Challenges and potentialities of nursing work in street medical offices

ABSTRACT Objective: to analyze elements of the nursing work process in the Street Medical Offices, highlighting the challenges and potentialities of care for homeless people. Method: this is an exploratory research of qualitative nature supported by the perspective of the health work process. The study was conducted through semi-structured interviews with nurses from the teams of the street medical offices at the city of Maceió and data were analyzed according to the content analysis technique, approaching issues related to the object, instruments and purposes of the nursing work process. Results: the identified themes were: Need for health care in the context of social and health vulnerability; Strategic planning and teamwork as tools for organizing the work process; Purposes and products of work: guaranteeing the right to access and care. . Before a work object designed by serious health needs resulting from the social vulnerability of this population, nurses use different instruments in their work process: strategic planning, acting in multiprofessional team and valorization of the light technologies of reception and bonding. Conclusion: apart from the difficulties, the study presents a successful experience that explores the potentiality of sharing relationships of humanized care.


Introduction
With the increase in the number of homeless people in Brazil and at the same time initiatives such as the institution of the National Policy for the Homeless Population (PNHP), the public managers of the larger municipalities began to outline strategies to identify and approach the demands of this social group (1) .
The Unified Health System (SUS) represents a public system responsible for offering health actions and services in a universal, comprehensive and equitable way to the Brazilian population (2) . In 2011, the Ministry of Health of Brazil launched the National Policy on Primary Care in which Street Medical Offices (SMO) were established as one of its devices, aimed to attend the problems and needs of this social group and offer, in a more timely manner, health actions and services (1) .
It is incumbent on street medical office teams (SMOt) to pay attention to health in a differentiated and dynamic scenario that challenges health professionals who assist users in situations that do not fit the schedule.
In order to overcome the difficulties, adversities and surprises found in this complex reality of the streets, the health work is organized in a multiprofessional and interdisciplinary perspective. In this context, it is expected that nursing, as part of the multiprofessional team, be able to maintain relationships that enable shared care, aiming at integral care of people in situations of extreme social vulnerability (3) .
In the context of the Brazilian Sanitary Reform and the change of the health care model in Brazil, some authors (4)(5)(6) stood out in the discussion of the health work process and its role as mobilizer and constructor of new care arrangements.
The work in the health area is always a relational work (7) because it depends on 'live work' in action, that is, a work performed at the moment it is (re)producing existences present in the act of care. These relations can be on the one hand brief and bureaucratic when care is centered in the prescriptive act, composing a model that has, in its essence, medical knowledge as hegemonic and producer of procedures, in which the dead work captures the living work.
For some authors (4)(5)(6)8) , health professionals understand the work process as a set of pieces of knowledge, instruments and means, having as subjects the professionals who organize themselves to produce services in order to provide individual and collective assistance to obtain products and results from their practice.
On the other hand, the nursing work aims to assist healthy or sick individuals, families and the community, performing care, management, and educational and investigative activities for the promotion, maintenance and recovery of individual and collective health (9) .
In this context, studying the nursing work process is important to understand the role of these workers and their work during the process, identifying their understanding about the object, the instruments used, the purpose and the final product obtained with the actions developed by the team and by nursing (10) .
Therefore, the care of the homeless population requires an increased focus on the health-disease-care process, as well as the use of various tools that value people and their needs, taking into account the territory and its singularities (1,3,11) .
Given the recent experience in Brazil of this public policy strategy and considering the fundamental role of nurses in the longitudinal follow up of this group that presents high social vulnerability, this study is justified by the fact that it brings to the fore a practice of nurses of major social relevance, focused on the qualification of care and the rescue of citizenship in the perspective of universal access to health services and health care.
It should be noted that, in the process of preparing this article, we observed a scarcity of studies related to the work process in SMO and a lack of publications related specifically to nursing work in this context.
In this scenario, the study was conceived by the guiding question: do nurses have the potential to play an aggregating and articulating role in street care depending on how they organize their work process?
In order to elucidate this question, this article aimed to analyze the elements of the nursing work process in the SMO: the objects, the instruments and the purposes.

Method
In order to achieve this objective, an exploratory research of a qualitative nature (12) was carried out seeking the meaning of expression of ideas, feelings, values, and ways of thinking, relating and acting of nurses. This approach was considered the most adequate to capture the dynamics of the work process (5)  The purpose of this analysis is to unravel the nuclei of meaning present in the communication, whose presence or frequency has some meaning for the object of study.
The steps of pre-analysis, material exploration, treatment of results and interpretation (12) were followed.
Thus, the following steps were performed: 1) data ordering, including the transcription, re-reading and organization of the reports; 2) then, categorization of the pieces of information after exhaustive and repeated reading of the texts for the definition of analytical categories; and 3) the third step consisted of the final analysis, which was based on the observed relationship between the empirical material (captured reality) and the theoretical reference on the health and nursing work process. In the set of empirical material, three themes emerged concerning the object of the work process, instrument and workforce, product and purpose of the work, defined as follows: "Need for health care in the context of social and health vulnerability", "Strategic planning and teamwork as instruments for organizing the work process"; "Purposes and products of work: guaranteeing the right to access and care". As already pointed out, all ethical criteria were respected and the study was approved on April 14, 2016, by the Ethics

Results
In the theme "Need for health care in the context of social and health vulnerability", the strong context of vulnerability in which the users of the service are inserted was evidenced by the nurses of the SMO: [ For workers, access to these devices would make them more likely to meet the needs of these users.
However, this access is hampered by the lack of services and, especially, by a deficient reception: Health needs, as an object of nursing work, are typical of a dynamic and differentiated environment, requiring unique instruments and forms of organization of the work process by the nurses who experience the provision of street medical care, as discussed below.
In the second theme, "Strategic planning and teamwork as instruments for organizing the work process", the following logic of work organization was  To describe the SHP process, nurses use definition of the SMO, schematically presented below in Figure 1.

Discussion
In the light of the analytical themes emerging from the nurses' speeches in this study, and when we focus specifically on the nursing work process, we have as object of work the "care" or "needs" of individuals, families, communities and collectivities. It is understood that the object of the health and nursing work is not limited to the physical/biological body of these individuals. This conception vary according to the conception of health and disease with which one is dealing (13) .
Thus, identifying the health needs of the users requires overcoming the disease-centered paradigm as the only means of dealing with the complaints presented by users, representing their health problems.
Health needs are not restricted simply to human biological aspects, but rather encompass the needs and vulnerabilities of the individuals (14) .
Another need that was highlighted in the interviewees' speeches is the access to health services.
This finding is ratified by the literature, because health needs also imply access to services and technologies that prolong or improve life, including the necessary referrals, as well as the scheduling of consultations in other points of the HCN (14)(15) .
Access to the HCN has also been discussed by authors (1,3,11)  Historically, the formation of the hegemonic medical-assistance model (4,17) was centered on hard and light-hard technologies as it was based on corporate interests, especially of economic groups (18) . Similar results were found in a study (1) performed with SMO teams in the city of Rio de Janeiro in 2013, in which the professionals indicated to work based on a perspective of shared care.
It is important to remember that health, driven and legitimized by the hegemonic care model, has undergone a strong fragmentation process due to the phenomenon of professional super-specialization and increasing technical and social division of health work (4,(17)(18) .
In the context of model change, the everincreasing need for new and complex tasks to reach a comprehensive health care is added to this panorama, requiring from professionals the capacity of interdisciplinary teamwork (15,17) .
The promotion of integrated teamwork aims to improve service responses to users' needs and the quality of health care (19) . This requires, therefore, Quality of life as a health promotion tool (20) encompasses, in addition to health status, satisfactory relationships with the environment, economic resources and time for work and leisure. Considering that the homeless population is marked by difficult living conditions, poor food and housing, besides lack of access to basic rights such as education, health and safety, it is understood that quality of life is sought in a more real and contextualized perspective, to provide more dignity to life (3) .
In this sense, efforts have been made to conquer spaces, as well as to establish a relationship between quality of life and social justice, so that the focus may not only be on reducing the risks of diseases, but also increasing life opportunities, for which progressive multiand inter-sectorial articulation is required (15) . This has been pointed out as one of the greatest barriers found, not only by SMO team workers of the northeastern capital, but also in other states, as described in studies already cited (1,3,11) .
The right to health, therefore, is signaled at all times as the primary purpose of the work process in SMO, understood as a set of minimum goods and services necessary for the survival and possibility of improving the quality of life, as established in article 25 of the Universal Declaration of Human Rights (21) . The discussion of the interface between universal human rights and health has mobilized national and international authors in a common understanding of favoring the empowerment of both users and health workers in the knowledge about human rights and citizenship, developing strategies that first ensure the interest of the human beings in dialogical and reciprocal actions of solidarity (22)(23) . In Brazil, this movement has been expanded with the National Health Humanization Policy, focusing on changes in health practices that value the life and the participation of people in care processes (24) .
In this perspective, the damage reduction (DR) was pointed out by the nurses as well as a purpose of their work process. Damage reduction was initially understood as an initiative aimed at controlling the consequences of the use of psychoactive substances, without necessarily imposing it on abstinence (1) . It is noteworthy that the nurses participating in this study,

Conclusion
The The study presented some limitations typical of exploratory qualitative researches: it was carried out in a single municipality, comprising a small number (5) of interviewed subjects, which represented at the time of field research all the nurses working in the CnaR of the municipality in question. Despite these limitations, the study met its objective and provided answers, by examining the constituents of the work process, about the potentiality of the nursing practice to improve street care.
Regarding the object of work, a broad spectrum of care needs was highlighted, including issues that emanate from the context of social vulnerability and that translate into needs of food, hygiene, housing and education, to issues of diagnostic and therapeutic intervention, highlighting the need for access to the Health Care Network.
To face with this reality, the nurses use instruments Because this is not a work that is limited to the hands and voices of the professionals of this device, but it is rather extended to actions that require co-responsibility and sensitivity of different points and sectors of the public service network, with a view to the extension of the rights of a population that already suffers so much and is forgotten in the urban centers in Brazil.