Nursing challenges for universal health coverage: a systematic review

Objectives to identify nursing challenges for universal health coverage, based on the findings of a systematic review focused on the health workforce' understanding of the role of humanization practices in Primary Health Care. Method systematic review and meta-synthesis, from the following information sources: PubMed, CINAHL, Scielo, Web of Science, PsycInfo, SCOPUS, DEDALUS and Proquest, using the keyword Primary Health Care associated, separately, with the following keywords: humanization of assistance, holistic care/health, patient centred care, user embracement, personal autonomy, holism, attitude of health personnel. Results thirty studies between 1999-2011. Primary Health Care work processes are complex and present difficulties for conducting integrative care, especially for nursing, but humanizing practices have showed an important role towards the development of positive work environments, quality of care and people-centered care by promoting access and universal health coverage. Conclusions nursing challenges for universal health coverage are related to education and training, to better working conditions and clear definition of nursing role in primary health care. It is necessary to overcome difficulties such as fragmented concepts of health and care and invest in multidisciplinary teamwork, community empowerment, professional-patient bond, user embracement, soft technologies, to promote quality of life, holistic care and universal health coverage.


Introduction
The route to Universal Health Coverage (UHC) and the Post-2015 development agenda is through the health worker (1) . This agenda includes reducing maternal mortality, end preventable deaths of newborns and under five-year-old children, end the epidemics of AIDS, tuberculosis, malaria and Neglected Tropical Diseases (NTDs), and ensure universal access to health care services (2) . All these objectives can be achieved using nurses and midwives strategically placed at the personcentered community-based level.
Nurses and midwives are the largest category of health workforce, related to eighty percent of health services, and are also the frontline health workers.
Nursing and midwives using a career pathway model of skill mix could be utilized to deliver health care and improve outcomes. However, affordable approaches to boost the performance of health workers are urgently required. The path towards UHC implies addressing the gaps in competency, quality, motivation, productivity and performance of health workforce (3) .
Key practical steps proposed by WHO for Nursing and Midwifery are: increase interdisciplinary, multiprofessional, nurse-led teams and leadership skills; empower nursing and midwifery workforce by clear role clarification, valid job description and professional recognition; implement positive work environments to improve motivation and retention (4) .
One way towards these steps was the inclusion of the National Humanization of Health Care and Health Care Management Policy, also known as the National Humanization Policy (NHP) and/or HumanizaSUS, in different nurses and midwives' workplaces (5) . This Humanization permeates the work processes and the stakeholders of primary care (6) . Considering this relation, the objective of this study was to identify nursing challenges for UHC, based on the findings of a systematic review focused on the health workforce's understanding of the role of humanization practices in PHC.

Method
The purpose of a systematic review is to enable the translation of the best scientific evidence into policies, practices and decisions in the healthcare context (7) . A mixed research synthesis by integrated design was used in this study. This design allows grouping the findings of both types of primary studies into thematic categories to reach meta-synthesis (8) . This integrated design uses PICo to guide data collection, a specific guide to extract information and to classify the quality of findings.
In November 2013, the search was conducted using the following databases: PubMed, CINAHL, Scielo, Web of Science, PsycInfo, SCOPUS, DEDALUS and Proquest.
The references of the articles selected for this review served as a source of new inclusions in the review process so-called reference of the reference (9) .
PICo was used to guide the systematic review question, these mnemonic identifies the key aspects Population, Phenomenon of Interest and Context (10) .
In this review, Population was PHC Professionals, Phenomenon of Interest was Experiences of humanization practices and Context was PHC Settings. Adjusting the objectives of the study to PICo, the guiding research question of this systematic review was "What is the understanding of healthcare professionals with regard to the role of humanization practices in PHC?" Brazilian NHP (5)  and Qualitative Studies (11) . Knafl & Sandelowski (11) tool provides guidance on how to transform raw data into data that can be systematically combined and analyzed.
Information was extracted from each report in the following domains: research purposes and questions, theoretical framework, method and design, sampling strategy, sample composition, data collection and analysis techniques, techniques to optimize validity or minimize bias, techniques to protect human subjects, findings, and discussion (12) . Based on these domains each study was analyzed and classified as Strong, Good, Weak and Noisy (when there was lack of information).
As recommended for systematic reviews aimed at providing a metasynthesis by integrating the results of qualitative and quantitative studies (Mixed research synthesis) (9,13) , the quantitative findings were qualified.
Findings were converted into a qualitative format in order to combine them, by themes. The data was organized into empirical categories that emerged from the analysis. Two independent reviewers assessed the categories in terms of their respective scope and definition, with disagreements also being resolved by consensus.
The analysis of findings from the systematic review considered the quality and results of the studies. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was applied to improve the quality of the recommendations presented in this review (14) .

Results
From potential 90 references, reduced to 53 non duplicated studies, 30 studies were included and systematically reviewed: 29 qualitative and 1 quantitative as Figure 1 shows. Studies retrieved were undertaken between 1999 and 2011. One study was published in English and 29 in Portuguese. Figure 1 -Diagram of the process of inclusion and exclusion for all the studies in the systematic review (15) www.eerp.usp.br/rlae Rev. Latino-Am. Enfermagem 2016;24:e2676 In total, studies included 1,179 PHC professionals from United States of America (A1) and Brazil (A2-30) as shown in Figure 2. Nearly 50% of these professionals were physicians from USA; the other 50% included professionals from Brazil, mostly nurses, auxiliary nurses, nursing technicians, physicians, community health agents, dentists and dentist auxiliaries and some administrative personnel.     (17) . human needs (19)(20)(21) .

ID
Therefore, in the health promotion approach, However, professionals also cited barriers to work according to these conceptions of health and care in order to deliver humanization practices. The barriers were not all present in a single practice, but were common at many units. It is a real challenge for teams, managers and health users to modify these barriers towards integral and universal care.

One of the biggest current ethical challenges in the
Unified Health System is to produce therapeutic linkages to ensure health users, family and community the possibility of health care in adequate time (22) . Difficulties The complexity of PHC also requires new professional profiles to meet community needs. The growing challenge of educational institutions is to prepare professionals to work at different levels of the health system, especially in PHC, in line with the system, teamwork, comprehensive health care, horizontal and more focused on the work process (18) .
Professionals, including health service managers, reported the need for more staff training. Professionals reported that they do not come prepared to work in the Family Health Strategy nor to accomplish humanizing practices. According to the professionals, this unpreparedness was related with the lack of such contents in undergraduate and continuing education.
To work with extended concepts of health and care in PHC, the concepts of health and care widespread trough graduation and training courses need to be reconsidered.

It is worth noting the Flexnerian influence in
the formation of health professionals, based on the mechanical, biological and technical aspect, and complain-conduct practice (24) . Teaching of humanizing practices also suffers from the influence of scientific biomedicine. The rationalist, mechanistic and dualistic Schveitzer MC, Zoboli ELCP, Vieira MMS.
model of scientific rationality, dominant in health, prevents the recognition of other "truths" about health care, contrary to the reductionism of clinical pathology and mechanical physiology (25) .
In relation to continuing education, a pedagogical intervention in two Health Centers with themes about health system and humanizing practices showed that, after one year, there was an impact on management and work processes of some practices, with improved access and better relationship between professionals and community (26) .
A health team needs technical, caring and management competence; demands beyond basic training, other skills that involve extended listening, speaking and teamwork (26) . This is the case of the skills related to nursing for universal health coverage.
Moreover, there is a demand for training and continuing education, linking theory and practice, in order to build nurses and midwives' qualifications to become effective leaders and managers, as proposed by the strategic directions for nursing and midwifery education, training and career development (27) .
Regarding the provision of humanizing practices, in some services, the entire health team or just some Also at the rear are physicians and dentists, who deliver support and advice to the user embracement team, however without presenting major changes in their work practice.
Workers of a multidisciplinary team in general realize that health work is done by different professionals in installments, but often do not realize that the absolute autonomy of a professional in relation to other workers and users hinders the construction of shared work (28) .
This was the case reported by some professionals It establishes what is to be achieved but little about how to get there. The first step is building a health workforce that is both fit for the purpose and fit to practice (30) .

Some of the Strategic Directions for Strengthening
Nursing and Midwifery Services (4) (31) .
One limitation of the study is that the majority of the studies included in the review are from Brazil.
Nevertheless, results may be applied to different realities, especially to low and middle income countries and health systems facing critical health and social challenges, since these are the challenges of Brazilian primary health care. Humanizing practices can enhance the care promoted by nursing and its responsiveness towards the implementation of universal health coverage.
Nursing as a social practice demands reflection on the complexity of social issues and health, in line with the plurality of current society. Nurses must combine, in daily work, principles and values with competence, in an atmosphere of co-responsibility and care (34) .

Conclusions
Nursing