Nursing practices in the primary health care context: a scoping review

ABSTRACT Objective: to identify and categorize the practices performed by nurses working in Primary Health Care and Family Health Strategy Units in light of responsibilities established by the profession's legal and programmatic frameworks and by the Brazilian Unified Health System. Method: a scoping review was conducted in the following databases: LILACS, IBECS, BDENF, CINAHL and MEDLINE, and the Cochrane and SciELO libraries. Original research papers written by nurses addressing nursing practices in the primary health care context were included. Results: the review comprised 30 studies published between 2005 and 2014. Three categories emerged from the analysis: practices in the service; practices in the community; and management and education practices. Conclusion: the challenges faced by nurses are complex, as care should be centered on the population's health needs, which requires actions at other levels of clinical and health responsibility. Brazilian nursing has achieved important advancements since the implementation of policies intended to reorganize work. There is, however, a need to shift work processes from being focused on individual procedures to being focused on patients so that an enlarged clinic is the ethical-political imperative guiding the organization of services and professional intervention.


Introduction
The Brazilian Unified Health System (SUS) is a public policy designed in the VIII National Health Conference that was constructed and institutionalized after a broad debate in Brazilian society that was encouraged by the health movement and was partially upheld by the Federal Constitution of 1988. It is a social experiment, the advancements of which are unquestionable, though considerable challenges still remain (1) . Brazil is the only country with more than 100 million inhabitants with a public health system that has universal coverage and that provides integral care free of charge -these are characteristics, which coupled with the country's continental dimensions, demographic transitions and epidemiological features, in addition to regional inequalities, entail many challenges to the system's consolidation.
One of these challenges arises from the health situation in Brazil, which has changed and is currently characterized by accelerated demographic transition, but which expresses a triple load of diseases -there is an unmet agenda of infectious and deficiency diseases, diseases caused by external causes, and the predominant presence of chronic conditions. Altogether, this synthesizes a situation that cannot be given a proper response by a still very fragmented, reactive, and episodic health system, mainly focused on coping with acute conditions and acute exacerbations of chronic conditions, in which the hospital is the privileged locus of the care model (1) .
Primary health care (PHC), a strategy to cope with this context and to support SUS, has gained recognition and increasing responsibilities as it is the entrance door into the system and the junction that connects and coordinates the healthcare networks. The PNAB (Primary Care National Policy), established in 2006, was recently updated (2) to expand the coverage of services, programs, and territories to meet emerging health needs and demands. The policy is guided by principles of universality, accessibility, establishment of bonds, continuity of care, integrality of care, accountability, humanization, equity, and social participation; that is, the guidelines of the new health care model implemented by the SUS are the guiding principles.
Measures to promote health, prevent disease and improve access to the system should have priority at the PHC level, especially via the Family Health Strategy (FHS), through which it is possible to reach areas and regions with greater population coverage. In the scope of health care delivery, the increase of chronic and complex diseases and the rapid aging of the population, have also led to significant increase in the number of visits of patients to PHC services. It is worth noting that there were approximately 30,000 family health teams providing care to about 98 million people in 2010 (3) . In this sense, systems around the globe have invested in remodeling healthcare actions to cope with the high costs of intermediate and highly complex services and the low capacity of interventions to solve health problems (4)(5) .
The role of nurses, be they in a management position and/or delivering care, providing education or promoting preventive measures at the PHC level, is essential and strategic. For this reason, the SUS, through its programmatic and legal frameworks, has ensured the presence of nurses on staffs and in covered areas (2) . Despite the positive aspects accruing from the reorganization of the care model, socio-occupational demands imposed within this space of intervention are complex and lead to dilemmas and ethical issues, theoretical-methodological and technical-operational issues inherent to the profession. The reason for this is that the demands faced in the routine of services still reflect the biomedical model, in which care is generally provided in a hospital setting through technical procedures and therapeutic diagnoses (6)   can use knowledge to strengthen nursing and PHC (7) .

Method
The scoping review, a methodology described by (8) and that was later systematized (9) , was adopted for this study. Even though a scoping review shares various characteristics of a systematic review, such as methodical, transparent and replicable aspects, studies adopting the first are designed to obtain less depth but broad and comprehensive results (10) .

Arksey and O'Malley
This scoping review is intended to assess and clarify the state of knowledge concerning nursing practices performed in PHC services based on the results of empirical studies comparing reality with the underlying theory. The scoping review's six methodological steps were followed: (1) identify the research question; (2) find relevant studies (search for relevant studies); (3) select studies; (4) extract data; (5) separate, summarize and list the results; (6) report results (8)(9) . The form used for this review is described in the study by Levac, Colquhoun and O'Brien (9) .
The research question should be open in order to reach the desired range of responses. A clear purpose, combined with a well-defined research question, enables researchers to achieve more accurate conclusions and eases the selection of studies and the extraction of data (8) . The question established for this study was: what is it known about the practices of nurses in the different PHC services in Brazil?
To ensure the identification of the most relevant studies addressing this topic, the search strategy should consider the terms to be used, sources to be searched, period of time, and the language of the papers (10) . Therefore, to properly answer the study's question, we
The papers were published in Brazilian journals classified between A1 and B3, according to the Qualis system (CAPES). Most studies were conducted in the South (n=10) and Southeast (n=13) or 76.6% of the sample; followed by the Northeast with four studies (13.3%); Midwest with two papers (6.6%); and finally, one paper was conducted in the North of Brazil (3.3%).
All the studies addressed nurses working in PHC

Practices in the community
This category includes actions nurses perform outside the health unit, though these activities can also be performed within the health services.
group activities are directed to pathologies or specific conditions -such as hypertension, diabetes, asthma, mental health and tobacco (23,31) -or specific populations, such as pregnant women, children, the elderly, and those receiving Bolsa Família (social welfare program); these are some of the activities performed in the services (15,23,31) .

Management and education practices
The category management and education practices presents and characterizes the coordination and management actions carried out by nurses in the scope of PHC (Figure 4). Among management practices, planning is described as essential to developing an action plan for activities that will be performed by nurses in the routine of health services (36) , with an emphasis on the idea that nurses should be able to simultaneously perform care and management activities (35) . The range of routines that unfolds from these attributions is associated with the notion of ethical competencies. Nurses construct technical and scientific knowledge during academic education to ensure a broad view concerning the health/ disease continuum, taking advantage of this knowledge in their daily practice, with autonomy and the competence to perform tasks and the understanding to maintain respectful behavior toward their team members (13) .
Home visits were also one of the practices most frequently reported by studies (11,12,14,17,19,23,(27)(28)(29)(30)(38)(39) . This strategy is used to bring the health team into proximity with the families and community (13) and to enable nurses to identify the context(s) in which they have to perform and then to be included in a given community.
The delivery of integral nursing care is possible when a horizontal relationship is created by the establishment of bonds (12) . Therefore, home visits are a key instrument for nurses working in PHC.
The main purpose of health education activities promoted in schools is to encourage preventive measures addressing oral hygiene, drugs, sexuality and unplanned pregnancy (15,18) by using recreational activities (40) .

Figure 4 -Management and qualification practices
Nurses from the basic health care network are responsible for supervising and training nursing technicians and/or auxiliaries (11,(23)(24)36) and health community agents (11,(19)(20)29,36,40) , in addition to conducting continuing education activities with workers (14,40) . The studies also include practices that involve the participation of nurses in Local and City Health Councils (36) , technical responsibility for the Regional Nursing Council (40) , fundraising, integrating and promoting a good relationship with the health staff, information system recording (35) , hiring and training human resources (15) , organizing schedules of days off and vacation (23) , scheduling consultations with specialists (23) , reporting diseases (23) , and recording the team's production (13) .

Discussion
The updating the PNAB (2) , consolidated this advancement and broadened the conception of health, aiming to promote the delivery of integral care (3) . In this sense, the greater incidence of studies focusing on PHC services implemented within the FHS shows that its objective to function as a reference for decentralized care and the preferred contact of patients, has been achieved.
In regard to the nurses' interventional agendas reported in the studies concerning the attributions provided by the PNAB (2) , these responsibilities are partially as a tool for health work processes to deliver patientcentered care in order not only to address the disease, but also the individual within his/her context and at the collective level (2) .   The identified gaps refer to two interconnected levels that impact the professional practice of nurses.
The first, the relative dominance of new management technologies, refers to underlying concepts that guide the organization of the work process in PHC care (2) . This Master's programs (50) . These initiatives are intended to enlarge the scope of the practices of nurses, developing and deepening the work among different professions in the PHC to achieve greater problem-solving capacity (51) .

Conclusion
This review's results show that, even though PHC is of service provided and professional intervention.
Finally, changing this context, in terms of education and work processes, represents an ongoing challenge for all healthcare workers, especially nurses, given their expressive and strategic role in the health system, including PHC.