Nursing consultation and diabetes: an educational and transformative process for primary health careObjective: to analyze the constituent elements that support nursing consultations with people with diabetes mellitus, and to develop an educational process based on the assumptions of the Chronic Conditions Care Model and mediated by a reflective-dialogical process with nurses, aiming to improve the quality of the practice in the Family Health Strategy.
Method: convergent care research carried out with 12 nurses. Participant observation, semi-structured individual interviews and convergence groups were used to collect data, which were treated by participatory analysis, with an interpretative approach.
Results: the promotion of self-care, the bond between professionals and users, and the support for lifestyle changes for people with diabetes were aligned with the proposed Care Model. On the other hand, attitudes, values and knowledge that weaken care were identified as divergent. The theoretical and practical deepening of the care model, diabetes, dealing with work overload, and the implementation of a guide and a protocol for the development of the nursing consultation were points of convergence for improving the quality of the consultation. It was also observed that nurses’ autonomy was strengthened, critical thinking was awakened, and the search for improvement and redefinition of the relationship with the user was sought.
Conclusion: the nursing consultation was enhanced through the active participation of nurses in an educational, reflective and dialogical process.
Descriptors:
Nursing Process; Diabetes Mellitus; Primary Health Care; Healthcare Models; Chronic Diseases; Problem-Based Learning.
Highlights:
(1) The Nursing Consultation for people with DM by nurses consisted of elements that are similar to and different from the MACC. (2) Elements that align with the MACC: as establishing a bond with users, accountability, longitudinal care, and the social and family approach. (3) Elements diverged from the assumptions of MACC: a limited understanding of the care model, the professional attitude of blaming the user and the weaknesses in the application of the nursing process. (4) The nursing consultation was enhanced through the active participation of nurses in an educational, reflective and dialogical process.
Objetivo: analizar los elementos constitutivos que sustentan la consulta de enfermería con personas que tienen diabetes mellitus, y desarrollar un proceso educativo basado en los supuestos del Modelo de Atención a las Condiciones Crónicas y mediado por un proceso reflexivo-dialógico con enfermeros(as), con el fin de mejorar la calidad de la práctica en la Estrategia de Salud de la Familia.
Método: investigación convergente asistencial realizada con 12 enfermeros. Se utilizaron observación participante, entrevista individual semiestructurada y grupos de convergencia para la recolección de datos, los cuales fueron tratados mediante análisis participativo, con enfoque interpretativo.
Resultados: la promoción del autocuidado, el establecimiento de vínculo profesional-usuario y el apoyo a cambios de hábitos de las personas con diabetes se acercaron al Modelo de Atención propuesto. Por otro lado, se identificaron como distantes las actitudes, valores y conocimientos que debilitan el cuidado. Los puntos de convergencia para mejorar la calidad de la consulta fueron la profundización teórica y práctica del modelo de atención, la diabetes, el enfrentamiento a la sobrecarga de trabajo, y la implementación de una guía y de un protocolo para el desarrollo de las consultas de enfermería. También se constató el fortalecimiento de la autonomía de los enfermeros, el despertar del pensamiento crítico, y la búsqueda de perfeccionamiento y resignificación de la relación con el usuario.
Conclusión: la consulta de enfermería fue mejorada a partir de la participación activa de los enfermeros en un proceso educativo, reflexivo y dialógico.
Descriptores:
Proceso de Enfermería; Diabetes Mellitus; Atención Primaria de Salud; Modelos de Atención de Salud; Enfermedad Crónica; Aprendizaje Basado en Problemas.
Destacados:
(1) La Consulta de Enfermería para personas con DM por parte de enfermeras estuvo conformada por elementos cercanos y se distanciaron del MACC. (2) Elementos cercanos con MACC: el vínculo, la responsabilización, el cuidado longitudinal y el enfoque social y familiar. (3) Elementos se distanciaron del MACC: comprensión limitada del modelo, la postura profesional de culpabilización del usuario y de las debilidades del proceso de enfermería con las personas que tienen DM. (4) La consulta de enfermería fue mejorada a partir de la participación activa de los enfermeros en un proceso educativo, reflexivo y dialógico.
Objetivo: analisar os elementos constitutivos que embasam a consulta de enfermagem com pessoas que têm diabetes mellitus, e desenvolver um processo educativo fundamentado nos pressupostos do Modelo de Atenção às Condições Crônicas e mediado por um processo reflexivo-dialógico com enfermeiros(as), visando à melhoria da qualidade da prática na Estratégia Saúde da Família.
Método: pesquisa convergente assistencial realizada com 12 enfermeiros. Utilizou-se observação participante, entrevista individual semiestruturada e grupos de convergência para a coleta de dados, que foram tratados pela análise participativa, com abordagem interpretativa.
Resultados: aproximaram-se do Modelo de Atenção proposto a promoção do autocuidado, o estabelecimento de vínculo profissional-usuário e o apoio a mudanças de hábitos das pessoas com diabetes. Por outro lado, atitudes, valores e conhecimentos que fragilizam o cuidado foram identificados como distantes. Constituíram-se pontos de convergência para a melhoria da qualidade da consulta o aprofundamento teórico e prático do modelo de atenção, diabetes, o enfrentamento da sobrecarga de trabalho, e a implantação de um guia e de um protocolo para o desenvolvimento da consulta de enfermagem. Constatou-se também o fortalecimento da autonomia dos enfermeiros, o despertar do pensamento crítico, e a busca pelo aperfeiçoamento e ressignificação da relação com o usuário.
Conclusão: a consulta de enfermagem foi aprimorada a partir da participação ativa dos enfermeiros em um processo educativo, reflexivo e dialógico.
Descritores:
Processo de Enfermagem; Diabetes Mellitus; Atenção Primária à Saúde; Modelo de Assistência à Saúde; Doença Crônica; Aprendizagem Baseada em Problema.
Destaques:
(1) A Consulta de Enfermagem às pessoas com DM pelos enfermeiros foram constituídas por elementos que se aproximam e se distanciam do MACC. (2) Aproximação com o MACC: o vínculo, a responsabilização, o cuidado longitudinal, e a abordagem social e familiar. (3) Distanciaram do MACC: compreensão limitada do modelo, postura profissional de culpabilização do usuário e das fragilidades do processo de enfermagem. (4) A consulta de enfermagem foi aprimorada por meio da participação ativa do enfermeiro em um processo educativo, reflexivo e dialógico.
Introduction
Diabetes mellitus (DM) is a chronic non-communicable disease that caused approximately 2.0 million deaths worldwide in 2019. From 2000 to 2019, DM recorded a global increase of 3% in the number of deaths, and in the Americas, it surpassed stroke in terms of years of life adjusted for disability, thus ranking second1.
According to the International Diabetes Federation (IDF), the prevalence of the disease in low-income countries is 5.5%2. In Brazil, an incidence of 8.6% was identified, with 68.2% of the population being aware of their diagnosis, 92.2% of those who are aware of their diagnosis undergoing drug treatment, and of these, only 35.8% have controlled glycated hemoglobin levels3.
Therefore, it is essential to pay attention to the current and future damage caused by this disease, in order to implement effective public policies, as most countries have made little progress in meeting Sustainable Development Goal 3.4, which foresees a one-third reduction in premature mortality from non-communicable diseases between 2015 and 2030. In this context, screening and treatment of DM are high-priority interventions to reduce mortality from chronic diseases4.
Primary Health Care (PHC) in Brazil, organized at the national level through the Family Health Strategy (FHS), should be the preferred entry point for people who have DM into the health system. It is the strategic point of care to better accommodate health needs, including longitudinal and continuous monitoring5. Treatments for DM are based on non-pharmacological and pharmacological approaches to glycemic control, which must be chosen considering the biopsychosocial-spiritual aspects of each person, through an interpersonal relationship between professional and patient, because this directly influences adherence to treatment.
Hence, the nurse is the professional in first contact with the patient, who must assume a leadership role in the detection, treatment and rehabilitation of diabetes. It is also up to this professional to support efforts to prevent the disease and to promote the health of people living with diabetes, thus allowing them to participate in decision-making related to their treatment6.
For the World Health Organization (WHO), the contribution of nursing to preventing and managing diabetes in the health system is demonstrated by six characteristics: 1) coordination of care to ensure that patients’ health needs are met over time; 2) participation in a multidisciplinary approach to care based on an integrated relationship between health professionals, allowing different professionals to work as a team to improve the quality of care; 3) mobilization and training of the nursing workforce to specialize in noncommunicable diseases, aiming for more effective and sustainable treatments; 4) improvement of access to care; 5) empowerment of individuals and the community; and 6) utilization of technology to maintain access to essential health services and reduce exposure to COVID-197.
There are efforts by Brazilian nurses to contribute to adherence to DM treatment, providing scientific bases for nursing care, with the aim of directing actions that promote greater adherence to treatment with the active participation of the patient, reducing complications, hospitalizations and mortality8. On the other hand, an international study9 showed that diabetes is still not a priority in primary health centers. The nurses explained the importance of working on primary prevention of diabetes, prioritizing the care of people with pre-diabetes, and pointed out the need to establish clinical guidelines, support in care knowledge and skills, in addition to the implementation of an interprofessional work process, crucial aspects in the health care of people with diabetes that are based on the Chronic Conditions Care Model (MACC, in Portuguese).
The MACC was proposed by Eugênio Vilaça Mendes to meet the specific needs of the Brazilian public health system. It has its origins in the Chronic Care Model (CCM) from the United States, and incorporates two other models, the Risk Pyramid Model (RPM) and the Social Determinants of Health Model, to adapt to the requirements of a public and universal health care system such as the Sistema Único de Saúde (SUS)10. This is an operational instrument, established in the National Plan to Combat Chronic Conditions to achieve the millennium development goals by 2030.
The nursing consultation (NC) guides the nurse’s critical thinking and clinical judgment, directing it towards the care of the person, family, community and special groups. In the context of the FHS and care for people with chronic conditions, the NC favors resolute, proactive and humanized care, based on educational actions capable of empowering users to achieve goals established in the care and self-care process.
However, the difficulties faced in the practice of NC within the scope of PHC are worrying, such as: lack of time, lack of agility for nursing diagnosis, problems in the interface between care and management, and excessive bureaucratic demands11.
In the scientific field, there is much to be investigated about nursing consultation for people with diabetes in the context of PHC, given its relevance, especially when associated with the MACC assumptions. There are few studies on this topic, which is committed to promoting changes and/or innovations in healthcare practice, adopting a constant perspective of constructing thinking and doing.
In view of the above, this research aims to analyze the constituent elements (knowledge, technologies, beliefs and values) that support nursing consultation with people with diabetes mellitus, and to develop an educational process, based on the assumptions of the Chronic Conditions Care Model and mediated by a reflective-dialogical process with nurses, aiming to improve the quality of the practice in the Family Health Strategy.
Method
Study design
Convergent care research (CCR) that aims, during the research process, to promote changes and/or innovations in care practice, based on the continuous construction of thinking and doing12. Its development adhered to the recommendations of the Consolidated Criteria for Reporting Qualitative Research13.
Study location
The study was carried out in a medium-sized city located in the central-west region of the state of Rio Grande do Sul, Brazil, which is part of the Health Care Planning project and has 11 FHS units, covering 86% of the total population.
Period
The data was produced between August 2020 and December 2021, during which the COVID-19 pandemic was ravaging the country. All precautions to prevent transmission were taken.
Participants and selection criteria
Nurses who worked in the FHS and had at least 6 months of experience in NC with people who have DM were included [according to Article 442-A of the Brazilian Consolidation of Labor Laws (CLT, in Portuguese), this is the maximum probationary period that employers can require for hiring purposes]. The exclusion criterion was established as follows: nurses who for some reason were away from work for more than 30 days during the data collection period, which did not occur. Thus, 12 nurses were contacted by email for a meeting to present the proposal and, in all cases, they agreed to participate in the study.
Data collection
Triangulation of techniques was adopted for data production: active participant observation14, semi-structured interviews15 and convergence groups16.
The objective of participant observation was to capture and record the most varied elements and impressions about the conduct of NC for people who have DM. Therefore, a pre-established script was used, which included the following aspects: professional relationship with the user, communication, stages of the nursing process, nursing record, and environment.
The researcher’s interaction during the observations occurred gradually. During the NC, she sought to maintain a more passive position, interacting strictly when necessary. Active participation occurred mainly after the end of the consultation, when, between one appointment and another, there was a dialogue about the case and knowledge was shared based on the researcher’s perceptions and the doubts listed by the participants.
The interruption of observations was established using the theoretical saturation criterion17, which consisted of individual compilation, seeking to identify whether the elements proposed by the script were explored. Once all elements had been covered, and no other new information relevant to the study topic emerged, observations were concluded. Totaling 120 hours, and with an average of 10 hours/participant, the data produced at this stage were recorded in a field diary and digital recorder, immediately after completion, coded and later transcribed into the Microsoft Word text editor.
The semi-structured individual interview was carried out by the researcher after reaching observation saturation and before the convergence groups. To this end, they were encouraged to talk about the daily routine of CE with people who have DM, addressing aspects such as objective, what they do and how they do it; about the MACC, their knowledge and applicability in daily life; about the challenges and potential for carrying out CE with people who have DM; and suggestions for the convergence groups. A pilot test was applied, but was not part of the sample of participants. Twelve interviews were conducted, previously scheduled with the participants, in the health units, audio-recorded, with an average duration of 40 minutes. Then, a trained research assistant transcribed the material in the Microsoft Word text editor.
The data obtained through these two techniques supported the Convergence Group (CG), which aims to carry out research simultaneously with healthcare practice within the collective, focusing on health education or clinical practice. In this space, discussions are promoted on a specific topic, the focus of the research, in an interactive process between participants and researchers, in order to allow dialogicity18.
The meetings were held according to a schedule developed with the participants, in the meeting room of the Municipal Health Department, with an average duration of 2 hours and 30 minutes. They were audio-recorded using a digital recorder, and the researcher was assisted by a research assistant, a student in the Master’s Program in Nursing, who received training and actively contributed to the planning, execution, observation and transcription.
To achieve cohesion, the convergence group went through a four-phase process, called the Four Rs Process: recognition, revelation, redistribution and rethinking16. The purpose of the recognition phase was to enable the group’s first meeting and establish relationships between participants and the researcher so that group cohesion could occur through participatory dialogue. This phase consisted of two meetings. The first aimed to analyze participants’ knowledge about the NC in terms of its purpose and assumptions. To this end, group activities were carried out, including the creation of posters, dramatization and debates. The second meeting focused on knowledge about the MACC, using keywords and images as resources to promote interaction and dialogue.
The revelation phase comprised the moment in which participants identified with their peers through their shared experience with the proposal of the meetings. This process was triggered when they were encouraged to talk about their experiences with NC with people who have DM and to develop the concepts that guide their care practice.
The redistribution phase was the moment in which the group, mediated by the exchange of experiences, was led to make shared decisions regarding the purpose of the meeting. This phase had three meetings and included a more active participation by the researcher. The activities were supported by reading, discussion of scientific materials, dramatizations, case studies and matrix support from a nutritionist.
The rethinking phase was characterized by the group’s reflection on the implications of the problems identified and the possibility of transferring what was shared and learned to the participants’ daily lives16. This phase took place in three moments, with the use of strategies such as: Brainstorming technique, case studies, group dynamics and preparation of the guide for NC with people who have DM.
The group meetings were planned and developed taking as a reference Paulo Freire’s Liberating Pedagogy, which has been used in studies in the areas of education, health and nursing. At this point, Convergent Care Research is linked to this framework, since it is grounded on liberating critical dialogue, based on the principle that critical reflection leads to action (practice), called praxis19.
Data analysis
The analysis was based on participatory research with an interpretative approach, carried out through the construction and feedback of narratives20. Built on the assumptions of Gadamer’s Hermeneutic Theory, this approach considers that acts of interpretation are dialogical, exploring participatory strategies and suggesting some changes in the classic way of conducting research. Among these changes, two strategies are used: narrative construction and validation, and participatory consensus production20. In this way, the participant engages in the investigation process, which enables the resignification and self-reflection of their actions21.
During the process of transcribing and organizing the data, several in-depth readings were carried out with the aim of understanding and exploring new testimonies. Thus, it was possible to perceive recurring, peculiar, divergent reports and expressed contradictions involving the practice of NC, and to make the first inferences and questions.
Given these considerations, the analysis was carried out as follows: after transcribing each of the semi-structured interviews (n=12), a narrative was constructed. Afterwards, the researcher returned to the field and read the narrative to each participant and, through the dialogic process, the participant reflected on the narrative and had the opportunity to contest or reinforce and validate it. With the convergence groups, in the same way, nine narratives were produced, one from each meeting, which were read and validated with the participants as the meetings took place. Before the next group began, the possibility of co-production by the participants was reinforced.
In order to facilitate the organization of this data and the categorization of the argumentative cores, the observation notes and the narratives of the interviews and groups were inserted into NVivo Corporate Software. Therefore, with the development of 21 narratives and observation notes, it was possible to construct and link the argumentative cores, which sought to answer the research question20.
Ethical aspects
The research followed the guidelines of Resolution nº 466/12 of the National Health Council22, as well as Resolution nº 510/2016 of the Ministry of Health, which emphasizes the ethical specificities of research in the human and social sciences and others that use methodologies specific to these fields23. It was approved by the Research Ethics Committee of the Universidade Federal de Santa Maria, under opinion number nº 4.209.003. All participants agreed to participate in the study and signed the Free and Informed Consent Form. Anonymity is guaranteed with the following codes: O (Observation) followed by the letter E (nurse), numerals 1 to 12 and date (day/month/year); NE (Nurse Narrative) followed by numerals 1 to 12; NGC (Convergence Group Narrative) followed by numerals 1 to 9.
Results
Twelve nurses participated in the study, mostly women (n=11), with an average age of 42 years (minimum of 33 years and maximum of 51 years). The average time since graduation in Nursing was 12 years (minimum of 5 years and maximum of 25 years), and the time working in the FHS was, on average, 7.5 years, with the shortest time being 6 months (n=1) and the longest 11 years (n=3).
The results will be presented through the following argumentative cores: Constituent elements of Nursing Consultation with people who have DM that align with and diverge from the Chronic Conditions Care Model assumptions; and Now it makes sense: the convergence between research and the educational process.
Constituent elements of Nursing Consultation with people who have DM that align with and diverge from the MACC assumptions
The elements of the NC with people who have diabetes in the FHS include characteristics that align with and diverge from the MACC, as demonstrated in Figure 1.
Nurses face some challenges in carrying out CE with people with diabetes that have persisted for some years, namely: work overload, lack of nursing protocols and standard operating procedures (SOPs), and the insufficient number of nursing professionals to meet care and management demands. [...] I believe that what most limits user assistance during consultations is overload! I am here to provide assistance to users, but that is not all I do! There are management issues related to the service, as well as spontaneous and administrative demands [...] (NE3). [...] the nurse was interrupted several times during the consultation to resolve administrative issues related to the service, such as requesting materials, receiving supplies, contacting another service, informing the vacation period of the community agent; she asked for permission and left the room to assess an injury in the dressing room (NO 08/09/2020). We recognize the need to develop and implement SOPs and nursing protocols, because we witness situations every day in which, if we had these instruments, we would have more autonomy [...] not to mention better quality in patient care. This way, our time would be better used [...]. For these reasons, looking for the issue of resolution in primary care, we understand that one of the possibilities are protocols, the SOPs. (NGC1). Even before the pandemic, the number of nursing professionals was already insufficient. We were no longer able to cope because we would actually need one nurse for the care area and another for management. And we only have two nursing technicians on the team; however, there is often one who is unavailable due to being on vacation, on duty, on leave, off, or engaged in another activity, such as now, when one is assigned to another unit to provide support for vaccination. (NE10).
On the other hand, the participants recognized some contextual factors as means of enhancing nursing consultation in the FHS for people with diabetes, such as support from municipal management, the city’s health care network, and sharing of care with the specialty outpatient clinic; the population’s recognition of the professional performance of nurses; and the bond with users and the professional relationship with the unit’s doctor: [...] I feel included in this management. Our demands are met; we have protected hours for team meetings and training (NE9). What enhances the consultation is that primary care is very strong in the city. [...] Users have access, support, recognize the unit as a point of entry, and acknowledge our work as nurses [...] (NE1). The issue of interconsultations with the doctor, as it helps in resolving it (NE4). [...] we have a specialized outpatient clinic to refer users who need evaluation [...] and they always give us feedback to implement care (NGC3). [...] we also have a health care network for users here in the city, such as laboratories, a social assistance reference center, a family health support center, nutrition and we can make all of this available to them at the Consultation, the user has access whenever they need it. (NE7).
Now it makes sense: the convergence between research and the educational process
From the convergence between research and care practice, demands emerged to qualify the Nursing Consultation in the FHS with people who have DM. The educational process developed in the convergence groups is represented in Figure 2.
In this study, the exchange of knowledge between the researcher and participants supports concrete actions for change and reflection-action movements that resulted in the collective construction of a guide for NC with people who have DM and the implementation of a nursing protocol. These changes are represented in Figure 3.
Discussion
People experiencing a chronic condition such as diabetes require appropriate care from the onset of diagnosis, so they can undergo a favorable adaptation process to their new health condition and maintain the balance of their well-being24. Therefore, various organizational models are used with the aim of educating and supporting self-management for individuals with chronic diseases, with the Chronic Care Model (CCM) being the most widely used, as highlighted in a review study25.
It is important to mention that the MACC has its foundations based on the CCM and, in addition to being an organizational model, it encourages changes in paradigms in care, aiming at comprehensive care, with the user at the center of care10. In this research, elements of CE with people with DM were highlighted that diverge from the assumptions of MACC, as a hegemonic view of the nurse-patient relationship is observed, with disease-centered and curative practices. Recent international research explored nurses’ perceptions of family-centered care for adults with diabetes and, similarly, the dominant medical model remains a challenge to overcome26.
In light of this reality, Brazilian nurses must reflect on the importance of their ethical and political role in caring for individuals with chronic diseases, in fulfilling and strengthening the principles of the Sistema Único de Saúde (SUS), as well as in enhancing the visibility of the profession. The way in which the participants of this study understand and operationalize the MACC differs exponentially from other realities, such as Austria, where nurses are recognized for their competence and are preferred by users to lead chronic care programs/models. This has practical implications for how care models are staffed and presents an opportunity for the nursing workforce to play a leadership role in service delivery27.
In Singapore, patients receiving diabetes care in the primary health care system who adopt CCM also reported satisfaction with the nursing care provided, continuity of care, and the patient-centered approach involving goal setting and problem solving28.
However, the nurses in this study identified several challenges in carrying out NC with people who have DM related to the work process, such as overload, overlapping management and care duties, and the need to implement protocols. To overcome these challenges, Bolivian nurses identified the need for support in the care of people with diabetes at the primary level, encompassing four dimensions: organization of care and health policies; strengthening the knowledge, skills and attitudes of the health team; training of people living with diabetes and their families; and education about diabetes at the community level29.
The challenges highlighted in this research could negatively impact the quality of care provided and, consequently, lead to metabolic imbalance and complications such as diabetic foot and limb amputations in people with diabetes. Thus, effective multidisciplinary management of the clinical condition of diabetes is necessary, which requires adequate recruitment of health professionals, a well-defined team, adherence to evidence-based guidelines, a good infrastructure for data collection and mechanisms for quality improvement based on the review of clinical data30.
In this research, the CCR method allowed nurses to reflect on their practice in NC with people who have DM and to initiate a process of change. In this way, the recognition by nurses of the need to overcome challenges occurred through an educational process that stimulated reflection and critical thinking, making them active agents and transformers of reality, which contributed to the establishment of strategies to minimize them. Similarly, studies carried out using the same method in other healthcare areas also enabled investments in in-service training, aiming to qualify nursing care31-32.
The research participants redefined the practice of NC with people who have DM, understanding the nurse’s practice as the art of continuously and thoroughly perceiving the needs of the person being cared for, valuing the subjective aspects, which will allow them to reveal the person in their entirety, resulting in the choice of the best intervention for them18.
The professional attitude was perceived as a need for change, being resignified as co-responsible care, which the participants called “caring with the patient”. Scientific evidence indicates that a centered professional-user relationship, with a dialogical approach, which prioritizes the emancipation of the subject and biopsychosocial aspects to determine care needs, enhances care for people with DM33 34 35.
The perception of the need for professional training and qualification was fundamental. Continuing education in health is an integral part of the work process and allows the development of skills and abilities consistent with the care model recommended by the SUS36. Furthermore, when nurses receive structured training and support, and use treatment algorithms and technologies, nursing care becomes more effective, impacting glycated hemoglobin values, with reductions of 0.03 to 2%37.
The demands for theoretical deepening of MACC and CE raised by the participants were conducted in a way that ensured significant learning based on reality38, resulting in satisfaction with the methodology used. This type of learning enables the improvement of critical thinking, autonomy, motivation to learn, active attitude, ability to work in a team and solve problems. To this end, we agree that nurses, during their ongoing training process, can develop skills to act effectively in PHC, reflecting on and about their practice and deciding on the need to remain in constant training to deal with issues arising from this practice39.
It is worth highlighting the importance given by participants to discussions about scientific knowledge in nursing, resuming conceptual differences in the systematization of nursing care and the nursing process (NP), as well as the use of standardized language systems, that is, knowledge and tools that qualify NC with people who have DM. In 2024, the Conselho Federal de Enfermagem (COFEN) resolution nº 736, was published, which, in its Article 2, conceptualizes and qualifies the NP as a method that guides the nurse’s critical thinking and clinical judgment for care, which must be based on theoretical support, such as care models, standardized language systems, validated risk prediction assessment instruments and protocols40. Hence, it can be inferred that the aforementioned concept is strongly linked to what nurses experience during the educational-reflective process.
In this study, it was essential to obtain the result that the participants perceived that the NP aims to positively interfere in nursing care for people with DM, as it directs them towards clinical reasoning and the prescription of nursing care, aiming at a higher quality of care. As evidenced in a systematic review study, it is necessary to develop more research that analyzes the use of the nursing process in community health and public health contexts and, similarly, that evaluates nursing interventions and the population’s satisfaction with the NP41.
Another result points to the review of work management, with a desire expressed by participants to adopt a practice of interprofessional collaboration, when they cited some of its characteristics, such as teamwork, communication, division of tasks and planning. Norwegian PHC nurses recognized that learning interprofessional collaboration skills represents a significant opportunity for quality improvement in PHC services42.
In this systematic process of construction and reconstruction of praxis, developments occurred in the context of nurses, such as the construction of the guide for the development of CE with people with DM, which was later validated43, and the implementation of Conselho Regional de Enfermagem do Rio Grande do Sul (Coren/RS) nursing protocols through Municipal Decree nº 067/2023. In this way, participatory study designs are strongly supported, for the possibility of identifying innovative solutions with the potential to improve person-centered care for diabetes44. From this perspective, it is fundamentally important in the construction of educational technologies to encourage a high level of involvement of people with diabetes as an equally interested party45.
Therefore, this research has some strong points that are similar to a previous study that also used CCR46, such as the fact that it considers the reality and experience of participants in their workplace, which favors the content and its feasibility, expressing the potential for translating knowledge into practice.
In this sense, the transformation of practice generated direct satisfaction for the user, and consequently professional appreciation. Therefore, it is confirmed that in the spaces where people meet, the hierarchical barriers implied by biomedical logic are broken, there is a democratization of health knowledge, a resignification throughout the entire trajectory and a constant movement of action-reflection-action47. We believe that the strategies used in this research that culminated in positive transformations in the work process of FHS nurses can be adapted and applied in other realities.
The limitations of this research are attributed to two factors. The research design did not include the participation of users, which could have triangulated the results brought by the nurses. The research conducted, even though it is a CCR, does not provide for the continuity of monitoring the NC to track the quality improvements achieved.
The choice of participatory analysis for the CCR represents an advancement in the scientific knowledge of nursing, as it enabled nurses to adopt the researcher’s perspective. Furthermore, allowing participants to discuss and review the collected data is a methodological improvement in qualitative research, and in this study, associated with CCR, it proved to be a feasible possibility.
Conclusion
The Nursing Consultation conducted in the FHS with people who have DM was carried out by nurses through elements that align with the MACC, such as establishing a bond with users, accountability, longitudinal care, and the social and family approach. However, they diverged from the assumptions of this model when there was a limited understanding of the care model, in addition to the professional attitude of blaming the user and the weaknesses in the application of the nursing process with people who have DM. These elements that portrayed the need for change in care practice were the starting point to support the educational process developed with the participants through the CCR.
Convergent Care Research has been developed over a long period of time and has allowed for the promotion of an action-reflection-action process with positive results for the translation of knowledge, such as: nurses who are aware and willing to change, interested in the theoretical and practical deepening of MACC and NP, and collaborative for the construction and implementation of instruments and technologies that favor the work process (protocol and guide). It can be seen, then, that the transformations that have occurred benefit users and contribute to the qualification of nursing care in the FHS. Therefore, research that demonstrates this commitment to articulating theory and practice is relevant in the field of Nursing, as it breaks away from the utilitarian idea of research and, in fact, promotes changes and brings innovations to the health sector.
Acknowledgements
We would like to thank master nurse Bárbara Belmonte Bedin for her collaboration during the data collection phase.
References
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How to cite this article
Silva SO, Moreira ACA, Centenaro APFC, Girardon-Perlini NMO, Weiller TH, Schimith MD. Nursing consultation and diabetes: an educational and transformative process for primary health care. Rev. Latino-Am. Enfermagem. 2025;33:e4464 [cited year month day]. Available from: URL . https://doi.org/10.1590/1518-8345.7546.4464
Publication Dates
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Publication in this collection
17 Feb 2025 -
Date of issue
2025
History
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Received
16 June 2024 -
Accepted
18 Sept 2024
*NC = Nursing consultation; †DM = Diabetes mellitus; ‡MACC = Chronic Conditions Care Model
*NC = Nursing consultation; †MACC = Chronic Conditions Care Model; ‡DM = Diabetes mellitus