Multi-professional team care: discourse of women in preoperative mastectomy

Objective: The aim of this study was to investigate the multidisciplinary team regarding the preparation of women in preoperative from mastectomy. Methods: This is an exploratory study with qualitative approach, performed in the surgical clinic of a public hospital in João Pessoa PB. The sample consisted of seven women who would make a mastectomy. Data collection was initiated in the period of February to May 2011, after obtaining the assent of the Committee for Research Ethics No 751/10 and No CAAE 0578.0.126.000-10, using the technique of recorded interview. Results: The data were analyzed using the technique of collective subject discourse, generating four central ideas highlighting the role of the multidisciplinary team comprising relevant guidance to the surgical procedure, preoperative psychological, spiritual and nutritional. Conclusion: We conclude that there is a need for greater integration of the multidisciplinary team to provide better care to women during preoperative care of mastectomy.


INTRODUCTION
Breast cancer is the most common among women, being 22% of new cases each year.In 2012, it was estimated for Brazil, 52,680 new cases of breast cancer, with an estimated risk of 52 cases per 100,000 women.In the state of Paraíba gross incidence rate estimated for the year 2012 for breast malignancy is 32.41 cases per 100 thousand inhabitants.In João Pessoa-PB this index almost doubles, 63.33/100,000 inhabitants, higher than the national average rate 1 .
It is one of the cancers most feared by women, due to their high frequency and psychological effects, such as changes to sexuality and body image, fear of recurrence, anxiety, pain and low self-esteem 2 .It is importante to highlight the knowledge and understanding of women about risk factors for breast cancer are relevant as some of them are modifiable.One should also consider the relationship between the level of knowledge of women and adherence to screening practices and early detection, which directly influences the time of diagnosis and prognosis 3 .
In the case of women with breast cancer, the multidisciplinary team must rescue human values in their work process, deconstructing the mechanized and routinized care, provided an innovative and transformative praxis of the professional relationship and patient 4 , allowing the woman a holistic care, namely, promoting the restoration of health in its broadest sense: the individual viewed as a biopsychosocial and spiritual being.
Under this view, humanizing health encompasses respect for the uniqueness of each person, customizing assistance 5 and transforming health practices towards guided care in more suffering than the disease, the point of this practice recognizing and dealing with the pain and human distress.Logo, solidarity to women in pre-operative mastectomy involves teamwork, the most elementary sense of the word, as an integrated towards something in common group, a united staff, ie, united toward humanized care patient, and not as a group that fulfills its functions individually.
We believe that this study will involve the dissemination of knowledge in the subject and may influence further research in the area and lead to improvements in humanized care multidisciplinary team front women with mastectomies.Indeed, it is expected that the results of this research guide health practices by the importance and need for bonding of the multidisciplinary team, in appreciating the different hospital services from strategies geared to host humanized care, interdisciplinary, respect, human dignity and professional ethics.
The relevance of this research focuses on the humanization that also includes the pre-operative patient care, incurring the integration of multidisciplinary team argument.Thus, the research confined the following question: The care provided by the professional staff of women in pre-operative mastectomy is in the context of the National Humanization Policy?To answer this question, this study aimed to investigate the discourse of women in pre-operative mastectomy regarding the care provided by the professional staff.

METHODOLOGY
Exploratory study with a qualitative approach, performed in the surgical clinic of a public hospital in the city of João Pessoa -PB.In the survey participated women in pre-operative mastectomy who reported on the care of the multidisciplinary team, during the period February to May 2011.To select the sample, we used sampling accessibility, this is often used in exploratory research and qualitative nature 6 .
The seven women were in preoperative surgical mastectomy and were selected based on the following criteria: Have greater than or equal to 18 years old; be preoperatively the surgical unit of the institution elected to study at the time of the data collected; present findings of breast cancer diagnosis and agree to participate.
To enable the collection of data a recorded interview technique by a semistructured form containing relevant to the purpose of the study questions was used.The empirical material was analyzed qualitatively by means of multivariate analysis of the discourse of the collective subject, proposed by Lefèvre and Lefèvre 7 .
The technique of the Collective Subject Discourse is the analysis of verbal material collected by extracting the central ideas testimonials and/or anchors and their corresponding expressions key.Thus, the CSD aims to give light to the number of significant figures that are part of the social imaginary 7 .This is a speech designed in the first person from the speech that most recur and may suppress the exaggeration of repetitions throughout the building, to give coherence to the final speech.This technique was implemented in four stages.In the first stage, was effective selection of key expressions of individual speech, obtained from each subjective question proposed for the studies.Second, we identified the central ideas that each of the participants involved in his speech feature and key phrases for each response of a given issue, thus forming the summary of the content of these expressions 7 .
In the third stage, clustered similar or complementary central ideas involving the same answers to a particular question, it literally transcribing the terms used by the participants.The fourth stage was the structuring of speech synthesis, or the Collective Subject Discourse (CSD), by grouping similar central ideas, which represents a single speech, as if everyone had been uttered by one individual 7 .
This study was approved by the Ethics and Research Committee (CEP), University Hospital Lauro Wanderley (HULW), with certificate Nº 751/10, paragraph CAAE 0578.0.126.000-10.It is noteworthy that during the data collection guidance to participants as to the purpose of the study, guaranteed confidentiality, possibility of removing and requests for consent through the Term of Free and Informed Consent were performed, as required by Resolution 466/12 which deals research involving humans.

RESULTS
Regarding the characterization of the sample, one (14%) women were aged between 30-49 years old and six (86%) was 50 years old.Regarding marital status, three (43%) were single and four (57%) were married or living in common-law marriages.One (14%) women had no children, two (29%) had two sons, three (43%) have 3-4 kids and one (14%) more than four children.
With regard to education, one (14%) were illiterate, four (57%) had incomplete primary education and two (29%) with higher education.The family income was less than the minimum wage for one (14%) women, of up to three minimum wages for three (43%) women and 2-3 minimum wages for three (43%) women.In relation to religious orientation, five (71%) were Catholic and two (29%) Prostestant.
From the analysis of the empirical material it was possible to construct four central ideas: the surgical procedure guidelines: Role of the Doctor; Preoperative Guidelines: Role of the nurse; Psychological and Spiritual Support: Role of the Psychologist; and Nutritional Guidance: Role of the Nutritionist.
The speech below was generated from the question: What is the pre-operative care provided by Doctor?
The surgical procedure guidelines: Role of the Doctor [...]She said that withdrawing the lump will only get a very ugly scar, she will need tinkering and it was better to take off the total [...]; she said she has to take everything;

[...] She said she had to take away, take away only one quadrant; [...] She said that I would do the surgery and because it was at the beginning, taking the breast I'd be cured, because if you take half it can then commit; [...]
The doctor said it would be done the surgery, she would take a breast that I had to do a biopsy to see if I would have to take the glands of the axilla [...];She explained that she was taking the breast because I need to remove the entire breast.[...] That I would decide if I wanted to do a mastectomy; [...]She asked if I accepted then I said, I accept [...] she said she had to take away, take away only one quadrant, but I did not want it, just wanted to take the whole [...] she asked if I agreed.
The Collective Subject Discourse of women participants, regarding the transfer of preoperative instructions by the doctor reveals a communication in the surgical procedure.While valuing the autonomy of the patient and the type of surgery, it is clear that the discourse of these professionals is still far from what is encouraged by health practices, as the host and humanization, which involves other aspects related to the welfare of women facing the diagnosis of breast cancer.
The doctor as a member of the multidisciplinary team is responsible for communicating with the diagnosis of breast cancer for the patient.With respect to communicating bad news, it should be thought of the patient as a being that has its own peculiarities and feelings, especially if it happens abruptly, will have affected their emotional dimension, impacting negatively on their biological function and inhibit the process of treatment and recovery.
In a comparative study, the response of women showed that at diagnosis and definition of therapy, they rarely have autonomy in decision-making process.It is noteworthy that most surgical techniques disregards the patient as person of the subject and its treatment process.The importance of information about the disease, treatment and its consequences are fundamental.The guidelines should be forwarded to encompass aspects related to prevention, treatment and its implications for women's lives 8 .
These aspects are considered essential to decrease anxiety and fear when diagnosis and treatment.Thus, for surgical treatment become more human, the patient should be emotionally prepared and guidelines should be complete.The research suggests that the care provided by medical professional is not just talking the type of surgery and it is but to explain each step, ie, the reason and the real needs of the surgical procedure, care before, during and after surgery and its consequences, so that the patient can be aware of their treatment, working on his recovery 8 .
Early treatment of breast cancer results in increased survival rates, but there is still a feeling of vulnerability, because of the possibility of recurrence and/or death.Effective communication during treatment allows better recovery of women with mastectomies, causing a decrease in anxiety and fear 9 .
Furthermore, the study shows that newly diagnosed with breast cancer patients need support to understand the complex medical information, dealing with diagnosis and treatment decisions difficult.As patients receive from their doctors useful information and emotional support to decision-making is likely to increase their confidence level 10 .
Thus, it emphasizes the importance of encouraging the appreciation of medicine at its most human character, especially in times when the information unveil the severity of a diagnosis or approaching a fatal outcome 11 .Study highlights that some doctors work so consistent with the principles of humanization, to see the other as a holistic being and to understand the patient's view not only their biological needs, but also seeking to clarify doubts and anxieties about the treatment and recovery from surgery, preparing them psychologically for the whole process.
The following is the speech of women from the question: What is the preoperative care provided by nursing staff?
Preoperative Guidelines: Role of the nurse

[...] She did a lot of questions, that about religion and that stuff [...] she was here with me, she made my record [...] just asking the questions [...] she said that I would not eat, I would take what I had brought in supplies, prosthesis, and these things [...] she said it was not about of some food,
Pre-operative of women in mastectomy by the Multidisciplinary team Nascimento KTS, Fonsêca LCT, Andrade SSC, Leite KNS, Zaccara AAL, Costa SFG that I did until yesterday [...] she guided that when going to the surgical block, remove the teeth, the alliance and the earrings that I have [...] said it was to take the watch, the panties; [...]She said, stay calm, if not the pressure will rise [...] she checked the pressure and said it was a little high.
In this CSD we can see that the study participants emphasized the role of professional nursing, as the person who uses an instrument to collect data in order to gather information about their health status, inform about the care before surgery and directly follows the framework clinical patient by checking vital signs.
It is known that the history of nursing is a presente instrument in some clinics for the development of nursing consultation, during the time of hospital admission.On this occasion, the nurse gets the patient and forwards him to the respective nurse and bed.On hospitalization there must be interaction of nurses with patients in the intention to seek information about the reason for admission, complaints, personal and family history, preexisting conditions, eating habits, among others.
Instructions on removing objects, accessories and underwear, as well as accreditation of fasting and measurement of vital signs are part of the function of the nursing team.These interventions before surgery are essential for the proper course of operation.However, similar to medical professionals, nursing staff seems to have been limited to the transfer of information by rote and not individualized.
Nursing actions when initiated from pre-operative stage, has the potential to become the most peaceful time of surgery, which reflects in a good recovery of the patient.Research indicates that the role of the nurse in the patient with breast cancer is to reduce stressors intrinsic to the surgical procedure, directly affecting the physical, psychological and social adjustment of such women and helping to prevent and overcome depression and anxiety 12,13 .The nurse should be present also in sharing information about the surgical procedure and the nursing interventions that will prepare him for surgery.
The patient must be the central focus of nursing thus know his opinion about the care being provided is essential.The caring and considerate treatment is experienced by surgical patients during all stages of the surgical process, which confirms the need for humane care and consolidates a focused plan of care 14 .
Under this view, the nursing care to women with breast cancer should not be restricted to gathering information on hospitalization and the disclosure guidelines preoperatively, but should focus on humanized care, focused understanding the human being.
Nurses have a key role in the multidisciplinary team, acting as promoter of humane practices in the care of inpatients process and especially with those who are undergoing a procedure considered mutilating, as women in this study, to undergo surgery of breast cancer may suffer from breast removal, something sudden and distressing.
Thus, it can be stated that nursing's role is to attend the biopsychosocial needs of patients, making the hospital stay a pleasant time, ensuring biological and emotional stability of women, which will facilitate preoperative mastectomy.
Here are the women's speeches about the question: What is the preoperative care provided by (a) social service?
Psychological and Spiritual Support: Role of the Social Worker

[...] He said to me to stay calm, no one wants it, but it happened [...] he gave me a lot of support and talked to me, he helped me a lot because he gave a word of encouragement, victory [...] he gave me advice to be close to God and that He was ahead of everything.
In this discourse, there is an evident reference to the intention of social service professional to strengthen the confidence to surgery which would be submitted.These statements reveal the importance of social assistance aimed at qualified hearing, favoring a reaction of the patient regarding openness to apprehend the words of this person as an incentive to overcome this difficult phase of life through spirituality and formation bonding.
Thus, the care of patients with breast cancer delineated by the benefits provided by the use of positive spiritual coping strategies are consistent with a study that shows, for example: high treatment compliance, facilitating access to support networks and social integration, production meaning and purpose of life, increased level of hope and depressing symptom reduction 15 as results approach of this size.However, to offer a carefully covering the biopsychosocial and spiritual aspects still presents as a challenge to the professional responsible for assisting the patient with cancer.
Within this context, every day becomes more relevant the existence of a multidisciplinary team to attend the cancer patients, with regard to guidance, referrals and treatments with the aim of generating positive results.And for the success of the service, the staff must act in socioeconomic, educational and rehabilitational fields, through close contact with the patient and his family should know the clinic, diagnosis, treatment adjuncts, in order to intervene on psychosocial aspects, to be a determining professional in the success of treatment 15 .
On this issue, a study emphasizes the need for social support offered by the multidisciplinary team and therapy with psychologists, in addition to the support of family and partner, who also play an important role in the adaptation of the patients 16 .Another research associates social support for reducing the severity of depression and anxiety, moreover, it suggests that the greater the number of people offering this social support, whether family, friends or social worker, the greater the level of psychological well-being of the patient 17 .
Pre-operative of women in mastectomy by the Multidisciplinary team Nascimento KTS, Fonsêca LCT, Andrade SSC, Leite KNS, Zaccara AAL, Costa SFG The professional social service is a member of the multidisciplinary team, that through conversation can solve the doubts and refer the patient to the appropriate sector.It is through dialogue that the social service system can identify the difficulties and the various needs of the patient, by supporting and establishing a bond in this case with individuals who will undergo surgery for excision of breast cancer.
This conversation with the patients may be essential for greater emotional stability and increase their confidence, making the process of preoperative less traumatic.We notice that all health professionals, people like members of a multidisciplinary team should contribute to a better adaptation of the patients, more specifically, those women who are in pre-operative process considered quite delicate.
The following central idea was built on the question: What is the pre-operative care provided by (a) nutritionist?
Guidelines on eating habits: Role of the Nutritionist The role of professional of nutrition is essential to the continued preparation of the patients in the surgical procedure regarding dietary clinical history.Thus, many metabolic and body composition changes can happen in patients with breast cancer as a result of surgical injury as a result of special nutritional needs.
With inadequate nutritional intake, patients can progress to a state of malnutrition.Thus, a study found that the estimated energy is a decisive factor in the prognosis of the patient.Considering it is the responsibility of the nutritionist the dietary prescriptions and important and essential the presence in the multidisciplinary team of nutritionists to atend women since their preoperative hospitalization 18 .
It is important to emphasize that other professions included in the form as psychology and physiotherapy, were not mentioned when women were asked about the information they received from the multidisciplinary team.
It is indispensable to the psychologist, offering support and guidance to those women of the period the diagnosis being confirmed, because of the variation of the feelings they expressed during the course of the disease, until the ending of treatment.Furthermore, we believe that physical therapists should also be present in order to provide their assistance before and after the surgery due to immobility time of the upper limbs in order to minimize and prevent the possible sequel.It should be mentioned that the research presents a limitation of the small number of participants, which prevents generalization of results.

FINAL CONSIDERATIONS
The results of this study showed the importance of the composition of a company committed to the welfare of patients in preoperative multidisciplinary team mastectomy.Discourses revealed that each professional worked in his field without showing greater involvement with the other members of the healthcare team.
Medicine, Nursing, Social Work and Nutrition performed interventions according to their skills, demonstrating an understanding of these professionals in a reductionist and mechanical performance, reflecting the conceptions passed by educational institutions.
The main obstacle of the multidisciplinary team in this research was not evoke its capabilities in providing surgical preparatory process information, which are necessary for the satisfactory during surgery, but the sense of dislocation of team members, in order not to favor comprehensive care and committed to the individuality of each patient preoperatively mastectomy.
Communication between health professionals is relevant to the practice of welcoming, the opposite being a characterization of discontinuity of care for health demands that favors a faulty construction of humanization, as seen in this study.However, this research was conducted with a small group of women, whose findings should be restricted to the area of research and should not be generalized to the entire national context.
It is suggested to health professionals entered in multidisciplinary teams, greater involvement among its members through regular meetings, to provide the patient pre-operative mastectomy a call on its completeness, through the exchange of technical and humanistic character, considering biopsychosocial needs.
Furthermore, the inclusion of a group of post-mastectomy women and preoperative, attended by several health professionals in their different categories with a commitment to conducting regular meetings is a salutary initiative for changes in practices the health service.
[...]She asked if the intestine was good, if I had milk, any bad food [...] what was I liked to eat, if I ate everything [...] she asked on my feed [...] she asked me what I would eat; [...]She said: you will eat today because tomorrow you will not eat, you will eat only after [...]She guided me to go without food until the time of surgery [...] she said I was supposed to going without food from yesterday 10 pm till today.