Single Therapeutic Project and Nursing Process from an interdisciplinary care perspective

Abstract

OBJECTIVE

To analyze the single therapeutic project and the nursing process regarding its specificities and intersection points from the interdisciplinary care perspective. METHODIntegrative review of the literature from articles available in the Lilacs, SciELO, MEDLINE and PubMed databases, published in Portuguese, English and Spanish from 2005 to 2015.

RESULTS

It was identified 23 articles. From these, 17 on the nursing process, six on the single therapeutic project and one about multiprofessional residency. From the analysis, their specificities and intersection points that describe the alignment and similarities between them were identified in the primary and mental health cares.

CONCLUSIONS

The single therapeutic project and the nursing process are aligned in health practices in primary and mental health cares. The multiprofessional residency allows this alignment among them, and the nurse contributes to the interdisciplinary care with the nursing process.

Keywords:
Nursing process; Health care; Family health strategy; Program evaluation; Staff development

Resumo

OBJETIVO

Analisar o Projeto Terapêutico Singular e o Processo de Enfermagem quanto as suas especificidades e pontos de interseções, na perspectiva do cuidado interdisciplinar.

MÉTODO

Revisão integrativa da literatura de artigos disponíveis nas bases de dados Lilacs, SciELO, MEDLINE e PubMed, em português, inglês e espanhol, publicados no período de 2005 a 2015.

RESULTADOS

Foram identificados 23 artigos. Destes, 17 sobre o Processo de Enfermagem, seis sobre o Projeto Terapêutico Singular e um sobre residência multiprofissional. Da análise identificaram-se as suas especificidades e pontos de interseções que descrevem o alinhamento e similaridades entre os mesmos, nos serviços de atenção básica e saúde mental.

CONCLUSÕES

O Projeto Terapêutico Singular e o Processo de Enfermagem se alinham nas práticas de saúde nos serviços de atenção básica e saúde mental. A residência multiprofissional possibilita esse alinhamento dos mesmos, e o enfermeiro contribui para o cuidado interdisciplinar justamento com o processo de enfermagem.

Palavras-chave:
Processo de enfermagem; Atenção à saúde. Estratégia saúde da família; Avaliação de programas e projetos de saúde; Desenvolvimento de pessoal.

Resumen

OBJETIVO

Analizar el Proyecto Singular Terapéutico y el Proceso de Enfermería como sus características específicas y puntos de intersecciones, desde la perspectiva de la atencíon

interdisciplinaria.

MÉTODO

Revisión integradora de los artículos disponibles en las bases de datos LILACS, SciELO, MEDLINE y PubMed, en portugués, Inglés y Español, publicado en

el período 2005-2015.

RESULTADOS

Se identificaron 23 artículos. De éstos, 17 del proceso de enfermería, seis en el Proyecto Singular Terapéutico y uno residência multiprofesional. El análisis identificó si sus especificidades y puntos de intersecciones que describen la alineación y similitudes entre ellos en la atención primaria de salud y salud mental.

CONCLUSIONES

El Proyecto Singular Terapéutico y el Proceso de Enfermería se alinean en las prácticas de salud en la atención primaria de salud y salud mental. La residência multiprofesional permite esta alineación de los mismos, y la enfermera contribuye a la atención interdisciplinaria desde justo al PE.

Palabras clave:
Proceso de enfermería; Atención a la salud; Estrategia de salud familiar; Evaluación de programas y proyectos de salud; Desarrollo de personal.

INTRODUCTION

The history of the construction of the National Health System (SUS) over the years shows that the health concept has been magnified and that health actions have been expanded with the purpose of contemplating interventions capable of guaranteeing the integrality of health care. It was observed that it would be necessary to integrate different professionals into the several services and levels of health care in order to enable the integrality of health care, and thus expand the possibilities of health care from an interdisciplinary perspective¹. Interdisciplinarity in health care is expressed through the integration and articulation of different knowledges and practices capable of producing interventions in common, while valuing the knowledge and assignments from different professional categories¹.

This context implied reorganization of the health system operationalization, with the creation of the Family Health Program (Programa Saúde da Família - PSF), currently Family Health Strategy, based on primary care, being necessary to qualify for vocational training². The action possibilities from several health professionals demand skills that indicate the need for continuing training. In this perspective, the importance of the Permanent Education Policy in Health for the training of professionals to work in the SUS was noted, based on the possibility of transforming professional practices³.

Thus, multiprofessional health residency was created with the purpose of enabling the training reorientation of these professionals through in-service teaching⁴. The multiprofessional residency has as one of its characteristics to develop expanded care interventions, overcoming weaknesses in undergraduate education and consolidating SUS guidelines, strongly based on the principles of integrality, universality of access to health services and equality of health care in order to meet the population health needs^5-6.

In this sense, it is observed that the proposals of the multiprofessional residency are initiatives aimed at health humanization, being a strategy for care and management practices in the public health services, since it promotes the reorientation of these practices based on the dialogue networks between the education, health service and community^4,7.

In this context, the single therapeutic project (Projeto Terapêutico Singular - PTS) is adopted as a care instrument inserted in the interdisciplinary context for interventions centered in the subjects' health needs on their social context^8-9. This instrument is used as a strategy for the work process reorganization of health teams in the different levels of care, as well as in the context of multiprofessional health residency, besides interconnecting services within the care network with a view to integral health care¹⁰.

Among the professionals included in the multiprofessional health residency is the nurse, who also guides his or her practice in a specific model, i.e., the nursing process (NP), which organizes health care, focusing on problems, risk factors and potentialities of individuals and groups^11-12. However, even nurses effectively using NP, there are limitations sometimes, since there are interventions that depend on other professions to enable continuity of care in order to ensure the integral health care.

In this context, the NP is characterized as a care technology, since the structured knowledge associated with dialogue and listening in its construction are present and define the nurse action, being care the focus of nursing. It is understood that nursing care is an interactive process not restricted only to the use of equipment and structured knowledge, but in actions that are configured as relationship and subjectivity intervention processes, containing communication as a necessary tool to mediate this technology. Therefore, the process as technology requires openness to new working modes and technologies, such as PTS embedded in professional practices^11-12.

In the logic of multiprofessional work, it is necessary to add different knowledge in the construction of nurse learning, besides contributing with interdisciplinary care. This sharing is something under construction in nursing and multiprofessional residency establishes a "bridge" for this new way of working, where PTS and NP intertwine. Thus, it is necessary to reflect on the different ways of doing based in these models, identifying similarities and intersection points among them.

The relevance of this study lies in the fact that it allows the reflection on how to make contemporary NP in the sense of interdisciplinary care, with PTS as an ally in this new perspective. Furthermore, the importance of deepening the knowledge about this care way and how PTS can broaden the training strategies of nurses is highlighted.

Thus, this study aims to analyze the PTS and NP in relation to their specificities and intersection points from the interdisciplinary care perspective, based on a literature review with a reflective analysis of the findings.

METHOD

Integrative literature review (ILR), according to Cooper¹³, to support the analysis of specificities and intersection points between PTS and NP from the interdisciplinary care perspective.

The IRL course occurred with the delineation of steps described in Chart 1.

The problem delimitation was developed from the following guiding question: "How is the nursing process inserted into the health care model proposed by the single therapeutic project?"

The articles were written in Portuguese, English and Spanish, published between 2005 and 2015, fully available on-line in Lilacs/SciELO databases, MEDLINE/PubMed Central, with the descriptors/DeCS Processos de enfermagem, Atenção à saúde, Estratégia saúde da família, Avaliação de programas e projetos de saúde e Desenvolvimento de pessoal; the terms/MeSH Nursing process, Delivery of health care, Nursing care management; and the keyword projeto terapêutico singular. Letter to the editor, case reports, theses and dissertations, and duplicated articles were excluded from the selected databases.

The Boolean operator AND was used to refine the search of studies through the merge of descriptors and terms¹⁴. The variation of descriptors and terms used to search the studies were selected in order to contemplate the interdisciplinarity, context in which the PTS is described. The combination of descriptors and terms in each database was performed for the search; the descriptor/term processos de enfermagem/nursing process was used always associated with the Boolean operator AND with each of the other descriptors and terms.

Data collection occurred from January to April 2016. For this purpose, the authors created an instrument that contemplate the identification of the article; objectives; methodological design; results; limitations and conclusions.

The analysis and presentation of the data synthesis were given in synoptic charts that included the information extracted from the studies related to the guiding question. The study considered the ethical aspects, maintaining the authenticity of ideas, ensuring the authorship of the researched articles.

Chart 1 shows an overview of the study steps.

Chart 1
Description of the integrative literature review

RESULTS

A total of 23 studies that showed data to answer the guiding question of the study were found. Most of the publications occurred in the years 2011 (seven - 30.4%) and 2015 (five - 22%); with a predominance of Brazilian studies (20 - 87%), besides one (4.3%) American study and one (4.3%) Spanish study.

Regarding the study design, eight (35%) were descriptive exploratory, four (17.4%) literature reviews and four (17.4%) with aqualitative approach. They were published in several journals, being the Revista da Escola de Enfermagem from USP and the Revista Latino-Americana de Enfermagem the ones that presented the highest number of analyzed publications.

The information contained in the article identification data (authors, title, journal, year of publication, study type, source and Qualis or impact factor) are described in Chart 2.

Chart 2
Characterization of analyzed articles

Among the 23 studies in the sample, 17 (74%) addressed the NP, five (22%) the PTS and only one (4.3%) on RIMS and PTS in the same study. Two studies addressed PTS and NP concurrently, in primary and mental health cares, but any study on them in hospital care addressing interdisciplinary care.

Most of the studies on PTS and NP were developed or had the primary and mental health cares as a discussion scenario. Only one study on RIMS presented considerations about the use of PTS as an instrument in the care production from an interdisciplinary perspective in hospital care.

From the analysis of the 23 studies, 37 specificities were identified, both from PTS and NP, which are described in the form of categories that refer to the content of the analyzed studies, grouped into three guiding axes: individual, family and social context, the work team, and the care environment. From the 17 studies that addressed NP, 20 different specificities were identified, and from the five studies that addressed PTS and one on RIMS, 17 different specificities were identified.

Table 1 shows an overview of the NP specificities. From the 19 different NP specificities, six are not similar to those from PTS: Autonomy in clinical decision-making in nursing, Actions of health education, Actions of continuing health education, Interpersonal skills, Intellectual competences and Definition of methodological model and technological instrument.

Table 1
Synthesis of the Nursing Process specificities (n = 68) described under categories grouped in guiding axes

Axes	Nursing Process Specificities	f(%)
Individual, family and social context	Integrality of individual, family and community care	5 (7)
	Use of health technologies (soft and soft-hard)	5 (7)
	Singularity recognition of individuals and collectives	4 (6)
	Health education actions	3 (4.4)
	Interaction technologies in the health care of the individual, family and community	3 (4.4)
	Care actions to individual, family and community	2 (3)
	Interventions for the promotion, prevention, recovery and maintenance of the health of individuals, families and communities	2 (3)
Work team	Autonomy in clinical decision-making in nursing	5 (7)
	Actions of continuing education in health	1 (1.4)
	Shared construction of diagnostics and therapeutics	1 (1.4)
	Problematization of health practice	1 (1.4)
	Team meetings	1(1.4)
Care environment	Management of care and work processes	9 (13)
	Mode of organization in stages (investigation, nursing diagnosis, planning, implementation and assessment)	9 (13)
	Interpersonal skills	6 (9)
	Multiprofessional team work	4 (6)
	Comprehensive understanding of the health-disease process	3 (4.4)
	Definition of methodological model and technological instrument	3 (4.4)
	Intellectual competences	1 (1.4)

• ^Source:
  Research data, 2016.

Table 2 presents an overview of the PTS specificities. From the 17 different PTS specificities, four are not similar to those from the NP: Insertion in the interdisciplinary context, Discussion of clinical cases, Use of the extended clinical concept, and Interconnection of services within the health care network.

Table 2
Synthesis of the Single therapeutic project specificities (n=41) described under categories grouped in guiding axes

Axes	Single therapeutic project specificities	f(%)
Individual, family and social context	Integrality of individual, family and community care	5 (12)
	Singularity recognition of individuals and collectives	4 (10)
	Use of health technologies (soft)	3 (7.31)
	Care actions to individual, family and community	2 (5)
	Interaction technologies in the health care of the individual, family and community	1 (2.43)
Work team	Shared construction between team, individual, family and social network	3 (7.31)
	Team meeting	3 (7.31)
	Insertion in the interdisciplinary context	3 (7.31)
	Problematization of health practice	1 (2.43)
	Discussion of clinical cases	1 (2.43)
Care environment	Comprehensive understanding of the health-disease process	3 (7.31)
	Health service management (matrix support)	3 (7.31)
	Multiprofessional team work	3 (7.31)
	Use of the extended clinical concept	3 (7.31)
	Care management (reference team)	1 (2.43)
	Interconnection of services within the health care network	1 (2.43)
	Mode of organization in stages (diagnosis, goal setting, division of responsibilities, reassessment)	1 (2.43)

• ^Source:
  Research data, 2016.

The synthesis of specificities described in the synoptic tables in the form of categories, subsidized the identification of PTS and NP alignment with intersection points, allowing to list 14 similar specificities between these two care models among the 37 specificities found for them.

The synthesis of these intersection points between PTS and EP described in the form of categories, which refer to the content of the analyzed studies, are grouped in the three axes already described (Table 3).

Table 3
Intersection points between the Single therapeutic project and the Nursing Process described in the form of categories, grouped in guiding axes

Axes	Intersection points between PTS and NP
Individual, family and social context	• Care actions to individual, family and community
	• Integrality of individual, family and community care
	• Recognize the singularity of individuals and collectives
	• Interaction technologies in the health care of the individual, family and community
	• Use of health technologies
Work team	• Shared construction of diagnostics and therapeutics
	• Problematization of health practice
	• Team meetings
Care environment	• Comprehensive understanding of the health-disease process
	• Care management
	• Management of work processes and health services
	• Interconnection of services within the health care network
	• Mode of organization in stages
	• Multiprofessional team work

• ^Source:
  Research data, 2016.

DISCUSSION

PTS and NP analysis from the literature review allowed answering the guiding question of the study, and thus identifying specificities and intersection points for each of these two models.

Brazilian studies (91.3%) published in nursing journals were predominant, considering that the use of care instruments, such as PTS and residency programs, are relatively recent strategies focused on care practices and management of public health services in Brazil. Descriptive exploratory studies (35%) were the most frequent, which demonstrates the search for understanding and improvement of knowledge about NP, and the more frequent studies addressing the PTS were two literature reviews (9%) on the care instrument.

Regarding the combination of descriptors and terms for the search of studies, a variation of these was chosen, which would allow finding studies that approached PTS and NP together in an interdisciplinary perspective under different health care levels. This variation of descriptors and terms was based on the assumption of a scarce literature on the subject due to the recent insertion of multiprofessional residency and the use of care instruments in health services, such as PTS.

Only two studies that addressed PTS and NP^27,38 concomitantly were found, one in primary care and another in mental health care. However, we did not find a study of them in the hospital care approaching the interdisciplinary care in the nurses' care practice. It is suggested that the scarce scientific production addressing PTS and NP together is due to the recent insertion of this care instrument in health services, especially in hospital care.

However, the PTS concept has been under construction since the beginning of the 1990s, being modified along the SUS history, since the sanitary movement and psychiatric reform³⁹. Studies on PTS in the context of mental health describe that its implementation process and results are positive in intensive or specialized care services, such as the psychosocial care centers (CAPS), in which the results of these studies show PTS as a powerful tool in the care of subjects assisted by these services^40-41.

This corroborates with our findings, in which four (17.4%) PTS studies were developed or had mental health cares as a discussion scenario. The studies sought to understand or discuss the construction of the therapeutic project of CAPS users and the articulations of the mental health team with other health services and sectors of society. It was observed that the construction of the PTS is based on the health needs of each user, through mutual effort between the team, users and families, being an important mental health care instrument and a strategy for the organization of these services^17,32.

The elaboration of PTS in hospital care was identified in only one (4.3%) study on the insertion of multiprofessional residency in a university hospital in Brazil. In the study, the therapeutic project was used as an instrument to integrate the different actors of the health production process, with integrated care practices focused on the health needs of each individual, and in line with the model of health care recommended by SUS¹⁹.

Other PTS studies in hospital care available in the literature are experience reports and were excluded from the study sample^42-43.

We did not find studies that approached NP in the hospital care in an interdisciplinary perspective. However, care strategies based on the extended clinical concept, considering the subject singularity, are observed in primary and mental health cares from articulated health practices with multiprofessional team. It is observed also that integral care, which is SUS principle, is something that permeates the health practices of nurses and other team professionals in these health services^20,37.

Regarding the identified PTS and NP specificities, they were described in categories referring to analyzed studies and were grouped into three guiding axes of the discussion.

In the individual, family and social context axis, the specificity Integrality of individual, family and community care of PTS and NP refers to contents that allow identifying subjects as totalities, considering the care integrality as a whole, including their biological, psychological and social health needs, besides their subjectivity. Receptiveness and listening spaces are developed in order to meet their needs, humanize health practices and expand users' access to services^22,33,37.

In the specificity, the use of health technologies, from PTS and NP, those observed in the studies were soft technologies, such as receptiveness, connection, listening, dialogue, co-responsibility and user autonomy; and hard technologies, such as the production of procedures. Soft technologies allow developing relationships involved in the worker-user meeting by listening and building links, making it possible to capture the singularity and understand the context in which the user is inserted³⁸. In the construction of therapeutic projects, these soft health technologies favor the user's adherence to treatment^30,32.

The specificity Singularity recognition of individuals and collectives, from PTS and NP, refers to the subject in its social and single context, where the health professional recognizes their particularities, individualities and health needs in care. The singularity of individuals and collectives is the essence of the therapeutic project, considered as the central articulating element of this instrument^17,25.

In the work team axis, the frequent specificity of PTS was the insertion in the interdisciplinary context. The therapeutic project is inserted in the interdisciplinary context to expand and qualify the interventions, with the contribution of specialties and different professions, aiming at the principle of integrality, seeking to broaden the view of the subjects based on multiprofessionality^25,30.

Still in this axis, the shared construction specificity between team, individual, family and social network, frequent in PTS and similar to NP, includes the sharing of diagnostic and therapeutic information between professionals, subjects and family in decision making, perceptions and reflections from different team members in the elaboration of the therapeutic project^21,26,31,34. This sharing should go both towards the health team, the health services, and towards the users, providing conditions for integral care through intersectoral articulations^21,28,44.

In the care environment axis, the frequent specificity of NP was the Mode of organization in stages. The NP, as a methodological model and technological instrument, describes how nurses organize care in five stages, data collection or history, nursing diagnosis, planning, implementation of interventions and nursing assessment^{(16,23,26,29,36 , 45)}. PTS is also organized in steps similar to those from the NP^{21,27,30,32,46}.

The specificity Multiprofessional team work, from PTS and NP, refers to the expressed care in an interdisciplinary way subsidized in the extended clinical concept and in the health needs of each user, with articulated actions developed by multiprofessional team. Thus, team work is considered a strategy for the construction of interdisciplinary actions in the practice scenarios, which should favor the service organization and the construction of articulated and integrated care practices, overcoming the fragmentation of health knowledge and practices^1,19,21,32.

The specificities Management of care and work processes and Health service management (use of the extended clinical concept) were frequent in NP and in PTS, respectively. Regarding the Management of care and work processes of the nurse, in the primary care scenario, actions such as monitoring of user’s health situations, team and service management, management of therapeutic projects and articulation of health services were observed as a system of health care networks^1-2,18,27. In a recent study, PTS proved to be an effective tool for the care management for professionals of an ESF team in primary health care⁴⁷.

The identification of these specificities of PTS and EP allowed observing an

alignment between these two care models with intersection points, especially in primary and mental health cares. It was observed that nurses develop expanded strategies of care in these services that contemplate the individual in its totality, from health practices articulated with multiprofessional team.

It is noted that the stages of PTS and NP have important intersection areas, where nursing can work on their specificities and simultaneously interact with other health professionals in the search for the individuality care for each individual, based on the integrality health care perspective.

In this interaction, the multiprofessional residency allows an alignment from the NP with different care instruments, such as the PTS, in which the nurse's role in the multiprofessional team allows adding different knowledge in the construction of their learning, besides contributing with the team precisely with the NP. However, RIMS provides a "bridge" to this new way of working with a view to extended health care, where the PTS and the EP intertwine and complement each other.

FINAL CONSIDERATIONS

PTS and the NP analyses made it possible to observe that these care models have similarities and complement each other.

It is observed that the integrality principle of nursing care is expressed in the relationship with the health team, the care environment and the subject, in which the nurse visualizes the whole in the health care context. However, there is a predominance of this limited integrality in the health practices specific from the profession and that does not articulate with the other actors involved in the care production.

It is noteworthy that despite the similarity of these care models, PTS's health practices go beyond those from the NP, since the therapeutic project uses a greater arsenal of care tools and instruments for the SUS health policies as allied to its health practices in order to guide care.

However, the intersection between PTS and NP is considered as an extended production of health care and innovative health practices in the SUS, being the PTS an innovative strategy to enhance the nursing care and management model in the health care of individuals and families. Thus, Nursing must consider that new technological care instruments are necessary for the profession.

The restricted literature on the subject and the variation of the descriptors used to search the studies are highlighted as limitations of the study. It is suggested to conduct new studies that can analyze how the care instruments, such as PTS have been processed in the perspective of changes in the production of integral care and how these instruments have strengthened the nurse training in the multiprofessional residency context.

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Publication Dates

• Publication in this collection
  02 July 2018
• Date of issue
  2018

History

• Received
  29 Mar 2017
• Accepted
  25 Aug 2017