Nurses from the Mobile Emergency Service : profi le and developed activities

Objective: to characterize the profi le and identify the activities developed by nurses from the Mobile Emergency Care Service of a state of southern Brazil. Method: an exploratory, descriptive study. Data were collected through a questionnaire with 63 nurses. Results: the profi le showed a workforce predominantly female, young and having specialized training. The activities were organized in the dimensions of caring, managing and educating, verifying the predominance of the fi rst one. Care actions involved multiple procedures, but the use of the Systematization of Nursing Care (SNC) was not mentioned in the development of care activities. Then, the managerial dimension with a predominance of bureaucratic activities was emphasized. Educational activities were less prominent. Conclusion: care actions are the focus of the activities of nurses, predominantly the prescribed institutional care without the use of instruments such as SNC that could contribute to the greater visibility of their professional work.


INTRODUCTION
The care network for emergency and urgency in Brazil is currently organized and regulated under the Unified Health System (SUS) by Ordinance 1600, 2011.It consists of the following components: Promotion, Prevention and Health Surveillance; Primary Health Care; Mobile Emergency Service (SAMU 192) and its Medical Regulation Centers of Emergency; Stabilization room; Health National Force of SUS; Emergency Care Units (UPA) and the Emergency Services 24 hours; Hospital; and Home Care (1) .
SAMU is among the components of the healthcare network for emergency care that began its activities in Brazil a decade ago and since then it is expanding in the country.Health professionals and other workers of the team act on this network.Among these professionals, there is the nurse (1) .
Nurses are highlighted as essential in the different contexts of health work, including the SAMU.Nursing work is essential for health care at the institutional level.In Brazil, nursing professionals have different levels of training (nurses, nursing technicians and nursing auxiliary), but their work can only occur in the presence of nurses (2) .These professionals have the technical responsibility for the work of the nursing team, and their work requires technical and scientific competence in the permanent update.Health care organizations have also sought "multi-skilled and multi-function" nurses that dominate the language of computing, and high-tech machines, having quick thinking, initiative, being creative, competitive, communicative, mastering other languages, besides having leadership skills to form qualified teams (3) .
Within the prescribed legally, it is up to the nurse: the direction of nursing services (in health and education institutions, public and private, and delivery service); management of activities, such as planning of nursing care; the prescription of nursing care; direct care to patients with risk of death; medications prescription (established in health programs and routines); and all the greater technical complexity of care (4) .
The work of nurses in emergency care is regulated by the Federal Nursing Council (COFEN), through two Resolutions.The first one is the Resolution 375/2011 which prescribe the presence of nurses in Prehospital Services and Inter-Hospital in known or unknown risk situations.The second is the Resolution 389/2011 that ensures nurses with specialization in emergency care the right to register their certificate in the Regional Council of Nursing.This register gives legal right for these nurses to act in this field of the nursing profession (5)(6) .
In SAMU, nurses develop coordination activities and continuing education and also provide direct patient care in advanced support units, land or air.In the basic support units, there are the nursing technicians who develop less complex care (7) .
The literature mentions a lot the importance of emergency mobile care services to save lives and to limit damage from sudden diseases, accidents, violence and disasters (6) .It is also fully recognized that professional nursing work is crucial in these services (8)(9) .
In this scenario, it is considered that the urgent and emergency situations are complex and unpredictable, requiring interventions by professionals with high-level training, and that the Brazilian legislation includes professionals with different levels of training in the composition of the nursing workforce but gives to nurses have the technical responsibility for the professional work.It is also considered that there are few studies on the work of nurses in these services in Brazil.This study aimed to characterize the profile and identify the activities developed by SAMU nurses in a state of southern Brazil.

METHOD
It is an exploratory, descriptive study conducted in SAMU of a state of southern Brazil.It was decided to send a questionnaire with open and closed questions to be completed individually to collect data to face difficulties of access of the researcher to nurses spread across the state and intent of access to this entire workforce.From the 120 professionals working in the state, 104 were eligible for the study, because in this period 13 professionals were on vacation and three on maternity leave.The questionnaire was sent to all of them, and 63 returned completed questionnaires, representing 60.5% of the 104 nurses able to participate.The researchers were careful to ensure that everyone received the questionnaire.The return of 60.5% was considered satisfactory as it involved all regions of the state and we respected those who did not want to or not agreed to participate.Before sending the questionnaire to the nurses, this questionnaire had a pre-test with three nurses randomly hizo mención al uso de Sistematización de la Asistencia de Enfermería (SAE) en el desarrollo de las actividades de cuidado.A seguir, se destacó la dimensión gerencial con predominio de actividades burocráticas.Las acciones educativas tuvieron menor destaque.Conclusión: las acciones de cuidado son el foco principal de las actividades de los enfermeros, predominando la atención al prescrito institucionalmente sin uso de instrumental como la SAE que podría contribuir para mayor visibilidad de su trabajo profesional.Palabras clave: Ambulancias; Medicina de Emergencia; Servicios Médicos de Emergencia; Enfermeras; Trabajo.selected, that after answering it, they suggested providing a better understanding of the instrument.The suggestions were accepted.
The questionnaire contained questions related to the profile, such as gender, age, practice time in the SAMU and the nursing profession, training, postgraduate training, type of unit that acts and questions related to care actions for the patient and family, as well as administrative/managerial and educational dimensions.
Data were analyzed according to the assumptions of thematic analysis of content divided into three distinct phases: a) pre-analysis; b) exploration of the material; c) treatment of the results, including inference and interpretation (10) .The results were organized into two main themes: "profile and tasks performed by nurses of SAMU".The activities performed by nurses were organized in the three dimensions of nursing work: Dimension Caring, Educating, and Managing (11) .The numerical data were analyzed using descriptive statistics and presented in the form of tables in simple percentage rate (12) .
The project was approved by the Ethics Committee of the Federal University of Santa Catarina.In addition to the data collection instrument, a cover letter explaining the study´s purpose and the importance of their participation and two copies of the Statement of the Consent Form were sent.

Profile of nurses working in the SAMU
Of the 63 nurses who participated in the study, 69.8% were female, with a predominance of the age group from 31 to 50 years old (73.0%).
As for the acting time in the SAMU, the results showed that 57.1% are working from 01 to 05 years and 15.8% work at SAMU for more than five years.Considering that only 27.1% work less than a year in the SAMU, we can say that there was a predominance of nurses with experience in this activity among the participants of the research.
Relating the working time in SAMU with the profession acting time, we observed that most of the survey participants (57.1%) has been acting for over 06 years.
When asked if they were trained to act in the SAMU, 82.5% responded that they were trained.This data associated with training in graduate school shows the predominance of professionals who have a degree qualification since 76.2% have a specialist title.Only 11.1% have a minimum titer that is the undergraduate nursing.
None of the nurses who participated in the study acts in basic life support units (92.1%), most of them act in Advanced Support ambulances (Table 1).

Activities performed by nurses of SAMU
From the actions developed by nurses in the SAMU, the caring dimension were 63.1% of the actions of these professionals, followed by actions related to managing dimension (26.1%) and educational activities (10.8%).

CARING DIMENSION
In this dimension, there are described the care actions taken to patients/users during a typical workday.Tables 2 and 3 below shows the actions performed by nurses; the first table shows the actions of care to individuals in emergency situations, and Table 3 shows the care actions to the families.Describing care actions, some nurses cited a single action, but there were nurses who described two, three or more actions (N=59).Actions are ranked by the number of times they were cited.In the care actions performed by nurses, the most cited are assessing the injury and treatment, with 18.6%; followed by medication administration as prescription drugs, with 11.6%; checking vital signs, 11.0%; and puncture venous access with 10.4%.In care actions carried out to the families, the most cited with 70.0% was psychological/emotional support and user embracement, and then, check vital signs and medical care, with 16.7%.

MANAGING DIMENSION
In the managing dimension, nurses were asked about the administrative/managerial actions they took in SAMU (N=60) (Table 4).
The most cited activities were filling the occurrence form with 27.4%, check the list of materials/medicines/equipment with 24.0% and report in the minutes book (on duty notebook) with 13.7%.

EDUCATING DIMENSION
Nurses were also asked about educational activities carried out in SAMU.In this dimension, 13 nurses pointed not performing health education actions.
Of educational actions, the most cited was guidance on the patient´s situation, on the recommendation of not following the ambulance during transfer of the patient and about referrals with 75.0%; then the continuing education of staff was identified with 14.0%, and guidance on what is the SAMU with 5.2%.

DISCUSSION
The characterization of the profile and description of the activities undertaken by the SAMU nurses in the state where the research was held contribute to the exploration of this practice scenario, which is extremely important and expanding in Brazil since its implementation for over ten years.Also, despite the results were about the work of nurses in a particular scenario, it can be considered a contribution to the understanding of who they are and what nurses do work in this service in Brazil.
Regarding the profile of nurses working in SAMU, there was a predominance of females, corresponding to the composition of the nursing workforce.However, it was highlighted the percentage of 30.2% of men above than the one found in the official records of the Regional and the Federal Council of Nursing.Data from the Regional Council of Nursing in the state where the research was carried out, show that of the total 10,991 registered nurses in the Council, 10,050 (91.43%) were female, and 941 (8.57%) were male (13) .The largest number of men among the nurses of SAMU may be related to the specificity of this work but can also indicate a change in the gender profile of this workforce as shown on data from a study conducted in the United States.The study showed that nursing is still a predominantly female profession, but there is a growing number of men in the profession.The percentage of male nurses tripled 1970-2011, from 2.7% to 9.6% (14) .
The predominant age group was 31-50 years old, which corresponds to 73%, and 23.8% are under 30, being a predominantly young population.These data are in line with the survey released in 2015 on the profile of Brazilian nursing that shows that 85.8% of nursing in Santa Catarina were under 50 years old (15) .
About the time of working as nurses, most of them (57.1%) have been acting for over six years of formation, considering that nurses have some professional experience.
Other data related to the profile that is worth noting is that 15.9% of nurses began acting in SAMU without receiving training to operate this service.The fact that nurses leave the graduate with a general title does not mean that received in their undergraduate curriculum content related to the mobile service of urgency.Also, the national political attention to emergency care is recent in Brazil.It is a complex activity and requires special training for dealing with unpredictable situations where knowledge interferes with the outcome of the work (2) .
The Ordinance 2048, of 2002 describes that the contents taught in undergraduate courses in nursing and medicine, being insufficient to theses professionals work in the Pre-Hospital Mobile Medical Services; and also that they should be enabled by Education Centers in emergencies.These centers aim to promote training and continuing education programs for the training according to the diagnosis of each region, qualifying human resources, stimulate the creation of multiplying teams, among others (7) .
Another fact that stands out is that none of the nurses said to act in the basic support units.This may mean that nursing technicians perform assistance without the supervision of a nurse.This is a concern because the service is requested via telephone, in which the regulator doctor sends an ambulance to the scene only to information passed on by an unknown person and lay on the subject.Often, upon arriving at the scene, the nursing technician and driver-rescuer may encounter a much more serious situation than that reported no subsidies and have to act in situations that may require knowledge beyond their competence.
In the state where the study was conducted, there are only basic support and advanced units.The literature shows that there are other arrangements in the context of urgency and emergency.In the Emergency Medical Services of Portugal, there are basic support units where work two rescuers; there are the advanced support units where work doctor, nurse and paramedic; and there are the Immediate Support Units of Life (SIV).
The SIV have the task of ensuring hospital care, such as resuscitation maneuvers.The crew, in this case, consists of a nurse and a paramedic and aims at improving care to the population in the prehospital environment.In addition to all the equipment and materials of a basic support unit, the SIV have monitor-defibrillator and several kind of medicines.The equipment allows the transmission of ECG and vital signs to the central medical regulation (16) .It is observed that in this type of ambulance, autonomy and responsibility of nurses become even bigger, requiring even knowledge by these professionals.
The results showed several care actions performed by nurses to patients/users of the SAMU.In addition to the care actions to patients, they also provide assistance to families.Another point to observe is that the nurse participates in the evaluation of the patient, which strengthened his role with professional characteristic, that is, exceeds the performance of specific and delegated actions (17) .The Systematization of Nursing Care (SNC) is an important tool in assisting the individual.It is exclusive of nurses and aims at the development and organization of the nursing teamwork, strengthening the profession (18) .
Emotional support and user embracement of patients and families are also concerns of these professionals, as can be seen by the number of times that this action was mentioned.The user embracement is "an ongoing process that involves sensitivity and technical-scientific knowledge of professionals to identify health needs derived from social, physical, biological, mental and environmental processes" (19) .
The Ordinance 2,048, 2002, approving the Brazilian Technical Regulation to the States related to of Urgency and Emergency Systems, establishes the need for a Nursing Responsible for nursing activities.The Nurse Care will be responsible for necessary nursing care for resuscitation and stabilization of the patient at the venue and during transport.The ordinance also states that the nursing assistants and technicians will act under the immediate supervision of the professional nurse.It also establishes that nurses can fit the following competencies/responsibilities corresponding to the established in the Professional Practice Law 7498/1986 (2) : In addition to care, actions direct to patients and families, actions to manage are developed in large numbers by SAMU nurses.In mobile units, various documents are filled, whether printed or electronically.These records are of utmost importance and allow the formation of a database that can contribute to decision-making, to reinforce actions that have proven adequate to either change and correct procedures or the methodologies used by the service.Also, it is the defense of the importance of using the SNC and the record of it.Register gives visibility to the work of nursing at the same time as it enables evaluation of care provided by nursing (18) .
The actions of the administrative/managerial type developed by SAMU nurses in this study involve multiple activities, including filling out forms, to perform shift change, the preparation of the ambulance to the next service, participation in projects and making decisions for the functioning of the service.This set of activities is essential for the work to succeed.Also, it lies in the literature the recognition of the complexity of management actions performed by nurses, as well as the importance of these actions for the services (7) .The nurse's managerial action changes depending on where it acts.These actions are linked to the structure of the unit, definition of staff, materials, equipment, and processes.The management activities are planned and performed to ensure the quality of care (19) .
Healthcare organizations seek for quality service to its clients incorporating new technologies.For this, it is necessary for nurses to seek knowledge about costs since this professional is responsible for the management of human, material, and financial resources and has been taking more and more space management in health services (20) .
The educational activities also appear to expression in this study.Among the educational activities made by SAMU nurses, there are the guidelines provided to patients and families about the service and how to proceed in the situation.
It is essential to know the reality in which the patient/individual is inserted and know their strengths and weaknesses to institute health education, so that the health education process can be carried out to meet the needs of individuals need it (21) .
In the case of SAMU, it is difficult to know the reality of all patients, as there is a variety of treatments and realities, making health education a more complex challenge.
It is worth also noting that the use of a questionnaire to collect data had some limitations, as was the case of sample loss.The nurse had to be motivated to complete the questionnaire and return it to the researchers.There is also the way some questions were answered, with telegraph messages, hindered greater understanding of the complexity of the content that the answer required, as well as capture the nuances of the content of the speech of participants.

CONCLUSION
The findings allowed characterizing the profile and identifying the activities developed by the SAMU nurses in a state of southern Brazil.
It is concluded that the workforce of nurses is mostly female and with some qualifications to work in the emergency area.Among the activities developed by the SAMU nurses, caring actions are the focus, followed by managerial and educational activities.
Care actions are several predominantly care actions directly to patients/users, which range from the evaluation of the occurrence of the scene to carry out various procedures, including delivering babies.The nurses also conduct service to family, welcoming them and even medicating them when necessary.
In addition to care actions, these professionals perform various activities of administrative/managerial actions, which are essential for the care activities can be carried out successfully.
Educational activities are also held, but with greater emphasis on the instructions were given to patients and families, or individual actions.Educational activities collectively to the population were rarely mentioned.The collective educational activities can have a positive effect to set the work done in the SAMU.At the same time, they can contribute to the appreciation of the professional work of nurses.
The results of this study contribute to reflection within the profession about the care mode in SAMU since at any time was described that they realize the systematization of nursing care, that is nurses cannot see the Systematization of Nursing Care as an instrument to value their work.This is an exclusive activity of nurses and regulated by COFEN through Resolution 358/2009.The Systematization of Nursing Care contributes to the greater visibility of the work done by nursing and nurses in particular.The documentation of the work of nurses possible to quantify what has been done and provides a tool for critical appraisal of nursing work.
The research findings indicate that the actions of management and education inherent in nursing work had less relevance in this study, which can serve as a stimulus to reflection.Could the investment in the qualification of these activities contribute to giving greater visibility and appreciation of the professional work of nurses in the SAMU and the health care area?

Table 1 -
Profile of nurses working in the Mobile Emergency Service (N = 63) in the state of Santa Catarina, Brazil, 2014 Note: SAMU -Mobile Emergency Care Service

Table 2 -
Care actions taken by nurses of the Mobile Emergency Care Service to patients in the state of Santa Catarina, Brazil, 2014

Table 3 -
Care actions of nurses from the Mobile Emergency Service for families in the state of Santa Catarina, Brazil, 2014

Table 4 -
Actions of coordination/management performed by nurses of the Mobile Emergency Care Service in the state of Santa Catarina, Brazil, 2014 Note: SAMU -Mobile Emergency Care ServiceTo be continued

Table 5 -
Educational actions performed by nurses of the Mobile Emergency Care Service in the state of Santa Catarina, Brazil, 2014 Note: SAMU -Mobile Emergency Care Service