Primary Health Care Team Research Articles

Reflective Tool on Advanced Access to Support Primary Healthcare Teams: Development and Validation of an Online Questionnaire.

Awareness of their standing relative to best practices motivates primary healthcare (PHC) teams to improve their practices. However, gathering the data necessary to create such a portrait is a challenge. An effective way to support the improvement of the practices of PHC teams is to simplify the availability of data portraying aspects of their practices that might need improvement. Timely access is one of the foremost challenges of PHC. Yet, very few tools supporting reflections on the implementation of best practices to improve access are available to PHC teams. To develop an online reflective tool that evaluates the state of a PHC team member's advanced access practice and formulates customized recommendations for improvement. This sequential multimethod study was informed by a literature review and an expert panel composed of researchers, patients, provincial and local decision-makers, and PHC clinical and administrative staff in the province of Quebec, Canada. Consensus was reached on the content of the questionnaire and the prioritization of the recommendations. No reflective tool on advanced access practices was found in the literature review. Grey literature was used to create an initial version of the questionnaire. This version was revised and enriched through consultation phases with the expert panel. Then, five iterations of the tool were tested with 169 PHC team members, which led to the conception of two distinct versions: one for clinical staff and one for administrative agents responsible for appointment booking. The final versions of the reflective tool are available online in both English and French. This reflective tool provides a portrait of PHC team members' advanced access practices as well as an automated report that contains personalized and prioritized recommendations for improvement. Further developments are necessary for its optimal use among PHC professionals other than physicians and nurse practitioners.

Colorectal screening program implementation in primary health care, in Loures-Odivelas, Portugal

Abstract Problem In 2020, Portugal had the highest cumulative incidence of colorectal cancer (CRC) in the European Union (103 new cases/100,000 inhabitants). The Colorectal Cancer Screening Program (CRCS) is based on fecal occult blood testing (FOBT) as the primary screening method. With the delivery of the stool sample collection device; instruction on its use is provided by the Primary Health Care team. The sample is processed at the Clinical Pathology laboratory of the Hospital Center (HC). In case of a positive result, the general practitioner communicates the result and refers the individual to the Follow-up and Treatment Center. Description The general objective of this project was to implement the CRCS in the 19 Family Health Units (FHU) of Loures-Odivelas Health Center Group, between September 2022 and April 2023. The following activities were carried out: 1. Sessions to present the patient pathway, record platform, and stool sample collection device; 2. Application of a checklist of essential points for the start of screening; 3. Preparation and dissemination of monitoring reports to the FHU; 4. Follow-up visits to clarify doubts. Results By March 2023, CRCS had been implemented in 15 of the 19 FHU (79%). Between September 2022 and March 2023, 1,430 devices were delivered and 959 FOBT samples were received (67%). Among the devices received with biological samples, it was not possible to issue a result for 5%. Lessons The activities carried out allowed for the initiation of CRCS in most FHU. The involvement of professionals in these activities contributes to increased patient adherence and proper collection technique, reducing inconclusive FOBT results. It is necessary to continue this strategy of personalized support for the FHU to consolidate the implementation of CRCS in LO HCG. Ensuring that the necessary materials are available and that result issuance and referral deadlines are met are important factors for maintaining professional motivation. Key messages • The objective was to implement the Colorectal Cancer Screening Program (CRCS) in 19 Family Health Units (FHU) in Loures-Odivelas. By March 2023, CRCS had been implemented in 15 of 19 FHU (79%). • It is important to continue these activities in order to put into operation the CRCS in all FHU and to tackle the problem of colorectal cancer.

Behavioral incentives on pay-for-performance schemes in primary health care: a scoping review

Abstract Background Incentivizing healthcare professionals through pay-for-performance (P4P) schemes has become an essential strategy to enhance healthcare quality and efficiency. In Portugal, a P4P framework was put in place in Primary Health Care (PHC). Understanding how these incentives influence healthcare delivery is crucial for optimizing P4P effectiveness. Objectives This scoping review aims to compare the impacts of intrinsic and extrinsic incentives of P4P schemes within PHC teams. Methods We are conducting a comprehensive scoping review following the PRISMA-ScR guidelines. The databases PubMed/MEDLINE, Scopus, Web of Science, and PsycINFO are being searched to identify experimental and quasi-experimental studies. Eligible studies focused on PHC providers organized in teams, examining the role of intrinsic and extrinsic incentives under both public and private healthcare settings. Results Preliminary findings include a Dutch study demonstrating significant improvements in adherence to prescribing guidelines through electronic health records based P4P indicator. In Ethiopia, performance-based non-financial incentives led to enhanced data quality and evidence utilization among health workers. Conversely, a study from Burkina Faso highlighted mixed results in antenatal care quality improvement despite incentive implementation. In Scotland, studies on the removal of financial incentives indicated potential declines in certain quality care metrics, suggesting the complexities involved in the direct and indirect effects of incentive withdrawal. Conclusions The preliminary evidence indicates that both intrinsic and extrinsic incentives can significantly impact the effectiveness of P4P schemes, though the nature and magnitude of these impacts vary considerably. The findings underscore the necessity of a nuanced approach to designing and implementing incentive mechanisms in PHC to foster sustainable improvements in healthcare quality. Key messages • Intrinsic and extrinsic incentives significantly influence P4P scheme effectiveness in PHC. • Designing P4P incentives requires nuanced consideration of varying impacts on healthcare quality.

Informing policy with health labour market analysis to improve availability of family doctors in Tajikistan

BackgroundTajikistan has embarked on health reforms to orient the health system towards primary health care (PHC). The health labour market analysis (HLMA) was initiated by the Ministry of Health with the World Health Organization (WHO) on policy questions related to the PHC workforce team. This article presents the results with focus on family doctors as a critical part of the PHC team, providing lessons for strengthening family medicine and PHC in the European Region and central Asia.MethodsThe HLMA framework was used to guide the analysis. The data for analysis were provided by the Ministry of Health and Social Protection of the Population of the Republic of Tajikistan. Descriptive means were used to analyse the data. A Technical Working Group guided the process.ResultsThere has been an increase in the number of health workers in the country over the last 7 years. However, there is a huge shortage of family doctors when compared with norms, with decreasing family doctor densities over the last 7 years. Family doctors have the highest vacancy rates among specialists and also constitute the highest proportion of specialists who migrate. There is inequitable distribution of doctors across the regions. Overall number of enrolments and graduates in family medicine are declining. Although salaries in PHC are higher than in hospitals, the overall health workforce salaries are lower than the national average. While there have been efforts to retain and attract doctors to PHC in rural and remote regions, challenges exist. The attraction of doctors to narrow specialties may be leading to undermining PHC and family medicine. While the optimal skill-mix and availability of nurses provide an opportunity to strengthen multi-disciplinary teams at the PHC level, shortages and unequal distribution of doctors are affecting health services coverage and health indicators.ConclusionsApplication of the HLMA framework has helped identify the bottlenecks in the health labour market flows and the possible explanations for them. The policy considerations emerging out of the HLMA have contributed to improving evidence-based planning for retention and recruitment of the PHC workforce, improvements in medical and nursing education, and higher investments in the PHC workforce and particularly in family doctors. Implementation of the Action Plan will require political commitment, financial resources, strong inter-sectoral collaboration, stakeholder management, and cross-country learning of best practices. Through this process, Tajikistan has shown the way forward in implementing the Central Roadmap for health and well-being in Central Asia and the Framework for Action on the Health and Care Workforce in the WHO European Region.

Health profile and care demands of children with special health needs

Objective: To identify the profile and clinical care demands of children with special health needs cared for by Primary Health Care teams in a city in the countryside of Ceará. Methods: A cross-sectional study with a quantitative approach, carried out in a Family Health Unit in the city of Tauá, Ceará, from May to December 2023. To identify children with special health needs (CSHCN), the Triagem de Crianças com Necessidades Especiais de Saúde instrument was applied to family members at home. Results: The majority of children were male (71.4%), preschoolers and schoolchildren (85.8%), students (82.1%), accompanied by their mother (82.1%), with family income greater than or equal to a minimum wage (60.7%) and living in urban areas (92.9%). The most significant demands were medication demands (85.7%) and development demands (85.7%), being perceived by family members/guardians or professionals in the age group of 1 to 3 years (39.3%). Of the 28 children, 89.3% have a diagnosis. It was observed that 60.7% have autism spectrum disorder (ASD), with six having a diagnosis of associated attention deficit hyperactivity disorder (ADHD). Conclusion: It was evident that health care is still mostly medical-centered on care for CSHCN treated in Primary Health Care.

Integrating traditional practitioners within primary healthcare teams: Development of an accreditation framework.

While the work of Traditional Healing and its practice is centuries old, many mainstream healthcare providers do not recognize its value. A priority for the Indigenous Primary Health Care Council (IPHCC) is to support Indigenous people, communities, and partners in the work of reclaiming safe spaces for Traditional Healing within primary healthcare settings. The primary goal of this IPHCC-led initiative was to understand barriers for organizations to integrate Traditional Healing and cultural services and from this information design an accreditation model for Traditional Healing Practitioners. This included the protection and maintenance of the experiences and knowledge of our Traditional Healing Practitioners through promoting and delivering Traditional Healing training and mentorship opportunities for the next seven generations of practitioners; and the creation of curriculum that will embed the concept of Two-Eyed Seeing as it relates to integrated Traditional Healing within mainstream practice.

Patient safety reporting and learning system of Catalonia (SNiSP Cat): a health policy initiative to enhance culture, leadership and professional engagement

Patient safety reporting and learning systems (PSRLS) are tools to promote patient safety culture in healthcare organisations (HCO). Many PRSLS are locally developed. WHO Global Action Plan on Patient Safety...

Services for older adults in rural primary care memory clinic communities and surrounding areas: a qualitative descriptive study

Background/ObjectivesAs part of a larger study, and in collaboration with rural primary health care teams, RaDAR (Rural Dementia Action Research) primary care memory clinics have evolved and continue to spread in communities across southeast Saskatchewan, Canada. This study focuses on the geographical areas of the four communities where RaDAR memory clinics were first developed and implemented and describes the services and supports available to older adults including memory clinic patients and families living in these areas. Our goal was to identify and describe existing programs and gaps, create inventories and maps, and explore the service experiences of family caregivers of people living with dementia in these rural areas.MethodsUsing a qualitative descriptive design, an environmental scan of services was conducted from December 2020 to April 2021 using focus groups (n = 4) with health care providers/managers (n = 12), a secondary source (e.g., program brochures) review, and a systematic internet search targeting four RaDAR memory clinic communities and surrounding areas via community websites, online resources, and the 211 Saskatchewan service database. Data were analyzed using content analysis; findings informed semi-structured interviews with caregivers (n = 5) conducted from March to July 2022, which were analyzed thematically. Geographic areas explored in this study covered an area of approximately 5666 km2.ResultsFrom the scan, 43 services were identified, categorized into 7 service types, and mapped by location. Seventeen services were dementia-related. Services included social/leisure activities (n = 14), general support/referrals (n = 13), transportation (n = 7), information/education (n = 4), respite (n = 2), in-home care (n = 2), and safety (n = 1). Service levels included local (n = 24), provincial (n = 17), and national (n = 2), and were offered in-person, remotely (or both) with 20 services across 4 service types offered remotely. In general, most services had no fees, involved self-referral, and providers had a range of education/training. Key interview themes reflected the need for locally available, accessible services that offer (i) individualized, flexible, needs-based approaches, (ii) in-home care and continuity of care, and (iii) both formal and informal supports. Key gaps were identified, including (i) locally accessible, available services and resources in general, (ii) dementia-related training and education for service providers, and (iii) awareness of available services. Benefits of services, consequences of gaps, and recommendations to address gaps were reported. In general, service providers and program participants were an even mix of females and males, and program content was gender neutral.ConclusionsFindings highlight a range of available services, and a number of varied service-user experiences and perspectives, in these rural areas. Key service gaps were identified, and caregivers made some specific recommendations to address these gaps. Findings underscore multiple opportunities to inform service delivery and program participation for rural and remote people living with dementia and their families.

A qualitative examination of the experiences and perspectives of interprofessional primary health care teams in the distribution of the COVID-19 vaccination in Ontario, Canada.

Primary health care (PHC) teams contributed to all phases of the COVID-19 vaccination distribution. However, there has been criticism for not fully utilizing the expertise and infrastructure of PHC teams for vaccination distribution. Our study sought to understand the role PHC teams had in the distribution of the COVID-19 vaccine in Ontario, Canada. The key objective informing this study was to explore the experiences and perspectives of interprofessional PHC teams in the distribution of COVID-19 vaccination across Ontario. A qualitative approach was used for this study, which involved 39 participants from the six health regions of the province. Eight focus groups were conducted with a range of interprofessional healthcare providers, administrators, and staff working in PHC teams across Ontario. The sample reflected a diverse range of clinical, administrative, and leadership roles in PHC. Focus groups were audio-recorded and transcribed, while transcriptions were then analyzed using thematic analysis. We identified the following four themes in the data: i) PHC teams know their patients; ii) mobilizing team capacity for vaccination, iii) intersectoral collaborations, and iv) operational challenges. PHC teams were an instrumental component in supporting COVID-19 vaccinations in Ontario. The involvement of PHC in future vaccination efforts is key but requires additional resourcing and inclusion of PHC in decision-making. This will ensure provider well-being and maintain collaborations established during COVID-19 vaccination.

The role of community health workers in non-communicable diseases in Cape Town, South Africa: descriptive exploratory qualitative study

BackgroundCommunity health workers (CHW) are an integral part of primary health care re-engineering in South Africa. Cape Town is developing community-orientated primary care, with a central role for CHWs. Their role in human immunodeficiency virus, tuberculosis, maternal and child health has been articulated, but is less clear for non-communicable diseases (NCDs). Non-communicable diseases are now a major contributor to the burden of disease. The aim was to explore the current role of CHWs regarding NCDs in the Eastern sub-district of Cape Town, South Africa.MethodsAn exploratory descriptive qualitative study made use of non-participant observation and qualitative interviews with CHWs, their managers, and nurse coordinators. Data from nine semi-structured interviews and ten observations were analysed with the framework method and Atlas-ti.ResultsThe CHWs were embedded in their communities and provided services via support groups, household visits and delivery of medication. They linked people to care with assistance of nurse coordinators. They could also provide physical care in the home. They lacked the ability to counsel people on the risk factors for NCDs and their role in rehabilitation and palliative care was unclear. More nurse coordinators were needed to provide supportive supervision. Inter-sectoral collaboration was weak and hindered CHWs from addressing social issues. More standardised and comprehensive training should equip CHWs for health promotion and disease prevention during household visits. Data collected in the community needed to be analysed, reported on and integrated with data from the primary care facility. This should also contribute to a community diagnosis. Their relationship with facility-based members of the primary health care team needed to be improved. Attention needed to be given to the requirements for and conditions of employment, as well as working hours and remuneration. Some equipment was absent and hindered their services for NCDs.ConclusionsCHWs have the potential to provide a comprehensive approach to NCDs, but community-orientated primary care needs to be strengthened in many of the key areas to support their activities. In relation to NCDs, they need training in basic and brief behaviour change counselling and risk factors as well as in the areas of rehabilitation and palliative care.

Electronic distance based clinical skills training development in family medicine in Namibia.

Workplace-based evaluation is one of the most important, but challenging aspects of medical education. The aim was to improve the assessment of the rural community-based clinical training for undergraduate 3rd and 4th year family medicine students at the University of Namibia (UNAM) and implement a paperless process. An online module was developed on the Moodle platform to include a study guide, an electronic portfolio, and electronic resources (e-books and apps) to replace the current paper version of the logbook. We explored local resources by engaging with students and clinical trainers on how to best conduct the initial implementation. Engagement also entailed motivating students to actively participate in the implementation process. All 3rd and 4th year community-based education end service (COBES) students are now submitting proof of clinical learning electronically with the use of their phones in their online portfolio and using online resources. In addition, students in the practical family medicine module that has been introduced in the 6th year since 2023 are now also using an electronic portfolio and these assessment tools.Contribution:Overall feedback from students and supervisors indicates a positive atmosphere of learning and constructive feedback on performance from all team members, hopefully improving work-based assessments and ultimately patient care. More members of the primary health care team were involved and the carbon footprint has also been decreased.

Brazilian Ministry of Health strategy to increase vaccination coverage at bordersEstrategia del Ministerio de Salud de Brasil para aumentar las tasas de cobertura de vacunación en las fronteras

Evaluate the implementation of the Ministry of Health's "Action Plan: Border Vaccination Strategy - Agenda 2022" in the Brazil's 33 twin cities and evaluate the increase in the country's vaccination coverage (VC). Pre-post community clinical trial. Implementation of the strategy was analyzed, and pre- and post-intervention VC were compared in two stages: P1 (pre-intervention) and P2 (post-intervention). Based on statistical analyses of P1 and P2 coverage, calculations were made of municipal averages, standard deviation, and difference in VC between the two periods. Integration was observed between the primary health care (PHC), surveillance, immunization, and special indigenous health district (DSEI) teams, although there were difficulties, for example, in relation to migratory flows. While immigration flows present challenges in the areas of immunization, PHC, and DSEI, the difficulties are compounded by the polarization of these services, which hinders intersectoral integration. After carrying out the workshops, a total of 50 977 doses were administered in the general population in the 33 twin cities. There was an increase in vaccination coverage in children up to 1 year of age in the locations evaluated after the intervention, which may be relevant in terms of increasing VC in Brazil. There was an increase in vaccination coverage in children up to 1 year of age in the locations evaluated after the intervention, helping to increase VC in Brazil.

The need for practice enhancements and parental empowerment during their child’s day surgery process: A pilot study

Background: Perioperative experiences leave a lasting psychosocial impact on the parents of children undergoing surgery. Methods: A phenomenological study design recruited parents of children undergoing day surgery using purposive sampling. Semi-structured face to face interviews were conducted two weeks postoperatively. Results: Thematic analysis revealed 6 main themes with 12 sub-themes. Although the parents acknowledged the emotional support and tangible assistance from the healthcare team, mostly the themes revealed negative perceptions of the unique processes within paediatric day surgery. Conclusions: Parents’ feelings of anxiety, stress, helplessness and the pressure to be seen as a resource of physical and emotional support during their child’s perioperative period were expressed by them as their needs for additional information and counselling, remote access to the primary healthcare team postoperatively and advice on coping strategies. Practice enhancements using technology and innovative playtherapy in combination with active parental participation may make day surgery a positive experience for both parents and children. Journal of Paediatric Surgeons of Bangladesh (2019) Vol. 10 (1 & 2): 5-14

The territorial nature of the Primary Health Care of Brazil's Unified Health System (SUS): the proliferation of community medical clinics in the Metropolitan Region of Belém, State of Pará, Brazil

The scope of this article is an analysis of the proliferation of community medical clinics in the municipalities that comprise the Metropolitan Region of Belem. An investigation was conducted into the performance of the primary health care network of Brazil's Unified Health System, with a view to getting a better understanding of the reasons for, and origins of, the proactive stance of the community health sector. The discussion is based on the review of primary and secondary data, obtained via fieldwork in 119 community clinics in the Metropolitan Region of Belem, and information from Brazil's Unified Health System data center. It was revealed that the community health clinic sector has benefited extensively in recent years from the intensification of underfunding of Brazil's Unified Health System, especially the primary health care network, which is undergoing a process of fragmentation. This is directly responsible for the reduction and disruption of multiprofessional primary health care teams, in addition to the losses suffered in the supplementary health sector. The community clinics adopt an spontaneous and contradictory care model created by the private sector to meet the repressed demand of Brazil's Unified Health System.

A National Assessment of Public Health Instructions in Medical Schools of Thailand

Epidemiological transition, population ageing, and pandemics posed new challenges to the health system. Current global situation demands many new competencies within the scope of teaching public health in medical schools. The aims of this study were to identify the needs of public health competencies for medical doctors in Thailand and to assess the level of integration for technical collaboration in teaching public health. The national survey of all Thai medical schools applied the list of public health competencies framework recommended by the World Health Organization, Southeast Asia Regional Office (WHO-SEARO). Qualitatively, community representatives from 11 sample villages were interviewed in the focus groups and representatives from stakeholder organizations, particularly employers in the in-depth interviews. Data integration applied recursive mixed-method approach. While the survey identified that health economics, disaster management, leadership, and teamwork are not well addressed in curriculum, employers, and national health authority uttered the need to strengthen the health system sciences and leadership in new generation medical doctors. Almost two third of medical schools could not apply interdisciplinary integration to teach such public health subjects. Furthermore, experiential learning and role play are recommended, in addition to the usual teaching method and multiple-choice questions. Thai communities expect doctors to serve the community, lead the primary healthcare team and train the health professionals and community health volunteers. Therefore, future medical doctors require interdisciplinary competencies. The findings of this study may provide evidence to step forward to a national framework of public health core competencies and interdisciplinary collaborations.

A qualitative examination of primary care team's participation in the distribution of the COVID-19 vaccination.

Primary health care (PHC) has historically led and implemented successful immunization programs, driven by strong relationships with patients and communities. During the COVID-19 pandemic, Canada began its vaccination strategy with mass immunizations that later included local efforts with PHC providers. This study seeks to understand how PHC contributed to the different phases of the COVID-19 vaccination rollouts in Ontario, Canada's most populous province. We conducted a descriptive qualitative study with focus groups consisting of PHC providers, administrators, and staff in Ontario. Eight focus groups were held with 39 participants representing geographic diversity across the six Ontario Health regions. Participants reflected a diverse range of clinical, administrative, and leadership roles. Each focus group was audio-recorded and transcribed with transcriptions analyzed using thematic analysis. With respect to understanding PHC teams' participation in the different phases of the COVID-19 vaccination rollouts, we identified five themes: (i) supporting long-term care, (ii) providing leadership in mass vaccinations, (iii) integrating vaccinations in PHC practice sites, (iv) reaching those in need through outreach activities; and (v) PHC's contributions being under-recognized. PHC was instrumental in supporting COVID-19 vaccinations in Ontario, Canada across all phases of the rollout. The flexibility and adaptability of PHC allowed teams to participate in both large-scale and small-scale vaccination efforts.

A qualitative study exploring the challenges and enablers of pharmacists with a recent background in community pharmacy transitioning into primary care.

Pharmacists are an increasing part of the primary care health care team in Scotland. Recruitment to this expanding sector has largely come from community pharmacy. However, it is unknown if these pharmacists have specific needs to perform their role within the primary care team. To explore the perceived challenges and enablers of community pharmacists transitioning into primary care pharmacist roles. Eight pharmacists (5 female, 3 male, median age 32) across Scotland's largest regional health board who previously practised in community pharmacy participated in a recorded, semi-structured interview via Microsoft Teams® to explore their challenges and enablers of transition into primary care. Recordings were transcribed, verified, and thematic analysis then undertaken. Five themes were identified: challenging transition, transferable skills, transferable training from community pharmacy, training needs for primary care role, and benefits of structured learning. Participants reported lack of opportunity to apply their clinical knowledge and for professional development in community pharmacy. Pharmacists in our study reported a range of challenges (such as examination skills, improved clinical and therapeutics knowledge) required to practice in primary care, while their regular patient contact and knowledge of community pharmacy workings enabled their transition. Previous sectors of practice should be taken into consideration when inducting pharmacists into a new role and background specific inductions may need to be implemented to support these pharmacists work autonomously at an advanced level.

Minimum intervention oral care - incentivising preventive management of high-needs/high caries-risk patients using phased courses of treatment

This paper demonstrates how person-focused, prevention-based, risk/needs-related, team-delivered, minimum intervention oral care (MIOC) principles and approaches can be integrated into the dental profession for the delivery of environmentally sustainable, optimal care to high-needs and high caries-risk/susceptibility patients. It highlights the potential for NHS remuneration for prevention-based, phased, personalised care pathways/plans (PCPs) within a reformed NHS dental contract system. It emphasises the importance of comprehensive and longitudinal patient risk/susceptibility assessments, prevention and stabilisation of the oral environment before considering more complex, definitive restorative work. This paper forms the first of several components of a suite of educational/information materials needed to instil confidence and implementation protocols within primary care clinical oral health care teams delivering MIOC through phased PCPs, especially when managing patients with high needs and/or disease susceptibility.

Learning About Resilience from Rural Interprofessional Healthcare Teams: Insights from the “First Wave” of COVID-19

Building resilience is a key concern for adult educators today as we face unprecedented global challenges such as the coronavirus disease-19 (COVID-19). Nowhere is this more apparent than in educational initiatives with health professionals who experience many stressors in their work, now amplified by the pandemic. This paper reports the results of focus groups with three interprofessional primary healthcare teams in rural Nova Scotia, Canada, in the fall of 2021. The aim was to learn about their lived experience during the first year of the pandemic, as a basis for considering how resilience could be nurtured and supported in rural team-based collaborative practices settings. Findings reveal that, while each collaborative team experienced recognized COVID-19 workplace stressors, they leveraged a store of collective resilience to navigate the pandemic. The trust, sense of purpose, and shared problem-solving skills they derived from working in collaborative structures over time enabled them to regain equilibrium and to adapt to new norms, and to transform thier practices. The study highlights the power of collaborative learning to strengthen overall ability for resilient performance, and the adaptive capacity that is required to deliver and sustain quality healthcare. The study highlights the need for continuing professional education that values naturally occurring practice-based learning. Adult educators are well positioned to support health professionals and health systems to nurture and support resilient action. They bring an understanding of effective collaborative tools and processes that foster dialogue and collective awareness that leads to a shared identity and understanding. As this study reveals, it is this shared identity and capacity arising within a group that enables them to draw on their collective sources of support to deal with adversity.

Territory: meanings produced by primary care nurses

Know the meaning of territory from the perspective of primary care nurses. An exploratory-descriptive study with a qualitative approach was conducted in ten primary healthcare units located in the city of Boa Vista, Roraima, Brazil. The social group consisted of eight permanent municipal employees who are nurses. Data collection took place from December 2022 to February 2023 through semi-structured interviews. The audio recordings amounted to approximately one hour and twenty minutes, which were transcribed manually and analyzed according to Bardin's theoretical framework. The meanings related to territory from the perspective of nurses working in primary care were organized into three thematic categories, namely: territory understood as the area of coverage for professional healthcare services, territory seen as a meeting place for healthcare professionals with priority groups, and territory interpreted as a space for care management. The meanings regarding territory have been decoded as the geographical space for the activities of the primary healthcare team professionals. Territory as the care location for priority groups, with emphasis on children, pregnant women, elderly individuals diagnosed with hypertension and diabetes, bedridden patients, migrants, individuals with disabilities, disadvantaged and vulnerable groups. Finally, (re)recognized as the place where action planning, organization of healthcare practices, service coordination, primary team supervision, and care evaluation take place.