Actions and interactions in clinical nursing practice in Primary Health Care

Objective: Understanding the actions and interactions required for developing clinical nursing practice in Primary Health Care. Method: A qualitative study anchored in the Grounded Theory. Data was collected between April and October 2016 with nurses divided into two sample groups. Results: Eighteen (18) nurses participated in the study. The category “Recognizing the Systematization of Nursing Care as an essential element for clinical nursing practice” supports the “actions-interactions” component and it is composed of two subcategories: “Accomplishing clinical practice in nursing consultations”, which presents the challenges encountered in performing clinical practice; and “Highlighting management tools for evidence-based clinical practice”, which operates through strategies in response to the studied phenomenon. Conclusion: Care actions developed in clinical nursing practice are highlighted by the systematization of care in nursing consultations, a moment of direct interaction with the individual, thus contributing to improvement in the quality of care provided.


INTRODUCTION
Nurses' actions are mediated by a clinical practice that is based on care and understood as the essence of "doing" in nursing.This practice developed with technical and cognitive skills and abilities is supported by scientific knowledge aimed at performing actions which seek to satisfy the individual's health-illness needs (1) .
Clinical practice is developed among several nursing action fields in the Health Care Network (HCN), among which Primary Health Care (PHC) can be highlighted due to its objective of overcoming the doctor-centered model at national and international levels, with an expanded and comprehensive view of health-disease situations of the population and structuring the HCN in SUS (Sistema Único de Saúde -Unified Health System) (2)(3) .
In the world scenario, the number of nurses employed in PHC has been growing exponentially, highlighting them as key members of the multidisciplinary team who provide safe, efficient and high quality care practices that strengthen primary care services (4) .
In the Brazilian context, the presence of nurses is fundamental for consolidating the reorganization strategy of the health care model proposed by the Family Health Strategy (FHS), contributing with its varied functions which include management organization of the FHS activities and functioning of the health center, up to the direct care of individuals, families and communities (5)(6) .
In view of all the activities performed by nurses, it is worth pointing out nursing consultations, which represent an opportune space for developing clinical practice, through which the closest interaction between individuals and professionals takes place, thus generating the opportunity for nurses/professionals to get to know the individual, to listen to their demands, to evaluate their bio-psychosocial and spiritual health conditions, and to provide the necessary care (7) .
Clinical practice integrates different specific and shared attributions for the health care of individuals which contributes to them receiving comprehensive and quality care.These attributes refer to the management of individual clinical care characterized by consultations and performing exams, and also expanding to managing the family process by involving the family in the care and management of the organizational actions that permeate these activities, in the sense of coordinating and evaluating the necessary conditions for these actions to take place (8)(9) .
In this process, the multiple attributions of nurses in PHC can be highlighted such as the articulation between strictly care activities and administrative activities, complementary to the "doing" in nursing practice.In addition to needing to share their managerial and care activities, weaknesses regarding the knowledge in semiology and nursing diagnoses (10)(11) have direct repercussions on the care provided to individuals and to the community.
Regarding this issue faced by nurses while developing their work in PHC, the present study aims to understand the actions and interactions required for developing clinical nursing practice in Primary Health Care of a municipality in the south of Brazil.

METHOD
This is a qualitative study with theoretical and methodological support from the Grounded Theory (GT) which seeks the creation or discovery of a theory and a set of well-developed and systematically interrelated categories through interactions and relationships from the understanding of phenomena emerging from interactions between people (12) .The study scenario was the PHC network of a municipality in the south of Brazil which has 49 healthcare centers; 11 of which participated in the study since they had the highest number of spontaneous demand services performed by nurses according to data from the municipality.Data collection was carried out from April to October 2016.
All nurses from the 11 healthcare centers were invited to participate in the study via telephone contact, and those who agreed to participate had the interviews previously scheduled and carried out in private at their workplace.The interviews followed the initial open question: "Tell me about your clinical practice in caring for people in Primary Care".The interviews were individually conducted by the main investigator with an average duration of 40 minutes, recorded with the aid of a digital audio voice recording device and later transcribed in full for the data analysis and coding processes.
The first group consisted of 10 nurses who met the following inclusion criteria: providing direct assistance to individuals and to the community in order to meet the spontaneous demand.Based on the interview analysis of this first group, it was possible to observe that the nurses refer to the Permanent Commission for Systematization of Nursing Assistance (CSAE -Comissão Permanente de Sistematização da Assistência de Enfermagem) to seek incentives to broaden the clinical practice of nurses in the PHC based on nursing protocols, generating the hypothesis that the CSAE plays an important role in the preparation and the autonomy of the nurses in developing their clinical practice.
A second sample group was subsequently composed of nurses who are part of this committee and who met the proposed inclusion criteria: acting in the PHC of this municipality and providing direct care to individuals and to the population in their health center.Eight nurses composed this sample group.The exclusion criterion for both sample groups was being on leave from work during the data collection period, regardless of the reason.
The theoretical sample of this study was intentional and comprised a total of 18 nurses divided into two sample groups, and theoretical saturation was achieved based on the repetition of information and absence of new elements relevant to the research and understanding of the phenomenon.
Data analysis was performed in the three interdependent steps proposed by the method: open coding, axial coding and integration.Open coding identified the concepts which were grouped into categories according to their similarities.The categories and subcategories were subsequently related in the axial coding in order to obtain a more in-depth explanation of the data, undergoing a systematized process of comparison and connection guided by the paradigmatic model of three components.The "conditions" component expresses the reasons why a particular phenomenon occurs and why people respond in the way they respond to a particular phenomenon; the "actions-interactions" component refers to the responses that people give to problematic situations or to events that occur in their lives and going through the meanings attributed to these; and the "consequences" component corresponds to expected or actual outcomes based on the actions and interactions established by the people (12) .
Lastly, in the integration stage the phenomenon "Unveiling comprehensiveness in clinical nursing practice in Primary Health Care based on the Systematization of Nursing Care" emerged, a central category that connected the other categories.We chose to broaden and deepen the discussion regarding the "actions-interactions" component due to its relevance, thus presenting the development of clinical practice in response to everyday events and problems faced in professional practice.
The research project complied with the ethical precepts of research with human beings and with Resolution 466/12 of the National Health Council, and was submitted and approved by the Human Research Ethics Committee of the Universidade Federal de Santa Catarina (CEPSH/UFSC) under protocol number 1.475.139and the Certificate of Presentation for Ethical Appreciation (CAAE -Certificado de Apresentação para Apreciação Ética) 54002916.3.0000.0121.The participants were informed about the objective, methodology and ethical aspects of the research and signed the Clear and Informed Consent Form.
The letter E was used in order to guarantee the confidentiality and anonymity of the participants followed by the number corresponding to the order of the interviews to designate them and then the indication of the sample group, i.e. first group (G1), second group (G2) as follows: (E1G1), (E11G2).

RESULTS
The "actions-interactions" component represented by the category "Recognizing the Systematization of Nursing Care as an Essential Element for Clinical Nursing Practice", is comprised of two subcategories.The first presents the challenges and obstacles encountered by nurses to perform clinical practice in PHC, promoting and enabling the second subcategory to operate through strategies and inductive movements for the central phenomenon of the study.

Accomplishing clinicAl prActice in nursing consultAtions
Aspects concerning the nursing consultations in the PHC are highlighted, explaining the means by which these are developed and the factors that interfere in them, facilitating or sometimes hindering their accomplishment.Nurses attributed great value to clinical practice intrinsic to their performance in the PHC, which has been increasing over the years with the increase in their professional autonomy, either by the FHS's own conjuncture or by the advances regarding specific professional nursing practice.
The nurses pointed out that clinical practice is strengthened in the daily routine of the profession, in each experience that the work process in the PHC provides.They pointed out that it is during the nursing consultation that the importance of clinical practice for developing care actions becomes evidenced.

Clinical practice is important, it's inherent in my work. I cannot dissociate from it (...) it's my job to do this (E2G1).
The nursing consultation begins with the reason that has led the individual to seek the healthcare center, performing information collection regarding the health-disease condition of the individual, followed by the physical examination to more accurately evaluate the surveyed case of the nursing diagnoses, and finally preparation of the appropriate care plan for the situation.The nurses emphasized the importance of the physical examination as a base element for developing effective and quality clinical practice, however, they reported limitations regarding the knowledge and aptitude required for this activity.

I believe that we have to be prepared for the physical examination, because we cannot make a diagnosis if we only rely on what the person says or what you see, you have to be prepared for the physical examination (E14G2).
Also regarding the nursing consultations, the participants evidenced that consultations from spontaneous demand after the implementation of the PHC Services Portfolio (document implemented in the municipality that defines scheduling of consultations of all professionals for spontaneous demand by 50%, and 50% for scheduled demand) broadened the population's access to the health center.Thus, situations in which individuals sought an urgency/emergency service considering that it was the more quickly resolved alternative now integrates the PHC services, since the number of spots for spontaneous demand was much lower before implementation of the Service Portfolio.
Due to the increased access, health centers began to receive more users, overburdening the professionals and requiring the consultations to be quicker for this demand, focused on the individual's main complaint and on the clinical reasoning to prioritize actions that must be resolved at the time of the consultation.

(...) it ends up overburdening the professionals, because they have to attend the spontaneous demand, which is a fast demand. Within 5 minutes you have to be performing the consultation because there's a line out there that you have to attend (E1G1).
In addition to the need for faster and more specific consultations in this demand, this change has led to reduced scheduled demand (including pre-scheduled nursing consultations), which was once a priority objective of the PHC, reinforcing the high technical capacity of the professional for clinical practice and the discernment that at this point of the HCN they must be solution-focused and prioritize the longitudinal bond with users and families.
Another aspect is that at the same time the demand for scheduled consultations is high, some users miss these consultations because they prefer the agility of the spontaneous demand service.According to professionals, this makes clinical nursing practice even harder, interfering in the work process in the PHC as a whole.
The patient comes to spontaneous demand because they know it is faster, but they do not want to sit, to talk (...) they use the spontaneous demand to renew a prescription, but if you schedule an appointment they don't show up, you see? (E1G1).

highlighting mAnAgement tools for evidence-bAsed clinicAl prActice
Emphasis was given to the actions developed by municipal PHC management through the CSAE comprised of nurses who work in the administrative and care sphere, which is divided into subcommittees with actions to improve clinical nursing practice in the PHC.
As a response to the challenges and obstacles related to clinical practice, the clinical nursing protocols were created and the International Classification for Nursing Practice (CIPE -Classificação Internacional para a Prática de Enfermagem) was implemented, thereby leading to courses and training on these new actions.
Nursing protocols were created based on the assistance nurses' need in their clinical practice, providing subsidies in a more directive and practical way, legally supporting them regarding their conduct and decision-making.Based on the best evidence, the protocols have extended clinical nursing practice in certain cases, such as for the renewal of prescriptions of certain continuous use medications when there is stability in the clinical condition of the patient, thus conferring greater autonomy and safety to nurses for their decision-making.

The nursing protocol is directive, so you as a nurse know what is essential regarding managing tuberculosis, for example. So, if you have the clinical suspicion, you go to the protocol to find the tests for screening, diagnosis and follow-up, and how you are going to solicit these exams, which are the tests, under what conditions, how you confirm the case, how you make the diagnosis (E11G2).
The subcommittee that acts on the protocols is divided according to its expertise on the theme.Thus, each subgroup of nurses worked on the creation of a specific protocol, such as for hypertension and diabetes, for sexually transmitted diseases, for women's health and for meeting the spontaneous adult demands, with interest and commitment to the clinical nursing practice in PHC.
Associated to the nursing protocols and under testing in "pilot" health centers selected by the municipal management, the CIPE was developed with the aim of standardizing the records of nursing clinical practice by registration in medical records organized in the form of SOAP (Subjective, Objective, Assessment, Plan), and the indication of nursing diagnoses and interventions, thus giving greater visibility to nurses' work in PHC.

With the CIPE, every performed consultation is based on the nursing diagnosis. Every diagnosis has a code that we use when providing care for the patient. (...) Using this Subjective, Objective, Assessment, Plan systematization (SOAP) (E7G1).
Our role within the large commission is to list diagnoses that we use in our practice in PHC (...) we are using what is already available in the CIPE nomenclature of nursing diagnoses, and we are also creating some within the standards that they need to follow.We have organized a list of diagnoses to be used in the PHC, and from this list we determine the interventions and how to register them in the medical record, so that it is uniform (E14G2).
Development of the protocols and the CIPE occurred simultaneously.The diagnoses and care plans developed in the CIPE are in agreement with the clinical findings and the behaviors indicated in the protocols referred to each clinical specificity, in a joint effort aimed at improving and expanding clinical nursing practice in PHC.
In order for the employment of these actions to be effective, educational actions are necessary and have started to be developed more strongly by the nurses of the municipality PHC network.In addition to the team and district meetings, which were already part of their routine, the nurses of the practice began to receive training aimed at their knowledge of the protocols and use of the CIPE.We do workshops with the nurses, who are the CIPE pilots (...) to use the list of diagnoses (...) for us to analyze which diagnoses are more used, which interventions are more used (E14G2).
In addition to the training meetings that cover the entire population of nurses in the PHC network, there are specific meetings carried out monthly among the members of the CSAE to discuss the progress of such actions, its facilities and difficulties, as well as ways of solving the encountered problems.

DISCUSSION
The findings of this study have shown that actions and interactions in clinical nursing practice seek to overcome the medical-centered model, focusing on the comprehensiveness of the care, the longitudinality and improving the quality of the attention to the health of the individuals.Considered as inherent to their work process, the actions developed in clinical nursing practice mainly stand out for the systematization of care in nursing consultations, a moment when nurses are in direct interaction with the individual.
By developing the systematization of care in nursing consultations, nurses are faced with challenges to perform clinical practice such as responding to the spontaneous demand, which in the studied municipality brought changes to the health professionals in PHC, thereby increasing nurses' performance and highlighting the importance and the ability of these professionals in the health needs of the population.
All healthcare services are gateways to the health system.In addition to organizing the HCN, PHC is particularly anchored in public policies directed to the qualified service of risk classification, identifying vulnerabilities and teamwork, which enables nurses to organize and prioritize service to this demand (13) .In addition to being an inherent competence to their work process, nurses must be able to receive and embrace the situations arising from the spontaneous demand that can be totally or partially solved at the moment of the nursing consultation, requiring clinical knowledge and technical competence to guarantee the comprehensiveness of care and problem-solving of the presented situation (14) .
However, negative aspects have also been pointed out in this context, such as the professional overload due to long lines of users for this service (15) and difficulties in fully developing the physical examination, which evidences the need to strengthen clinical nursing practice in this scenario.In order to achieve such strengthening, investments in nursing education are needed to effectively prepare nurses with skills to develop effective and efficient clinical practice.Innovative teaching strategies for consolidating knowledge such as clinical simulations have proven to be valuable in preparing nurses to enter the field of work, enabling their participation in clinical interventions that simulate real situations that they will encounter in their professional practice (16)(17) .
In seeking to overcome the challenges found in clinical nursing practice in the PHC of the studied municipality, the CSAE appears in this study as an action strategy in response to the weaknesses revealed by professionals, aiming to improve the clinical practice of nurses in PHC through evidence-based practice, clinical nursing protocols and the CIPE.
Evidence-based practice consists of a safe and organized way of establishing professional conduct for solving problems, anchored in the tripod best scientific evidence available, professionals' expertise and the need for practice involving critical search and evaluation (18) .
Corroborating the findings in the present study regarding the importance of evidence-based practice, a study carried out in Spain with PHC nurses highlights that it is possible to provide high-quality care through evidence-based practice, in addition to providing greater visibility to the nurse's image and providing a legal basis for their performance (19) .Another study carried out in Iceland has shown that participating nurses value evidence-based practice and believe that it is possible to obtain improvements in the quality of care provided with its implementation (20) .
However, in order for evidence-based practice to be effective, it is necessary to overcome some obstacles that concern the autonomy of nurses, the lack of incentive to take advanced practice courses, the limited availability of evidence in nursing, as well as its scarce utilization, and the lack of communication between academics and clinical practice, as shown in a study carried out in Colombia (21) .
In this sense, the nursing protocols based on evidence and which regulate and support nurses' actions in PHC facilitate a more autonomous and resolute development of their clinical practice, directly influencing the health-disease situations of the population (22) .
Regarding the applicability of these protocols, an international study emphasizes that nurses resort to information that is easier to access and offers quick responses such as texts that are references in the presented demand and are available on the internet, and which are related to the need for quick decision-making and the limited time for care (20) as observed in the situations of spontaneous demand reported by the participants of the present study.
In addition, we can highlight the importance of nurses' performance in the entire process of development, implementation and use of the protocols, as reported in a study developed in the United States (23) .This finding corroborates those of the present study by showing an advance in the studied municipality when investing in practice based on evidence, involving care professionals to act in cooperation in elaborating and consolidating these practices (24) .
Still regarding the actions developed by the CSAE, the CIPE represents an important mechanism to strengthen the role of nurses in PHC, since it constitutes a system that aims to standardize the language used by these professionals, enabling organization of their work process through elaboration of individualized care plans, reducing variations in treating the individuals and thus providing an improvement in the care quality in more reflexive, effective and efficient clinical practice (25)(26) .
A study carried out in the northeast of Brazil pointed out the benefits and difficulties of using the CIPE in nursing care for people with hypertension, highlighting greater visibility to nursing practice, assistance in clinical decision-making and evaluation of the care provided, as well as the presented results among the benefits.The difficulties encountered were mainly due to the absence of specific characteristics or previously defined concepts, which hindered diagnostic reasoning (27) .
In this sense, the difficulties encountered in professional practice related to using the CIPE, protocols or for carrying out physical examinations require strategic actions in order to solve them.In line with the results of this study, a study developed in South Korea unveiled problem-based learning as an effective way of transferring theory to practice, improving nurses' ability to solve everyday problem situations through training that strengthens clinical practice (28) .Problem-based learning corroborates the training sessions developed by the CSAE, since these meetings seek to mutually and effectively solve the problems experienced in nursing practice, in addition to clarifying doubts and training on the developed actions.

CONCLUSION
This study has evidenced the actions and interactions that take place in clinical nursing practice in the PHC scenario, among which we can highlight the systematization of care in nursing consultations supported by evidence-based practice through the use of clinical nursing protocols and CIPE, as well as management actions aimed at strengthening clinical nursing practice through the CSAE and the co-participation of practitioners.
The nursing consultation proves to be an important mechanism for the development of clinical practice based on the principle of integrality and evidence-based practices, enabling systematized exercise capable of contributing to improving the quality of care provided.
The CSAE appears as an important instrument for improving nurses' performance in PHC with the elaboration of clinical protocols and application of the CIPE, which increase nurses' autonomy and problem-solving in professional practice, thereby giving greater visibility to their work.Furthermore, in view of expanding clinical practice it offers nurses constant technical and scientific improvement, provides the necessary framework for their performance in PHC and contributes to greater effectiveness in the developed actions.
In summary, the actions and interactions presented are in line with those recommended by the FHS, guided by the principle of comprehensiveness proposed by the SUS, and favor horizontal and interactional relationships with the health team when used by the nurses in PHC practice in the sense of sharing and integrating knowledge and practices toward the interdisciplinary care of individuals, in order to guarantee improvement in the nursing care provided.
Although this study was developed with methodological rigor, difficulties during the data collection process were encountered due to the nurses' lack of availability to participate in the research and to schedule an appropriate time for the interviews.As it was carried out in only one municipality with specificities regarding nurses' clinical practice in PHC, the findings of this study cannot being generalized for contexts that do not have similar characteristics.
It is important to point out the need for further studies on clinical nursing practice in different care settings, highlighting the importance of political investments for consolidating excellent clinical practice in seeking comprehensiveness and improvement in the quality of care to individuals, families and communities.
We also point out the continuous search for strategies aimed at qualifying clinical nursing practice in PHC, with incentive to the use of clinical nursing protocols in different points of the HCN, implementation of a unified record system, elaboration of nursing care diagnoses and plans such as the CIPE mentioned in this study, and the strengthening of evidence-based practice in nursing.