Nursing consultation in the Family Health Strategy and the nurse’s perception: Grounded Theory

La consulta de enfermería en la Estrategia de Salud de la Familia y la percepción del enfermero: Teoría Fundamentada

ABSTRACT

Objectives:

to understand the experience of nurses with nursing consultations in the context of the Family Health Strategy and propose a representative model.

Methods:

qualitative research using Grounded Theory, with 14 nurses working through non-directive interviews. For data analysis, three stages were used: open, axial and selective coding, which originated phenomena, themes, categories and subcategories, which supported the construction of the central category and, consequently, the theoretical model.

Results:

the interrelation of phenomena emerged from the essence of the nurse’s experience, revealing the central category: From nursing education to the practice of Nursing Consultation, unveiling learning, challenges and autonomy as intervening components. Final Considerations: the nurse’s experience is positive and, despite numerous challenges in daily life, the nurse has been performing it based on comprehensive care. New studies may add new understandings that enable the expansion of working conditions, valuing the nursing consultation.

Descriptors:
Office Nursing; Family Health Strategy; Grounded Theory; Nursing; Primary Care Nursing

RESUMEN

Objetivos:

comprender la experiencia de enfermeras con consultas de enfermería en el contexto de la Estrategia Salud de la Familia y proponer un modelo representativo.

Métodos:

investigación cualitativa mediante Grounded Theory, con 14 enfermeras trabajando a través de entrevistas no directivas. Para el análisis de los datos se utilizaron tres pasos: codificación abierta, axial y selectiva, que originó fenómenos, temas, categorías y subcategorías, que sustentaron la construcción de la categoría central y, en consecuencia, el modelo teórico.

Resultados:

la interrelación de fenómenos surgió de la esencia de la experiencia de la enfermera, revelando la categoría central: De la formación en enfermería a la práctica de la Consulta de Enfermería, develando aprendizajes, desafíos y autonomía como componentes intervinientes. Consideraciones Finales: la experiencia de la enfermera es positiva y, a pesar de numerosos desafíos en la vida diaria, la enfermera la ha venido realizando con base en una atención integral. Nuevos estudios pueden sumar nuevos entendimientos que permitan ampliar las condiciones laborales, valorando la consulta de enfermería.

Descriptores:
Enfermería de Oficina; Estrategia de Salud familiar; Teoría Fundamentada; Enfermería; Enfermería de Atención Primaria

RESUMO

Objetivos:

compreender a experiência do enfermeiro com a consulta de enfermagem no contexto da Estratégia Saúde da Família e propor um modelo representativo.

Métodos:

pesquisa qualitativa, utilizando a Teoria Fundamentada, por meio de entrevistas não diretivas com 14 enfermeiros atuantes. Para análise dos dados, foram utilizadas três etapas: codificação aberta, axial e seletiva. Estas originaram fenômenos, temas, categorias e subcategorias, que embasaram a construção da categoria central e, consequentemente, do modelo teórico.

Resultados:

a inter-relação dos fenômenos fez emergir a essência da experiência do enfermeiro, revelando a categoria central: “Da formação do enfermeiro à prática da consulta de enfermagem: desvelando aprendizados, desafios e autonomia como componentes intervenientes”. Considerações Finais: a experiência do enfermeiro é positiva; e, apesar de inúmeros desafios no cotidiano, o enfermeiro vem atuando embasado na integralidade do cuidado. Novos estudos poderão agregar outras compreensões que possibilitem ampliação das condições de trabalho, valorizando a consulta de enfermagem.

Descritores:
Enfermagem no Consultório; Estratégia Saúde da Família; Teoria Fundamentada; Enfermagem; Enfermagem de Atenção Primária

INTRODUCTION

The nursing consultation (NC) is an exclusive nursing assistance, established by Law 7.498/86 and used in work planning in order to provide health actions through guidance, instructions and actions in order to decide on a care plan within the health system, including assistance to the individual, family and community(¹).

In Brazil, the name “nursing consultation” appeared officially in 1960; however, before that, nurses already performed this assignment referring to care to pregnant women and healthy children by means of orientation. Over the years, this service has been extended to include care for tuberculosis patients and public health programs, which were previously called “post-clinical interviews”(¹).

Thus, nursing practices have evolved in partnership with science and technologies. As an example, in the 1970s, a Brazilian nurse by the name of Wanda de Aguiar Horta encouraged the implementation of the use of nursing theories in the academic area and developed the theory called “Theory of Basic Human Needs”.

Thus, the professional practice would be based on a theoretical framework, which gave rise to the Nursing Care Systematization (NCS), following the five steps developed by Wanda de Aguiar Horta, which refer to the anamnesis and physical examination, problem survey, diagnosis, nursing prescription and evolution(¹).

Currently, for the performance of NC, in addition to systematization, technical, scientific, ethical knowledge, critical thinking, clinical reasoning and action strategy are required of nurses at all levels of care, whether public or private(²).

In Primary Health Care (PHC), within the Family Health Strategy (FHS), the NC is presented in an expanded form to the community, offering care to different population groups, such as childcare, women’s health, pregnant women, adults, the elderly, chronic diseases, immunization, home visits, and continuing education(³).

To extend the care to the population, the nurses use as support and reference in the NC the guidelines described in the protocols of the Ministry of Health and validated municipal protocols, which support and direct the assistance regarding conduct, diagnosis, test requests, and drug prescriptions(³).

One of the main objectives in the planning of the NC is to provide care based on the integrality of care with the guarantee of quality services to the user. It is worth clarifying that comprehensiveness includes resolving interventions to meet the demands of the community in its different dimensions of care, considering the complexity of each human being(¹).

In the scientific field, there is much to discuss about NC given its relevance to PHC, especially when associated with the evolution and appreciation of nursing practice and meeting the needs of the population. In addition, there are few studies on this theme, and part of them focus on the analysis in a reductionist and linear view of classical science, restricting themselves to barriers in NC, without covering answers that meet the demands of comprehensive health care and explain how these obstacles interfere with professional conduct.

Given this scenario, this research started with the question: How do nurses experience the practice of nursing consultation in the Family Health Strategy?

OBJECTIVES

To understand the nurse’s experience with the nursing consultation in the context of the Family Health Strategy and propose a representative model.

METHODS

Ethical aspects

All ethical aspects were considered, and the project was approved by the Research Ethics Committee according to Resolution no. 466, dated December 12, 2012, which approves the guidelines and norms regulating research involving human beings.

Type of study

Following the Consolidated criteria for reporting qualitative research (COREQ), indicated for qualitative research, the option for the study was Grounded Theory (GT)(⁴), translated to portuguese as Teoria Fundamentada em Dados (TFD), in the Straussian approach, which makes it possible to generate explanations of the phenomenon based on the understanding of the actions of individuals or groups in a given context when facing problems or experienced social situations. Developed by Glaser and Strauss (1960), with influence from symbolic interactionism and pragmatism, the GT proposes a systematic analysis technique that instructs the author to develop sociological theories about the experience lived by the participants(⁴-⁵).

Study scenario

The research sample was composed of 14 nurses working in FHS units in a city in the interior of the state of São Paulo (SP). They were aged between 29 and 50 years and graduated between 1995 and 2010. All participated in continuing education, nine had completed the specialization course in Public Health, six had a master’s degree, and one nurse was pursuing her doctorate.

Collecting and organizing data

Data collection was conducted between June 2017 and July 2018, through non-directive type interviews, with the starting question: Tell me what is your experience with the nursing consultation in your unit?

The research participants were invited by telephone, scheduling a date and time for the interviews, outside their working hours, at the units where they worked. After reading and explaining the objectives and methodology of the study, all of them signed the Free and Informed Consent Term.

The interviews were digitally recorded and transcribed in full immediately after collection. The participants were identified by the letter “N” (for “nurse”) accompanied by a number (N1, N2...), to ensure anonymity.

Data analysis

Methodological rigor was followed whereby data were systematically compared across phenomena, themes, categories, and subcategories. The coding procedures for the GT were carried out in three complementary steps: open, axial, and selective. With this, the theoretical model was developed(⁴-⁵).

For the discussion of the data, we used the theoretical framework of integrality in health care and attention(⁶), which directs the construction of multidisciplinary practices of integral attention.

RESULTS

The strategy employed to discover the central category was to interrelate the phenomena named “From the beginning of the praxis to the daily life of NC” and “The NC in FHS practice” to build the theoretical model. Thus, the phenomena were identified through the five key categories that highlighted the nurse’s experience with NC.

Phenomenon 1 - From the beginning of the praxis to the daily routine of the NC - Represents the history of the nurse’s praxis since the beginning of working in the FHS, their continuous search for scientific knowledge until the professional preparation. Along this path, the participants recognize that NC is a constant learning process.

[…] I can’t tell you that, even though I have been doing it for ten years, I know everything or that I have the best consultation. It is all a learning process! [...] Maybe in ten years there will be other instruments [...] we have to update ourselves (N2.9)

[…] because we prepared ourselves, the university trained us initially, and then we had to look for specialization, training courses, and other demands to supply the needs that arise on a daily basis. I have many experiences, and the day-to-day experience is enriching. We learn a lot on a daily basis. (N4)

Category 1 - NC and nurse training - Brings together the processes that nurses went through during their graduation to acquire clinical knowledge aimed at the completeness of patient care through NC, including its deficiencies.

[…] In these seven years, I improved a lot and needed to look for many things. Actually, the undergraduate degree alone gives a base, but it doesn’t help in all these processes. You can’t just stick to your undergraduate degree. (N11)

Category 2 - NC being recognized by the nurse and accepted by the team and community - Portrays the professional gains related to the practice of NC, such as the professional recognition, valorization and visibility acquired during the care in the FHS.

In this unit, the nursing consultation is already well consolidated. Both for the team and for the population. Rarely, there are patients who don’t want to be seen by the nurse, or who encounter some obstacle. But, after a conversation, demonstrating the importance of our work, the protocols that we follow, and the theoretical basis, we usually manage to win the patient over and we are well accepted. (N4)

Phenomenon 2 - NC in FHS practice - Contemplates the NC developed in the FHS, the overcoming of challenges, the achievement of gains in the search for comprehensive care, and the overloads of the nursing process (NP). It interrelates the feelings presented by the nurses in face of the daily working conditions and the desire to qualify the NC.

[…] The nursing consultation is the main activity that we do and practice in family health care. And also in the visit, which is also a consultation, let’s say. [...] I think that what makes it difficult, for example, is the overload. Because, many times, in the units, nurses are assistant managers. At least in the Family Health units. (N9)

Category 1 - Having problems with spontaneous demand - Shows that every day FHS nurses face a dilemma with spontaneous demand - which is defined as any unscheduled care in the unit originated by the user’s momentary need. These facts present themselves as obstacles in the organization of the work process of nurses facing the NC.

[…] many times, we have difficulty in following the consultation. Because I see that we, professionals, have a very big challenge in the work process, currently, due to the high spontaneous demand, that is, the extra care, we end up acting as a complaint and conduct. So, doing a service like this, we end up following a path that is not a nursing consultation. (N8)

Category 2 - Interfaces between care and management - Represents the interrelationship between care and management activities, which complement each other in the assignment of the FHS nurse. The nurses report that they feel overwhelmed due to the high demand assigned to them, which involves care, management, and work structuring.

Doing the management part and dividing a little time for assistance. So I think it’s bad, because unfortunately the patients are the ones who end up losing out in terms of quality. (N3)

I can’t do everything at the same time. If I am doing consultation, I am doing management at the same time, someone is knocking on the door, someone wants to talk to me, someone is waiting for me […]. (N2)

Category 3 - Systematizing the NC - portrays the nurses’ attempt to systematize the NC, to develop all the steps of the NP learned during graduation. The participants demonstrate that systematizing induces the organization of work, but that, due to the overload, this practice does not occur in all care.

But we try to follow the steps, to take the history, the anamnesis, the survey of problems, the diagnosis, and the intervention. We try to follow everything! (N3)

After in-depth analysis, comparing the data, the central category of experience of nurses with NC, entitled “From nurse training to nursing consultation practice: unveiling learning, challenges, and autonomy as intervening components”. It was possible to configure experiences and abstract them into a theoretical model that deepened the understanding of this experience (Figure 1).

Figure 1
Theoretical model of the nurse’s experience with nursing consultation in the Family Health Strategy

DISCUSSION

Based on the theoretical model, it is possible to observe the experience of nurses with NC in the FHS since graduation, expanding the construction of knowledge and learning ways to systematize it in practice. The progress of this experience has allowed for better agility, and scientific knowledge, improvement of clinical reasoning, which structure and form the basis of NC, providing quality to the nurse’s work and leading to the practice of integrality of care.

The core of the model translates the meaning of the professional’s trajectory to successfully perform his private duties, going through challenges until he achieves achievements and recognition of his practice. It exposes the essence of the nurse’s experience through the NC, in the central category entitled “From nurse education to the practice of nursing consultation: revealing learning, challenges, and autonomy as intervening components. Thus, the model reveals the nurses’ training process, their expectations about NC, positive factors, realities experienced in practice, and negative factors experienced by them along this path.

The academic education of nurses is the foundation for professional practice, which is influenced directly or indirectly by several factors. Types of institutions (public or private), periods (morning, evening or full time) and distance education can shape differently the profile of future nurses. In addition, the year of graduation brings interferences in this formation, since the courses and contents improve with the advances in science(⁷). In Brazil, it is evidenced that most nurses have been graduated for ten years or less, characterizing a young professional category(⁸).

NC is one of the main activities worked on in the undergraduate course, because it is a component that cuts across the different lines of care and represents the main way of providing nursing care, both for healthy and hospitalized individuals(¹). The training also seeks to improve care techniques, which induces clinical reasoning, in addition to presenting the foundations for nursing management, which together strengthen the development of the care plan, regardless of the workplace or level of health care(⁹).

When the nurse begins the practice of NC in the FHS many expectations are revealed, such as qualified care, progressive knowledge, NCS and planned actions.

Regarding care, the participants expressed an integralist vision of care through qualified NC, that is, the desire to qualify and practice the profession in totality, with a search for progressive knowledge to expand clinical reasoning through innovative techniques and specializations related to the improvement of practice. Such expectations corroborate the literature, since the lack of qualification and improvement can compromise the performance of the health unit(¹⁰). In addition, it is necessary to have the theoretical and technical background to train the team and conduct health education for the community(¹¹).

Other expectations are related to the implementation of the NCS and the actions planned in the practice of the FHS, which are crucial factors for nurses in the development of their duties, as they are legitimate responsibilities of the category, demanded by the class organizations(¹²).

The NCS influences the performance of the NC mainly in the planning and organization of nursing actions, because it offers the nurse resources to apply his knowledge and skills to the user in a direct and independent way(¹³-¹⁴). In addition, it favors dialogue and listening, which must remain active to define goals and actions involving the care plan and quality of health care(¹⁵).

The planned actions refer to the organization of the NP, the distribution of the team’s work, as well as the programming of interventions and health programs, enabling accessibility to health for users and efficiency in the division of work time. Actions such as community health diagnosis, with territorialization, mapping, planning of home visits, and situational eco-map of the families are also included(¹⁶).

Following the theoretical model, the positive factors of the nurse’s experience are revealed, and the protocol is evident in the performance of the NC, because, through this instrument, the participants report acquiring autonomy and empowerment to perform their practice(¹⁷). This autonomy manifests itself in decision making when planning care for population groups in a resolute and integral manner, leading to professional recognition of nurses and also generating a sense of personal satisfaction with the work developed (gratification).

The protocol is an instrument that directs the NC. It includes descriptions of several specific situations of assistance, operational specificities, and details about what is done, who does it, and how it is done, guiding professionals in solutions for disease prevention, promotion, recovery, or rehabilitation of health(¹⁸). Although they do not always clearly describe all of the nurse’s duties(¹⁹), the protocols are positively referenced, as the NC evolves and improves.

The experiences reveal the opportunity to develop integrality of care, by being able to comprehensively address various aspects of the user’s life. This integrality is characterized by three sets of concepts: the articulation of health services, the comprehensiveness of workers’ practices, and the composition of government policies(²⁰).

In the routine of the FHS teams, integrality acts in the micro-processes of care, in the exercise of each professional through welcoming, commitment to the population, and health care in order to conquer bonds and establish goals for restoring the needs presented(²¹-²²).

To achieve integrality in the FHS care, collaboration of the health team is necessary, so that each member performs its function in an integrated manner, starting with the health system managers, overcoming barriers such as the biomedical model, which has fragmented attention and focus on disease(²¹).

Professional recognition in the community occurs based on the resoluteness that the NC imprints on the FHS, because, after an anamnesis, it is possible to go beyond the need presented as a complaint, exploring the family life, social and cultural aspects, and other conflicting factors that reflect in the health/disease process. Such conduct strengthens the bond with users, as pointed out by a Canadian study in which participants confirmed that the nurse was their preferred contact in primary care(²³).

In the professional experience of nurses, when the fullness of the NC is achieved, feelings of great satisfaction are revealed with the evolution of the work, providing the feeling of being useful and fulfilling their role in society. In this sense, a study conducted with FHS nurses, with respect to NC in childcare, found that performing it meant obtaining a great privilege, because it generates a sense of success, appreciation of the profession, and both professional and personal recognition(²⁴).

At the other end of the theoretical model, the nurse already trained and inserted in the labor market faces difficulties in the practice of NC, expressed mainly as scarce time, lack of agility for the nursing diagnosis, problem in the interface between assistance and management, besides the high bureaucratic demand.

The shortage of time stems from the services open to the population that generate high demand and unplanned flow, called “spontaneous demand”, which requires a period of unscheduled care from nurses, causing feelings of frustration and anxiety due to the long waiting list. Besides this, the high demand requires fast and punctual care so that everyone is covered, interfering with the pre-scheduled NCs(³) and hindering the practice of integrality(¹⁶).

Thus, the difficulty in systematizing NC emerges, especially in classifying the nursing diagnosis quickly and accurately. Despite seeking to ensure compliance with the norms of the profession by performing complete NC (anamnesis, physical examination, problem survey, diagnosis, intervention, and nursing evolution), nurses fear not being able to perform all the steps in their entirety, since critical sense and evolutionary capacity to plan the therapeutic process are required(¹).

To optimize this process before the high demand, there is a need for instruments that facilitate and expedite the performance of NC with practicality and standardization. The International Classification for Nursing Practice (ICNP) is an important tool, since it is a classification system with a single and universal language that standardizes NC in relation to diagnosis and intervention(²⁵). It is a way to organize care planning, reducing variations in users’ treatments and increasing the quality of care(³). However, the experience of nurses with the ICNP revealed challenges related to the lack of agility to find the diagnosis quickly and accurately during NC, given the complexity and need for memorization, which causes embarrassment when having to look for it, leafing through the book in the presence of the user, since most professionals do not have the computerized ICNP. Such difficulty is corroborated in research conducted in southern Brazil, in which participants also reported lack of mastery in the operation of the system, including already in the process of computerization(²⁵).

Another reality faced is the interrelation between care activities and managerial demands, which are overlapping in the nurse’s attributions in the FHS, causing the feeling of overload in the work structuring(¹⁶). In this context, the nurse’s exercise of leadership stands out, adding responsibilities in managerial and care practices that aim to meet the health needs of the population. Both attributions go together to strengthen PHC, but nurses express dissatisfaction with the overload in the NP caused by the high bureaucratic demand (filling out spreadsheets, documents, and requests under their responsibility(¹⁰), demands and referrals focused on time-consuming solutions), in addition to mismatches in relationships and communications that seem to hinder the resoluteness of actions and damage the credibility of the FHS team(¹⁶).

In general, NP involves several dimensions combined together, such as care, management, teaching, research, and political participation(²⁶-²⁷). Therefore, it is observed the crucial need for the FHS nurse to maintain the balance between his work dimensions, associated with the knowledge of his demands in the daily planning of his activities, in delegating pertinent activities to the team and in exploring the benefits that the practice of NC brings him in the progress of the profession.

Finally, the representative model highlights the negative factors experienced in the practice of NC in the FHS, which are directly related to the work process and are interdependent with reality. These factors are presented by the nurses as demands from managers, high user demand, protocol limitations, dependence on medical conduct, and feelings of sadness in face of these conditions(²⁸).

Negative feelings are demonstrated in another angle of the experience, in which professionals expose the discomfort faced with production demands, quantitative service goals, and pressure in terms of deadlines required by managers(¹⁰). Referring to the monthly goals, the frustration is manifested by the desire that each service be based on integrality and not characterized as just another simple procedure; by the disappointment in not being considered all the deficient aspects of the user, nor the multiprofessional sharing, necessary referrals and resolutive aspects, which demand time and technical knowledge.

Another negative aspect revealed referred to the dependence on the medical professional, because in situations of care, the nursing protocol does not cover certain actions, so that when there is need for prescription of medication to conclude the consultation, the information obtained there needs to be shared with the doctor. In this context, the expansion of the protocols would bring greater opportunities to solve community problems and contribute to the better functioning of the health unit, which often suffers from the absence of the physician for long periods of time(²⁸).

In summary, feelings of sadness are revealed when they see that the expectations of the training do not materialize effectively in the practice of the NC in the FHS. On the contrary, they see in their work the overload associated with lack of time and other negative factors that arise in their daily routine. It is suggested that nurses seek better knowledge of their duties in order to delegate functions in the teamwork process, with adequate time to perform their private activities, maintaining multi-professional meetings with incentives for continuing education, facts that can improve their performance in the NC and in the integrality of care(¹⁶).

Study limitations

The results of this study refer to the FHS setting, which compromises the expansion of the perception of nurses from other fields in PHC. In addition, for the discussion with the literature, the theme proved to be scarce; for this reason, new investigations are needed in the various scenarios of nursing practice.

Contributions to the field of Nursing, Health or Public Policy

These results contribute to the increase of science to the extent that they reveal the practical reality experienced by nurses inserted in the FHS. Changes can be provided based on the new meanings related to NC, allowing a better visibility and autonomy so desired.

FINAL CONSIDERATIONS

Nurses understand that NC in the FHS is linked to positive experiences. However, on a daily basis, they are faced with overload, high demand, bureaucratic demands, and limitations, which are factors that hinder professional practice.

Through the theoretical model, it was possible to reveal the nurses’ experience with NC in the FHS since graduation, expanding the construction of nursing knowledge and learning ways to systematize it in practice. Thus, the model expresses the nurses’ training process, their expectations about NC, positive factors, realities experienced in practice, and negative factors experienced by them in this trajectory.

This research is unprecedented, providing new insights into the practice of consultation developed by nurses. It was identified the lack of understanding of professionals about the importance of management as a complement to care, revealing a gap to be filled in undergraduate education. It becomes necessary to prepare future nurses with knowledge and skills that better correspond to the realities faced in professional practice.

The study also points out that there is a path to be followed in the profession, in which NC should be more valued by society and by the nurses themselves, as it is a rich instrument to increase the resolution of the population’s health problems at the primary care level.

SUPPLEMENTARY MATERIAL

Lima SGS. The nursing consultation in primary health care: from nursing education to professional practice [tese] [Internet]. Botucatu: Faculdade de Medicina, Unesp; 2021 [cited 2021 Nov 21]. Available from:https://repositorio.unesp.br/handle/11449/213718

ACKNOWLEDGMENT

Thanks to the Coordination for the Improvement of Higher Education Personnel (CAPES) for the doctoral scholarship.

The authors declare that there are no conflicts of interest.

REFERENCES

• ¹
  Crivelaro PMS, Posso MBS, Gomes PC, Papini SJ. Consulta de enfermagem: uma ferramenta de cuidado integral na atenção primária à saúde. Braz J Dev. 2020;6(7):49310-21. https://doi.org/10.34117/bjdv6n7-542
  » https://doi.org/10.34117/bjdv6n7-542
• ²
  Conselho Federal de Enfermagem (BR). Lei nº 7.498, de 25 de junho de 1986. Dispõe sobre a regulamentação do exercício de enfermagem, e dá outras providencias. Brasília, DF: COREN; 1986.
• ³
  Kahl C, Meirelles BHS, Lanzoni GMM, Koerich C, Cunha KS. Actions and interactions in clinical nursing practice inrimary health care. Rev Esc Enferm USP. 2018;52:e03327. http://doi.org/10.1590/S1980-220X2017025503327
  » http://doi.org/10.1590/S1980-220X2017025503327
• ⁴
  Corbin J, Strauss AL. Basics of qualitative research: techniques and procedures for developing grounded theory. 4th ed. Los Angeles: SAGE; 2015.
• ⁵
  Santos JLG, Cunha KS, Adamy EK, Backes MTS, Leite JL, Sousa FGM. Data analysis: comparison between the different methodological perspectives of the Grounded Theory. Rev Esc Enferm USP. 2018;52:e03303. https://doi.org/10.1590/S1980-220X2017021803303
  » https://doi.org/10.1590/S1980-220X2017021803303
• ⁶
  Mattos RA. Os sentidos da integralidade: algumas reflexões acerca de valores que merecem ser defendidos. In: Pinheiro R, Mattos RA, organizers. Os sentidos da integralidade na atenção e no cuidado à saúde. Rio de Janeiro: UERJ; 2006. p. 43-68.
• ⁷
  Pires DEP. Transformações necessárias para o avanço da Enfermagem como ciência do cuidar. Rev Bras Enferm. 2013;66(spe):39-44. https://doi.org/10.1590/S0034-71672013000700005
  » https://doi.org/10.1590/S0034-71672013000700005
• ⁸
  Humerez DC. Aspectos gerais da formação da enfermagem: o perfil da formação dos enfermeiros técnicos e auxiliares: debatedor 3. Enferm Foco. 2016;7(esp):32-4. https://doi.org/10.21675/2357-707X.2016.v7.nESP.690
  » https://doi.org/10.21675/2357-707X.2016.v7.nESP.690
• ⁹
  Bohusch G, Sanes MS, Vendrusculo C, Meltelsk FK. Melhores práticas de enfermagem na atenção primária à saúde: relato de ação pedagógica. Inova Saude. 2020;10(2)1-11. http://doi.org/10.18616/inova.v10i2.5212
  » http://doi.org/10.18616/inova.v10i2.5212
• ¹⁰
  Oliveira MM, Pedraza DF. Contexto de trabalho e satisfação profissional de enfermeiros que atuam na estratégia saúde da família. Saude Debate. 2019;43(122)765-79. http://doi.org/10.1590/0103-1104201912209
  » http://doi.org/10.1590/0103-1104201912209
• ¹¹
  Corrêa VAF, Acioli S, Tinoco TF. The care of nurses in the Family Health Strategy: practices and theoretical foundation. Rev Bras Enferm. 2018;71(suppl 6):2767-74. https://doi.org/10.1590/0034-7167-2018-0383
  » https://doi.org/10.1590/0034-7167-2018-0383
• ¹²
  Conselho Federal de Enfermagem (BR). Resolução Cofen nº 358/2009. Dispõe sobre a Sistematização da Assistência de Enfermagem e a implementação do Processo de Enfermagem em ambientes, públicos ou privados, em que ocorre o cuidado profissional de Enfermagem, e dá outras providências [Internet]. Brasília, DF: Cofen; 2009[cited 2020 Jun 02]. Available from: http://www.cofen.gov.br/resoluo-cofen-3582009_4384.html
  » http://www.cofen.gov.br/resoluo-cofen-3582009_4384.html
• ¹³
  Ribeiro GC, Padoveze MC. Nursing care systematization in a basic health unit: perception of the nursing team. Rev Esc Enferm USP. 2018;52:e03375. http://doi.org/10.1590/S1980-220X2017028803375
  » http://doi.org/10.1590/S1980-220X2017028803375
• ¹⁴
  Wanzeler KM, Bastos LBR, Cruz AB, Silva NP, Souza SPC, Bastos DAS, et al. Sistematização da assistência de enfermagem (SAE) na atenção primária à saúde. REAS. 2019;35(suppl 35):e1486. https://doi.org/10.25248/reas.e1486.2019
  » https://doi.org/10.25248/reas.e1486.2019
• ¹⁵
  Silva JP, Garanhani ML, Peres AM. Systematization of nursing care in undergraduate training: the perspective of complex thinking. Rev Latino-Am Enfermagem. 2015;23(1):59-66. https://doi.org/10.1590/0104-1169.0096.2525
  » https://doi.org/10.1590/0104-1169.0096.2525
• ¹⁶
  Spagnuolo RS, Bocchi SCM. Between the processes of strengthening and weakening of the family health strategy. Rev Bras Enferm. 2013;66(3):366-71. https://doi.org/10.1590/s0034-71672013000300010
  » https://doi.org/10.1590/s0034-71672013000300010
• ¹⁷
  Pereira JG, Oliveira MAC. Nurses’ autonomy in primary care: from collaborative practices to advanced practice. Acta Paul Enferm. 2018;31(6):627-35. https://doi.org/10.1590/1982-0194201800086
  » https://doi.org/10.1590/1982-0194201800086
• ¹⁸
  Pimenta CAM, Pastana ICASS, Sichieri K, Solha RKT, Souza W. Guia para construção de protocolos assistenciais de enfermagem [Internet]. São Paulo: COREN/SP; 2017[cited 2020 Jun 17]. Available from from: https://portal.coren-sp.gov.br/sites/default/files/Protocolo-web.pdf
  » https://portal.coren-sp.gov.br/sites/default/files/Protocolo-web.pdf
• ¹⁹
  Ferreira SRS, Périco LAD, Dias VRFG. The complexity of the work of nurses in primary health care. Rev Bras Enferm. 2018;71(suppl 1):704-9. http://doi.org/10.1590/0034-7167-2017-0471
  » http://doi.org/10.1590/0034-7167-2017-0471
• ²⁰
  Dias MMS, Carvalho JL, Landim LOP, Carneiro C. A integralidade em saúde na educação médica no Brasil: o estado da questão. Rev Bras Educ Med. 2018;42(4):123-33. https://doi.org/10.1590/1981-52712015v42n4rb20180094
  » https://doi.org/10.1590/1981-52712015v42n4rb20180094
• ²¹
  Pinheiro R. Atenção básica à saúde: um olhar a partir das práticas de integralidade em saúde. REME [Internet]. 2005[cited 2020 Jun 17];9(2):174-8. Available from: http://reme.org.br/sumario/32
  » http://reme.org.br/sumario/32
• ²²
  Viegas SMF, Penna CMM. A construção da integralidade no trabalho cotidiano da equipe saúde da família. Esc Anna Nery. 2013;17(1):133-41. https://doi.org/10.1590/S1414-81452013000100019
  » https://doi.org/10.1590/S1414-81452013000100019
• ²³
  Hudon C, Chouinard MC, Diadiou F, Lambert M, Bouliane D. Case management in primary care for frequent users of health care services with chronic diseases: a qualitative study of patient and family experience. Ann Fam Med. 2015;13(6):523-8. doi: 10.1370/afm.1867.
  » https://doi.org/10.1370/afm.1867
• ²⁴
  Campos RMC, Ribeiro CA, Silva CV, Saparolli ECL. Nursing consultation in child care: the experience of nurses in the family health strategy. Rev Esc Enferm USP. 2011;45(3):566-74. http://doi.org/10.1590/S0080-62342011000300003
  » http://doi.org/10.1590/S0080-62342011000300003
• ²⁵
  Kahl C, Meirelles B, Cunha K, Bernardo M, Erdmann A. Contributions of the nurse’s clinical practice to primary care. Rev Bras Enferm. 2019;72(2):371-6. http://doi.org/10.1590/0034-7167-2018-0348
  » http://doi.org/10.1590/0034-7167-2018-0348
• ²⁶
  Sanna MC. Os processos de trabalho em enfermagem. Rev Bras Enferm. 2007;60(2):221-4. https://doi.org/10.1590/S0034-71672007000200018
  » https://doi.org/10.1590/S0034-71672007000200018
• ²⁷
  Medeiros AL, Santos SR, Cabral RWL. Systematization nursing care: difficulties highlighted by the grounded theory. Rev Enferm UERJ [Internet]. 2013[cited 2020 Jun 17];21(1):47-53. Available from: https://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/6347/4520
  » https://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/6347/4520
• ²⁸
  Campos EC. Protocolo de assistência de enfermagem: visão do enfemeiro na estratégia saúde da família [Dissertação] [Internet]. Botucatu: Universidade Estadual Paulista; 2017[cited 2020 Jun 17]. Available from: https://repositorio.unesp.br/bitstream/handle/11449/148948/campos_ec_me_bot_int.pdf?s
  » https://repositorio.unesp.br/bitstream/handle/11449/148948/campos_ec_me_bot_int.pdf?s

Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Margarida Vieira

Publication Dates

• Publication in this collection
  30 Mar 2022
• Date of issue
  2022

History

• Received
  13 Nov 2020
• Accepted
  03 Nov 2021