man, being two nurses and three physicians (four women and one man) from PH and one nurse and five physicians (all women) from SC; ages from 45 to 68 years old; experience in service from one to 19 years; ten of these professionals with residency training or specialization. The exposition follows the order of emersion of categories/subcategories comparatively between the levels of care in which the actors worked.
Almost all of the participants knew the attributions of coordination, without identifying its execution in the network. The discourses in two levels of care revealed the non-recognition of the PH physician as the clinic responsible. Flaws in the usage and filling of mechanisms of reference/counter-reference are highlighted, as well as the non-existence of others, as clinical meetings and organizational barriers.
Aspects related to organization in health care levels (Table1)
A little more than half of professionals didn’t know the terms “clinical responsible”, “clinical and administrative management” and “coordination of information”; some confused the terms with management attributions or did not adequately refer the executed actions.

Clinical responsible
Even with medical recognition from the PH as clinical responsible for two physicians of these level and three from SC, only one from each level of care knew the concept and its importance to the adequate development of care, although they mentioned this function as not being developed in health network.
One nurse from the PH attributed to the ESF (family health strategy – Portuguese acronym) team the clinical responsible function and two SC physicians knew the term, but did not identify it as being the PH physician.
Problems with clinical management
Four physicians from SC reported problems in clinical management due to inadequate forwarding in PH, resulting in unnecessary displacement of users and needless occupation of vacancies.
Problems with administrative management
All interviewed professionals pointed organizational aspects which hindered the coordination between levels, emerging oftenly flaws in appointment consultations, insufficient vacancies, equipment and professionals in both levels of care, resulting in professional overwork and lengthy wait for assistance, mainly specialized care.
The National System of Regulation (Sisreg – Portuguese acronym) was recurrently pointed among all the actors as an organizative instrument which hindered coordination between levels by inadequate operationalization, yet a nurse from PH perceived it promisingly.
The disproportionality between population’s request and the offer of consultations and exams also emerged uniformly between interviewees of both levels. In the point of view of SC professionals, this contributed to reduce consultations length, compromising quality, adequate registration and counter-reference.
Problems with coordination of information
The speech of four physicians from SC revealed problems with misinformation in the profile of the referenced unit, resulting in mistaken forwarding to specialized centers. In the perspective of a physician from PH, the problems are due to the lack of communication between levels of care.
Aspects related to professionals: praxis in primary healthcare in specialized care (Table 2)
Theoretical and practical attributions of PH and SC
Most of professionals demonstrated being familiar with the role of the PH as care coordinator, approaching the sanitary responsibility shared in the territory (family, social and cultural aspects). Not always that the speeches were clear or secure, existing pauses for their expression, pointing restrictions to the performance of this role, with complaints in interpersonal, administrative and organizational relationships.
Among those who weren’t aware of the PH role, speeches were restricted to the control of the disease, emphasizing medical intervention to avoid worsen. There was consensus between informants about the acting of the specialist be supportive and in cases of major complexity, continuity of care.
None of the speeches expressed shared action between levels, the majority showed restrict comprehension about the role of SC, reducing it to diagnosis, examination request and drug treatment, without approaching its responsibility with the orientation of users and information to PH, being an obstacle to the care, in the perspective of all PH professionals.
All of the actors of both levels informed the non-accomplishment of their duties adequately, agreeing that the excessive amount of attended users is higher than preconized, resulting in overload and overcrowding.
All the informants revealed dissatisfaction with the performance of networks, with accusations and criticism between levels. The mutual recriminations referred to the lack of commitment of professionals and negative interfering due to the non-accomplishment of correspondent roles, non-recognition of PH’s technical competence by SC, barriers in the access of specialists due to flaws on Sisreg, leading to informal search for access to SC.
Attitudes which influence coordination of care between levels
The speeches of three PH physicians showed annoyance due to the disrespect of SC colleagues for not considering or reading their referrals, whilst all of the specialists complained about mistakes from PH colleagues in references and procedures.
Another difficulty to the coordination between levels pointed by three physicians and a nurse from PH was the unavailability of SC professionals for the orientation of cases which needed associated care, whilst for all the specialists this problem is due to the non-accomplishment of the adequate function of the PH physician, passing along non-complex cases to the secondary level. In the specialists’ perspective, this would be an alternative for the PH physicians to deal with the high request of service or to insufficient technical knowledge for accomplishing their tasks.
One physician from PH pointed lack of concerning from the colleagues of the same care level regarding commitment and clinical responsibility in the investigation and resolution of user’s requests, resulting in discomfort, annoyance and discontentment.
All SC professionals related flaws in the PH actions of promotion and prevention, in contraposition, three physicians and one nurse from PH identified resistance from patients to change lifestyle and lack of recognition with professionals of that level. In the perspective of one PH physician, there is lack of ability in professionals of this level regarding the adequate link with user when not considering biopsychosocial aspects in care providing, resulting in the search for SC.
The criticism to the lack of technical competence of PH professionals in the use of the reference form arose in the speeches of five specialists and a physician of the same level, which highlighted the importance of “well done and readable” referrals.
The conditions of work, understood as “structure” by one SC physician, were pointed as barriers by PH teams, prompting them to mistaken referrals to the specialized network.
Aspects related to professionals: mechanisms of coordination (Table 3)
Knowledge
All the interviewees knew the reference and counter-reference forms as a preconized instrument to the communication between levels, other mechanisms were quoted by only two PH physicians: clinical meeting, matrix team (Nasf), hospital discharge summary, institutional phone number and the Sisreg.
Utility
The utility of coordination mechanisms, in the perspective of a nurse and two physicians from PH, is to promote higher trustworthiness to the information about health conditions of the patients and possibility of knowledge building, whilst to four SC physicians, it favored the communication between levels.
Utilization
Some presented narratives were affirmed by the majority of actors as obstacles to the utilization of mechanisms: malfunction of Sisreg, deferring appointment scheduling in SC and transcription of patient’s transcription in a row; referrals from the PH without clinical information and exams; absence of clinical meetings between levels and unavailability for counter-reference.
All the professionals from both levels affirmed that the reference/counter-reference mechanisms are relevant, even though they are not used and is filling is incomplete and inadequate.
All the physicians from PH affirmed that they didn’t receive counter-reference and regardless of executing the reference, they believed it was not read, whilst five physicians from SC did not counter-referred and did not use the other mechanisms, with only one affirming that he stimulates the patient to show the PH physician the prescription when there is therapeutic modification.
Informal mechanisms
It was mentioned the usage of personal telephone and Whatsapp social network by a physician and a nurse from PH and two physicians from SC, by means of friendship links, to perform the follow-up of patients, clarifying doubts, discussing cases and provide orientation to professionals from other levels.
The medical prescription used to the referral to another level was referred by three physicians (two from PH and one from SC), who recommended the patients to show it to the destined colleagues.
Discussion
The trajectory of unveiling occurred by the action of trying to occupy the space of hermeneutic interpreters attempting the fusion of horizons with those of the interviewees in order to apprehend the meaning about the thinking and acting with relation to the coordination between levels of care. The majority of professionals knew the attributions of coordination, without identifying its execution on network. The PH physician was not recognized as clinical responsible by the majority of actors in both levels, associated to the unfamiliarity of his role in the perspective of the specialist, whilst the one from primary healthcare resented. Flaws in usage and filling of mechanisms of reference/counter-reference are highlighted, as well as the non-existence of clinical meetings, besides organizational barriers.
The emphasis to the supremacy of specialist physicians in detriment to those of primary healthcare reflects the tradition of teaching and medical care strongly linked to the medical paradigm of privatist assistance, generating the indefiniteness of roles and the magnification of conflicts in the care network. 21 In order to face problems which demand attention and continuous follow-up, the model of health surveillance proposes redefinition of policies and sanitary practices, which may assume specific configurations according to the necessity in health, organizing processes in health work.22 The study evidenced reciprocal transfers of responsibilities between physicians from the network due to failures of mechanisms of reference and counter-reference, which reflected severe communication and professional performance problems that pervade value judgments, postures and conceptions historically determined.21
Regarding the role of primary care, it became evident in the discourse of the majority of the participants of this level the recognition of its authority in the authoritative dimension, the “being-able-to-know-how” 19,23, encompassing the technical knowledge and the praxis of healthcare providing.
A partial perspective of the SC professionals about the primary level arose, restricted o the early treatment or the medical work and limiting the action regarding the possibility of resolution in/of team actuation. The attributed sense was of questioning and non-recognition of PH authority, denoting a perspective of technicist healthcare limited to the action in its own specialization dimension, separating the disease of the being in its totality, where the care is provided under the notion of “case – the part that fits you”.19 The relation was proven not being dialogic, but covered by methodic auto-conviction and auto-concept, given that it was guided by a superior knowledge (SC) in detriment of recognizing the other (PH) in the condition of authority as well, predominating the usage by the interviewees of the “art of cure” in the philosophical hermeneutics conception.19
The unavailability of SC professionals for the “conversation game” with their PH colleagues revealed to be present in their discourse about their roles as health authorities, attitude comprehended as authoritative, non-reflexive and without genuine auto-criticism or critical liberty, when perceived through the gadamerian assumption of tradition and prejudice. 18,19,23 It was recurrently evidenced barriers to fusionality which allowed the dialog of actors in their continuous “becoming” process, by the anticipation of the horizon of senses which promotes the comprehension of the “to-be-comprehended” 16,18 the coordination between levels. The “truth” emerged through tradition and technical knowledge, due to the hermeneutic circle appropriate and inherent for the re-opening of new meanings have remained attached to the conscience which doesn’t renew itself by means of dialogicity. 16,23,24
In the horizon of PH professionals a self-looking was unveiled, as well as a condition of “be-there-in-the-world” loaded of discontentment or indignation by their authority in healthcare. The historicity itself of their condition of ontological being is harmed by the dynamic relationship with the world which is anointed by the technical success of the SC physician and questions their practical success.23,24
Intertwined to the exposed, it prevailed amongst all SC physicians the posture of not counter-referencing, which was justified by service overcrowd and lengthy, non-objective instruments, that however important, could be filled by nurses.3,21,25 Likewise, they related not using references from PH physicians due to mistaken referrals. The speeches of specialists showed unbelief and discouragement regarding the utility of mechanisms and related to the flow of communication established among the levels.3,25
The speeches repeatedly expressed behaviors which fragmented the network, with negative consequences to care integrality, for the usage of information available in the referral report contributed to more secure diagnosis and coherence in handle, besides reflecting respectful attitude when know about the PH physician, whilst the counter-reference would ratify him.15,16 The discourses denounced damages to the care continuum, and, concomitantly, evidenced ruptures in the responsibility shared between levels which assumed horizontalized and fragmented postures in their assistance praxis.26,27
The valorization of practices focused in hard or soft-hard technologies in detriment of soft ones,28 revealed by informants, mainly from SC, pointed to the non-development of “good practice” in healthcare19,23,24 and to the fact that the coordination was affected by “bureaucratization of life” and minimally reflexive and creative practices. 19,23 The overestimation of specialization is linked to the medical educational culture, which represents the national tradition, which repercussions on the imaginary of the society, reaffirming prejudice to PH.
Even when professionals were invited to perform the exercise of critical-reflexive freedom in order to question the hermeneutic circle, tradition and prejudices prevailed, when they attributed meanings to healthcare coordination and its facilitating and deterrent aspects. The emerging speeches did not meet auto-criticism, as participants of services or regarding their spaces of ‘be-there-in-the-world” in distinct levels of care, 18,19,23 demonstrating to be bonded to their previous comprehension and revealing themselves to be resistant to transformative dialog.15,16
The reports in all interviews was permeated by high tension, discouragement, annoyance and interpersonal discomfort negatively interfering in the intersubjective relationship of professionals of different levels, showing incipient exercising of alterity among them, evidencing that there is no negotiation, in this relationship, as attitude to comprehend the coordination between levels. 15,29 This flaw in the exercise of alterity was evidenced in relation to the patient, in speeches which blamed the users for the worsening of their health conditions done by the majority of professionals.29
Philosophical hermeneutics proposes the opening to dialog producing the experience as inversion structure, experience of negativity of what is known or what is possessed to search for a meeting point and reach a “mutuality” of genuine conversation which promotes transformation. 15,29 The meeting between professionals would promote more agility, development of information exchange between the levels of care, strengthening of care coherence and adequate follow-up. 5,30-32
It is important to mention the challenge of re-listening to audio records from interviews whose script was not idealized from philosophical hermeneutics assumptions. However, an interpretative dialog proceeded, in which was searched a comprehensive totality about coordination between levels to retrieve elements which guaranteed the hermeneutic circle, avoiding relativism as refused by Gadamer. On the other hand, the limit imposed to this study was minimized when conceptual mediation of the theoretical referential of care coordination was used. 10-14 The limitations stimulated an even closer look for the categories of philosophical hermeneutics to arise, besides the triangulation of researchers in order to ensure internal validity.20
The unavailability for the “conversation game” and “fusionality” expressed by all the professionals showed the unfamiliarity with the authority, in its authoritative character, of the PH physician by the SC physician, feeling of less value of the first and technicist attitude and “specialization” in the praxis of all, which demonstrated their desire of domain of diseases by the “art of cure”. The coordination between levels under the perspective of these actors is on the condition of “there-to-be-understood”, which requires their immersion in the “comprehension game”, so that practices focused on integral care are built through dialog. 15,19
The task of engage in the search for comprehension on acting and thinking of professionals regarding to the exposed aspects did not intend unveiling meanings attributed in a complete or definitive manner, given that this would be presented as contradictious to the essence of philosophical hermeneutics. The horizon used for the circle of comprehension is exactly open to resignifications which are possible by new fusions of horizons and new openings of meanings for the truth arising from the praxis of other readers.

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