Nurses' practices at health basic units in a city in the south of Brazil

Abstracts

En la Salud Colectiva los enfermeros pueden influir efectivamente en la atención de las necesidades de la salud de las poblaciones. El objetivo de este estudio es caracterizar y comprender las prácticas de los enfermeros en Unidades Básicas de Salud. Se trata de una investigación cualitativa, en la cual fueron realizadas entrevistas semi-estructuradas con 15 enfermeros actuantes en Puerto Alegre, Brasil. Los datos fueron tratados con base en el análisis de contenido del tipo temático. Los resultados indican que las acciones ejecutadas por los enfermeros son influenciadas por el sistema de la salud y por sus limitaciones, especialmente la falta de trabajadores. Los enfermeros son solicitados para resolver problemas que no siempre presentan una relación con su trabajo, demostrando la diversidad de sus prácticas. Se concluye que la presencia del enfermero en lo cotidiano y su papel articulador contribuyen para modificar las realidades de la salud.

enfermería en salud comunitaria; enfermería en salud pública; rol de la enfermera; centros de salud

Na Saúde Coletiva, os enfermeiros podem influir efetivamente no atendimento das necessidades de saúde das populações. O objetivo deste estudo é caracterizar e compreender as práticas dos enfermeiros em unidades básicas de saúde. Trata-se de pesquisa qualitativa, na qual foram realizadas entrevistas semi-estruturadas com 15 enfermeiros atuantes em Porto Alegre, RS, Brasil. Os dados foram tratados com base na análise de conteúdo do tipo temática. Os resultados indicam que as ações executadas pelos enfermeiros são influenciadas pelo sistema de saúde e suas limitações, especialmente a falta de trabalhadores. Os enfermeiros são procurados para resolver problemas que nem sempre apresentam relação com seu trabalho, demonstrando a diversidade de suas práticas. Conclui-se que a presença do enfermeiro no cotidiano e seu papel articulador contribuem para modificar as realidades de saúde.

enfermagem em saúde comunitária; enfermagem em saúde pública; papel do profissional de enfermagem; centros de saúde

ARTIGO ORIGINAL

^IM.Sc. in Nursing, Faculty, Centro Universitário FEEVALE, Brazil, e-mail: [e-mail]

^IIPh.D. in Nursing, Associate Professor, School of Nursing, Rio Grande do Sul Federal University, Brazil, e-mail: [e-mail]

ABSTRACT

On Public Health, nurses can influence the care of the health needs of the population. The objective of this paper is to feature and understand the practices of nurses working at Health Basic Units. It is a qualitative research whereby semi-structured interviews were made with 15 nurses who work at Porto Alegre-Brasil. The treatment of the data was based on analysis of content of the thematic type. Outcomes indicate that the activities performed by nurses are influenced by the Health System and its limitations, especially the lack of nursing workers. Nurses are sought to solve problems that are not always related with their work, demonstrating the diversity of their practices. The conclusion is that the presence of nurses in the daily care and their articulating role contributes to change the realities of health.

Descriptors: community health nursing; public health nursing; nurse's role; health centers

INTRODUCTION

Public Health is considered a privileged area for Nursing and for team work, where each professional keeps their space and area of competence and responsibility⁽¹⁾. In this field, nurses have found a broad space to develop their routine work⁽²⁾, deciding on their actions, establishing how they do their work and keeping considerable autonomy in their practices, since the care model provide them greater freedom to use spaces to change local realities.

Health services and their structures influence the work of nurses; however, they can find escape lines in this context and look for alternatives different from those traditionally used for the situations. This escape lines can make workers change certain realities, using the resources found in the services and employing a social view, rather than only biological, of the body, thus demonstrating understanding of the social determination of the health-disease process, proposed by Public Health⁽¹⁾.

From this perspective, we understand that escape lines can also demonstrate how nurses have acted to transform their work. Because Collective Health is a field where professionals establish priorities of action, the following question is always posed: What are the characteristics of nurses in primary care? What aspects influence building up these practices?

The perspective of this study makes nursing practices, social practices that go beyond the technical and professional dimension, and consider the dynamics that include building of knowledge, socioeconomic and political reproduction and insertion of individuals in this context. Thus, nursing work is understood as presenting a social end with a biological perspective and that also includes psychosocial and cultural aspects⁽³⁾.

The field of competence and responsibility of nurses in health team is care. In the field of Collective Health, professionals develop several activities to care for users of these services⁽¹⁾. These activities are the bases of their work and the means they use to look for changes in the reality.

This article, written from a master's thesis⁽⁴⁾ aims at: featuring and understanding practices of nurses in Basic Health Units.

METHOD

This is a qualitative study⁽⁵⁾. Participants of this survey were 15 nurses working at Basic Health Units (UBS) in the city of Porto Alegre. We have intentionally selected two district management of the city that agreed and were available to take part in the study. Both managements encompassed population areas with poor socioeconomic conditions and dwellers in risk situations.

As a technique for data collection, we have used semi-structured individuals interviews⁽⁵⁾, based on a script, and with questions made from findings of the literature and the objectives of the study. Interviews were conducted in July and August 2006.

We have obtained authorization from the coordinator of the Primary Care Net of the City Health Secretariat and the project was approved by the Ethical Research Committee according to process # 001.034383.03.9. Each interviewed nurse received a written informed consent ensuring the prerogatives based on the Resolution # 196/96, of the National Health Council.

To treat data, we have used the content analysis technique and thematic analysis⁽⁶⁾.

RESULTS AND DISCUSSION

Interviews performed with nurses showed different realities in each of the Basic Health Units researched, with contrasts in working conditions, professional conceptions regarding their work, and in the practices performed in their routine.

Activities of nurses in their work routine

The activities of nurses can be classified as: management activities in the Health Unit; coordination activities, organization, training, control of nursing work; individual care activities, and collective care activities⁽⁷⁾.

Several activities were mentioned by nurses as part of their routine work. Description presented here does not entail all activities performed by them at UBSs in Porto Alegre, but they are only representing those that were most commonly mentioned by professionals during data collection.

Examples of management activities in the Health Unit were reporting diseases, asking for materials, scheduling appointments in the health unit, scheduling appointments with specialists in the central of appointments, and writing several types of reports. All nurses interviewed pointed out as part of their routine practice coordinating the nursing team of the Heath Unit and the actions of the team were under their responsibility.

Examples of coordination, organization, and training activities, and control of the work of the nursing team mentioned were: clock in records, recording absences, organizing shifts, day-off and holidays, supervising teams in the tasks performed in health unit (wound dressings, welcoming, vaccines).

Individual care activities included: welcoming, home visits, nursing appointments in the following programs (prá-nenê (for babies), hiperdia, women's health, and prenatal, prá-vida (for life), smoking, guidance for children with asthma), vaccine application, performance of Guthrie test, cytopathologic collection, screenings to prevent breast cancer, placing urinary probes, performing surgical dressing, checking blood tension, blood glucose test, requesting examinations, assessing laboratory examinations required by physicians (X-Ray, scans, ECG), assessment interview with couples for vasectomy, on the counter services. reception service, and giving medications.

Examples of collective activities were: education groups for family planning, smoking groups, diabetes groups, asthma groups and pediatric groups.

We may understand that nursing care is also directed, in collective health, at individual care and its systematization geared to priority groups that are characterized by biological risks, such as hypertensive, and diabetic patients, children in daycare centers, among others. This idea is confirmed on the study of the national survey of the International Classification of Nursing Practices in Public Health⁽⁸⁾ which states that even when dealing with groups or collective objects, the work of nurses present chronological cuts, due to diseases or places where care is provided such as daycare centers, schools, among others.

We did not want to investigate distribution of time nurses spent in each routine activity; however, we identified a greater variety of individual activities that do not necessarily correspond to the division of time dedicated to each activity. A study⁽⁹⁾ indicates that activities performed in the routine work of nurses can be quantified in the following way: 28% individual actions, 23.9% collective actions, 33% management actions, and 13.8% refer to coordination, organization, training, control and supervision of nursing work.

Interviewees mentioned performing activities exclusively to nurses, such as nursing appointments and supervising assistant and technicians. However, actions mentioned include several activities normally performed by assistants and nurse technicians. These activities can be performed by nurses; however, this situation becomes a problem when they stop performing their activities such as nursing appointments to help the nursing team with technical procedures due to shortage of workers.

Thus, from the findings of this study, we may consider the strong influence of local conditions in the practice of nurses, especially shortage of nursing staff. This lack of professionals is considered a condition of all the basic centers of the city. Nurses stop performing actions of their work to cover up for the basic work of Nursing in Health Units that supports all other works of the team. Home visits considered as a strategic activity in basic health is one of the actions limited by the shortage of nursing labor. According to the report of an interviewee, when leaving the Unit for this action, nurses leave a few assistants alone, without being able to help in case of need, and in the occasional absence of other health professionals responsible for the UBS.

A study performed in a capital in the south of Brazil^(10), identified similar aspects to those found in Porto Alegre, explaining the difficulties found by nurses when performing their activities due to other demands. The authors reported a significant difficulty in performing nursing appointments because nurses were in great demand for other activities.

The practice of nurses cannot be characterized only by the description of their activities. Analysis of these practices demand assessing what is considered in planning, the features and specificities of work.

Through the proposal of actions, nurses try to meet the needs identified by them or by the health team. Proposing actions is followed by counter-proposals of other professionals concerning the recognition of the work performed. That is, as actions are proposed by nurses and lead to positive outcomes for the team and for the population, more ideas and proposals are presented to nurses by their team peers. This situation shows a process of continuous assessment and change in the practice of professionals that are defined by technical division between the team members, of fields and activities related to each individual and, especially, based on the demands of the local population. A study performed in the reality of UBSs in another capital⁽¹⁰⁾ shows that regarding organizing the work in the Health Unit, some nurses go towards activities that are not direct care or they "specialize themselves" in some kinds of care: because of affinity, the demand or the work division.

Among the competencies of nurses in primary care described in the literature⁽¹¹⁾, is the fact that nurses are responsible for health care and contribute to the organization of this care, as well as foster commitment with health as an individual and collective right.

The presence of nurses at UBSs should be highlighted. The features of the working hours of most nurses enable them to be recognized as a professional with access to the population since they stay longer at UBSs, they work within several fields in the unit, and they perform more outside activities.

Qualities such as nice, generous, and humane have already been attributed to nurses of Public Health⁽¹²⁾. Because of these features, reinforced by the social idea that represents nurses as angels, users seek them, many times, to meet needs that go beyond their solving capacity.

(In)specificities of nursing work

Several interviewees said that "everything" is considered by users as a reason to look for nurses. This feature reinforces the articulating role of these professionals in the routine of UBS. Nurses articulate the demands of users with the structure of the service and with other professionals, as well as work as a reference for other members of the team in the referral of problems and requests. The articulating role of nurses was classified as positive in the interviews, since it reinforces the importance of the team and demonstrates the polyvalence of their work even if it means overload. The polyvalent feature, incorporated into the professional practice as a strategy to occupy spaces, may be characterized as a specificity of the nursing work⁽¹³⁾.

A study performed⁽¹¹⁾ highlights, among the competences of nurses in primary care the contribution of nurses for the construction of more humane care as they use their competences such as listening to users and demonstrating welcoming skills and sensibility. The uses of these skills are elements that guide and organize practices in primary care.

Polyvalence of the work of nurses refer both to actions with users and those related with team work, because as though they are not in a coordinating position at UBS, nurses are involved with the problems of other members of the team, outside the scope of nursing. An example of that is the case of a nurse who was called to solve a conflict between the cleaning assistant and the doorman of a health unit.

Other careers such as psychologists, social workers, physicians, and even lawyers were mentioned in the interviews to exemplify the reasons users looked for nurses and they considered nurses can solve or refer suitably to all kinds of problems. Thus, it is not the figure of other professionals that nurses get close to in this analogy, but rather to the work performed by these professionals.

Dissatisfaction with the situations presented was clear; however, nurses accepted this situation because they accept the several problems that are presented to them, even though they say they are not part of their job. When they accept the role of solving these situations, nurses take up work that cannot be measured, is not defined and cannot be classified. Thus, it is invisible work, that cannot be considered light or less important because of this feature, but which is closer to female and domestic work that has followed the profession since its beginning.

Association of their work with that of firefighters, done by an interviewee, indicates the extent of nurse actions in face of the demand presented, not only due to the need for health of the population, but for all kinds of problem. Some nurses present fixed, pre-determined activities, such as the schedule of nursing appointments and groups. But all of them said that in addition to these actions, they take up all the rest, indicating that there is a considerable amount of time consumed by this non-defined work.

Nurses have been using their space in a confusing way, becoming overwhelmed with activities in the daily work but without the corresponding political power of these spaces. This feature is reflected in the understanding of all issues important to nurses, and therefore, must be solve by them⁽¹²⁾.

When they absorb everything as theirs, workers in this field run the risk of becoming invisible to the institution, to the health team, and to society. Thus, professionals become invisible due to the invisible job they perform. When they tell users when they can get their working papers, when they get involved in the problems patients had because their medical certificate from a certain private outpatient facility was incomplete, when they advise a user regarding her marital problems (these are examples mentioned in the interview), nurses are performing important actions for these users that correspond to the need they have at the time, however, it cannot be considered as care within the activities predicted in the system.

Another element that should be considered in this issue may be related with the way some health services are organized, making users adapt their needs to the care supply. Reports from nurses enabled us to infer that interviewees are listening to their users and, in a way, indicate a solution for their several needs. In that, the problem of making supply suitable is left to nurses that spend a considerable amount of time in actions that cannot be recorded or quantified, and are not valued by other professionals and by the system and that contribute to the invisibility of the professional.

These actions, normally taken as guidance, are usually performed in the hallways or waiting room of the UBSs. In these places users can stop nurses and ask for help that occur usually verbally, with no possibility for formal record on users' charts or the outpatient production report. Thus, the action cannot be checked later, or seen by other professionals that can add to the record of behaviors, because it is considered that the "record of nursing actions on the chart is a significant instrument in nursing care and it is essential to proper patient care"⁽¹⁴⁾.

Practices and spaces of nurses were historically made with the objectives of ensuring the work of institutions and follow medical orders, as well as to meet the demands of patients, developing with that the skills and tradition for viewing the whole, which is very often mentioned to characterize the work of nurses. Thus, the actions that help this invisibility are those that guarantee the functioning of health institutions.

Visibility of the physicians' work and invisibility of the nurses' work is compared in a study⁽¹⁵⁾ that indicates that the first is made up of concrete and quantifiable actions, with a higher wage and payment for each action made, whereas the second follows the orders of the first even with their concrete, continuous and essential existence.

When points referring to this issue were discussed, there is a study questioning the need for nurses to define a role when performing care, because when they develop several ways of care, they carry with them an array of specific knowledge and practices, that they use to establish a relationship with users, taking up a role at each established relationship⁽¹⁶⁾. The statements of interviewees show an important sense of their work is to meet the several demands from users, and that the problems that are totally out of reach for them lead to frustration and fatigue.

Understanding the role of nurses require understanding Nursing as a social practice, historically influenced. Nursing presents internal contradictions in its knowledge/making, such as nursing care that is not performed only by nurses, the difficulty to measure its workforce in terms of market, and the several activities developed that are not always related with nursing or with the client, situations that are presented as a bases for a conflicting routine and, at times, frustrating for professionals⁽¹²⁾.

The several reports on the articulating role of nurses to solve several problems enable to consider the assumption that this job is especially for nurses, in addition, of course, to the other activities already described. To fix or correct what became a problem, meeting different requests and demands is a sophisticated work of articulation. Thus, this feature could be interpreted not as a difficulty to define roles of nurses but as a specificity of their work of great value to the development of team work and, especially, to the care of users' need.

FINAL CONSIDERATIONS

The practices of nurses present, at the same time, features of Health Units, with their local specificities, and features related with the nursing profession and their work. The current historical and political context influence the relationship that is established within the service among professionals and the community.

Knowing and understanding practices of nurses need to contemplate articulating these practices with those of all health workers involved in the work process. Thus, not considering the perspectives of other professionals is one of the limitations of this study, which deals with one side of the issue: the speech of nurses. From the point of view of nurses on their practices, we have privileged the dimension of subject as the modifier of the reality that builds the possibilities of change and innovation within the structural organization already established in the activities.

Recebido em: 17.12.2007

Aprovado em: 10.8.2008

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Nurses' practices at health basic units in a city in the south of Brazil

Taís Maria Nauderer^I; Maria Alice Dias da Silva Lima^II

Publication Dates

• Publication in this collection
  01 Dec 2008
• Date of issue
  Oct 2008

History

• Accepted
  10 Aug 2008
• Received
  17 Dec 2007