Attributes mobilized by nurses in family health: reaching performances when developing managerial competence

Abstracts

Estudo de caráter exploratório-descritivo, com abordagem qualitativa, objetivando identificar e analisar os atributos mobilizados nas situações de trabalho e que caracterizam os desempenhos das enfermeiras na área da competência gerencial na Saúde da Família, apoiado nos conceitos da competência dialógica. Para coleta de dados, foi realizada observação participante do trabalho das enfermeiras atuantes na Saúde da Família em quatro unidades vinculadas à Universidade de São Paulo em Ribeirão Preto - SP/Brasil, considerando-se uma semana típica de trabalho, totalizando 160 horas de observação. Através da análise de conteúdo, usando a técnica de análise temática, identificamos cinco temas relacionados a: supervisão, trabalho em equipe, controle social, organização do trabalho e planejamento. Os resultados apontam para um conjunto de atributos mobilizados pelas enfermeiras ainda centrado na organização do trabalho em saúde para o cuidado individual com raras incursões para um processo de planejamento sistematizado.

Enfermagem em saúde pública; Competência profissional; Saúde da família; Atenção primária à saúde; Conhecimento

ORIGINAL ARTICLE

Attributes mobilized by nurses in Family Health: reaching performances when developing managerial competence^*

Atributos movilizados por la enfermera en la Salud Familiar: aproximación a los desempeños en la construcción de la competencia gerencial

Lauren Suemi Kawata^I; Silvana Martins Mishima^II; Mara Quaglio Chirelli^III; Maria José Bistafa Pereira^IV; Silvia Matumoto^V; Cinira Magali Fortuna^VI

^IRN. MSc in Public Health Nursing. Doctoral student, Graduate Program in Public Health Nursing, University of São Paulo at Ribeirão Preto, College of Nursing. Professor, Undergraduate Nursing Program at the Federal University of Uberlandia, MG, Brazil. [e-mail]

^IIRN. Full Professor, University of São Paulo at Ribeirão Preto, College of Nursing. Ribeirão Preto, SP, Brazil. [e-mail]

^IIIRN. PhD in Nursing. Professor, Faculty of Medicine in Marilia, SP, Brazil. [e-mail]

^IVRN. Associate Professor, University of São Paulo at Ribeirão Preto, College of Nursing. Ribeirão Preto, SP, Brazil. [e-mail]

^VRN. PhD in Nursing. Professor, a University of São Paulo at Ribeirão Preto, College of Nursing. Ribeirão Preto, SP, Brazil. [e-mail]

^VIRN. PhD in Nursing. Professor, University of São Paulo at Ribeirão Preto, College of Nursing. Ribeirão Preto, SP, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

This exploratory-descriptive study was performed using a qualitative approach with the purpose to identify and analyze the attributes mobilized in work situations that characterize the performance of nurses in managerial competence in Family Health based on the concepts of dialogic competence. Data collection was performed through participant observation of the work performed by Family Health nurses in four units associated with the University of São Paulo in Ribeirão Preto - SP/Brazil, considering a typical workweek, with a total of 160 hours of observation. Through content analysis, using the thematic analysis technique, we identified five themes related to: supervision, teamwork, social control, work organization and planning. Results show there is a group of attributes mobilized by nurses which remains centered on work organization for individual health care with rare incursions for a systemized planning process.

Keywords: Public health nursing; Professional competence; Family health; Primary health care; Knowledge.

RESUMEN

Estudio exploratorio-descriptivo, de abordaje cualitativo, objetivando identificar y analizar los atributos movilizados en situaciones de trabajo que caracterizan los desempeños de enfermeras en el área de competencia gerencial en la Salud Familiar apoyado en conceptos de competencia dialogal. Para recolectar datos, se realizó observación participativa de trabajo de enfermeras actuantes en Salud Familiar en cuatro unidades vinculadas a la Universidad de San Pablo en Ribeirão Preto (SP-BR), considerándose una semana típica de trabajo, totalizando 160 horas de observación. A través de análisis de contenidos, usando técnica de análisis temático, identificamos cinco temas relacionados con: supervisión, trabajo en equipo, control social, organización del trabajo y planeamiento. Los resultados refieren un conjunto de atributos movilizados por las enfermeras, aún centrado en la organización del trabajo en salud para el cuidado individual con raras incursiones apuntando a procesos de planeamiento sistematizado.

Descriptores: Enfermería en salud pública; Competencia profesional; Salud de la familia; Atención primaria de salud; Conocimiento.

INTRODUCTION

The Family Health Strategy (FHS) is a public policy aimed to reorient health services launched in Brazil by the Ministry of Health in 1994, which has become a new field of work for nurses in primary health care (PHC). The FHS has been considered an important opportunity to intervene in the PHC field focused on multi-professional practice with the implementation of health services jointly with health promotion, prevention and recovery on a large scale, internationally recognized for its innovating nature in health care.

This proposal of an organization of services requires one to re-think: the organization of the health work process in which health practices are focused on the needs of families; the qualification of clinical action in care provided to individuals in their family and community contexts and that includes talking, listening, and the establishment of bonds, enabling dialogue and negotiation; integration of the health team in the face of an effort to interact and cooperate, among other aspects^(1-2).

This movement of transformation aiming to reorganize the work process will only be effective if it becomes part of the concern and practices developed by workers in the health field and more specifically in primary health care⁽³⁾. From this perspective, we consider management a strategic dimension for the transformation of the work process of the services at a local level, seen as a tool that directs the work process toward the production of an enlarged practice of care, that is, it is not restricted to bureaucratic and administrative activities, hence, enabling the development and transformation of care practices⁽²⁾ and seeking to separate from the rationale that prevents services from intervening in local problems and needs⁽⁴⁾.

The role of nursing in the care provided to families is not a new subject from the professional practice point of view, or from the standpoint of the production of knowledge. The participation and involvement of families in health care is considered a crucial aspect in nursing practice since the family contributes to the well being and health of its members and also influences the onset of diseases^(5-6).

We reiterate that the FHS in Brazil has the family as the main focus of care, however, this strategy does not seek only the participation and involvement of the family in the health care. This strategy was launched to reorganize the services and take into account the family included in the environment in which it lives and should be implemented following the principles of integrality, universality, equity, social participation and control, intersectionality, problem-solving capacity, health as a right, and humanization.

Hence, the analysis of the work of nurses in primary care based on the FHS conformity to the characteristics adopted in Brazil deserves a more focused view. Considering these issues, this study focuses on this view and identifies and analyzes the attributes (knowledge, skills and attitudes) employed in work situations and which characterize the performance of nurses in relation to the field of managerial competence in Family Health based on the theoretical concepts of dialogical competence.

We highlight that there are various lines/approaches of skills, among them: the behaviorist (emphasizes the expected responses), the functionalist (focuses on describing the results and not the processes needed to achieve them), the constructivist (even though it is work-centered and refers to the content of typical employment, it is still centered on the verification and fulfillment of tasks and results) and the dialogical⁽⁷⁾, the one we chose, and which considers the context and culture of the workplace and confers competence on a relational dimension between tasks and attributes. The performance of nurses is identified based on the work environment through a search of their actions. The attributes upon which these actions are based are identified including the ethics and values as elements that integrate the competent performance.

The proposal of dialogical competence is considered holistic and works with the development of skills or (cognitive, psychomotor and affective) attributes, while the combination of these skills include distinct ways of successfully performing essential actions and characteristics of a given professional practice⁽⁷⁾. Hence, the identification and analysis of the combination of various attributes can show the performance of nurses in various situations in the Family Health context. That is, they allow one to observe the types of technologies applied by nurses in their actions within the FHS, a strategy seeking to reorganize the current medical-hegemonic care practice in which the use of hard technologies (devices and equipment) and light technologies (technical knowledge) prevail⁽⁸⁾. We stress that to change the current care model – the FHS proposal – requires one to alter the use of technologies in health production and review the way work is organized and processed, focusing on a work process centered on the more intensive use of light technologies⁽⁸⁾, (the essence of which is the production of intercessor processes and relationships) and light technologies both for actions directed to the production of individual and collective care, organization and management of the work process.

It is in the construction of this approach of dialogical competence that relates the work environment (where practice is developed) and the development of professional practices^(7-9), where we can reconstruct health practices through reflecting on the nurses’ performance, that is, from the actions and attributes used in the various situations of daily professional practice.

From this perspective, this study enables one to implicitly think in problem-solving capacity in primary health care, which is related to the professionals’ attributes, observe what types of technologies are being used by nurses in the FHS, and support the development of pedagogical projects intended to educate nurses with knowledge, skills and contemporary attitudes in the Brazilian Unified Health System (SUS). For that, one needs to consider that devising such projects will only be possible if discussions concerning the current transformations in the work environment take place.

This study can encourage individuals to reflect on the practices of nurses in the PHC in different countries such as the Soviet Union, since a study⁽¹⁰⁾ conducted in Tajikistan reports that nurses in Family Health have implemented new practices. Additionally this study can enable reflections on the work performed by community nurses in Canada, Poland, and Iceland among other countries.

OBJECTIVES

To identify and analyze the attributes (knowledge, skills and attitudes) employed in work situations that characterize the performance of nurses in the field of managerial competence in the Family Health.

METHOD

This is an exploratory-descriptive study with a qualitative approach. The study’s setting is the city of Ribeirão Preto located in the Northeast of the state of São Paulo, Brazil. The number of PHC units has increased since 2007. There are currently 27 PHC units, five PHC District Units, one Regional Specialty Outpatient Clinic, one Pediatric Specialty Outpatient Clinic, one Regional Mental Health Outpatient Clinic, two Psychosocial Care Centers, and 22 FHS teams.

Family Health Units (FHU) were selected considering those that were already implemented and are still functioning in the city. Hence, four of the five FHU linked to the University of São Paulo were chosen. One of the FHU was excluded because it was a mixed unit, that is, a service with a FHS team within a Primary Health Care unit.

The study’s participants were nurses who had worked for more than one year in the FHS, which indicates they might have a certain experience in the field. The participants first answered a questionnaire called “Characterization of Nurses” addressing age, residence, educational background, time in the profession, previous experiences in the FHS, how they were selected and work contract.

Data collection was carried out in the second semester of 2006 through participant observation during typical weeks of work (40 hours), that is, there was no interference in the work routine, totaling 160 hours of observation.

Hence, the actions, how they were performed, the criteria and resources used, the interactions of nurses with users and the team, type of communication (verbal, non-verbal) and how it was used, decision-making process (centered, shared), among others, were observed.

Observations were simultaneously recorded. They are considered an almost identical expression of the study’s entire developmental process where the activities and physical aspects (related to the physical structure and the presence of barriers such as noises), social aspects (conversations), and also aspects related to interactions (with team members and users) are noted.

The records of observations were organized and composed the study corpus, which was analyzed through the thematic content analysis technique⁽¹¹⁾. The material was initially read several times aiming to familiarize ourselves with it. Then, it was separated into segments and the following were identified: action (what is done), employed attributes (how it is done), and field of competence (for what it is done). The text was skimmed through and the core meanings were identified, which were grouped into main themes.

The standards established by the Research Ethics National Committee (CONEP) were followed in the study development. The project was submitted to and approved by the Research Ethics Committee at the School Health Center from the Medical School, University of São Paulo at Ribeirão Preto (protocol nº 0192 CEP/CSE-FMRP-USP). Confidentially and freedom of speech was ensured for the study’s participants.

RESULTS AND DISCUSSION

The four nurses whose work was observed live in Ribeirão Preto, SP, Brazil and were hired through a selective process. Their age varied from 25 to 50 years and this age range is similar to that found in a study carried out by the Ministry of Health evaluating Family Health in ten large cities⁽¹²⁾, which verified that the age of the workers in the studied Family Health teams were predominantly distributed in two large age ranges – up to 30 years old, which reflects that the teams are young and another group above 45 years old, characterizing their seniority⁽¹²⁾.

In relation to their educational background, three nurses had masters’ and doctoral degrees. In terms of time in the profession, three professionals had worked in the FHS for five years and one for six years. In terms of their experience previously to the FHS, two nurses worked for short periods (one year and six months and two years) in FHU. These data indicate that workers had accumulated work experiences both in PHC and FHS, confirming the inclusion criteria used in this study.

Five main themes were identified in the analysis of the material and these are separately presented, though such division is only possible as an abstraction with an analytical character due to the dynamics of the work performed in the context of the health services actually keeping the separated themes connected.

The first theme: Supervision as instrument to control and educate indicates that supervision is part of the collective work process in health and is also related to the demand of services and to the objectives and goals to which they are directed⁽¹³⁾. It also indicates that supervision is an activity inherent to the routine of management of the nurses’ work and shows that it presents the dimensions of education (both the education of other workers and qualification) and control (of activities and personnel), and aims to check, correct and inform.

Performance of nurses in Supervision as an instrument to control and educate:

Nurses know the work of each member of the team, the routine and dynamics of the work in the unit, the workers’ health conditions and their limitations to the context of work; they use principles of justice, tolerance and responsibility; they communicate with workers through a direct, concise and clear language, enabling interaction and participation in the dialogue, explaining how the workday should be structured, showing respect and managing power relations; they evaluate the work performed by workers and specific changes that occur in their work and consequently in the team’s work process. In this process, they take into account factors related to the workers’ health such as workload, physical environment, safety, work practice, the unit’s and the team’s responsibility with care so that it is not interrupted, showing respect for users.

Considering the characterization of supervision, we observe that there is a concern for the qualification of the team at different points during the educational process, however, an educational process with a authoritative and vertical character predominates and it seems that continuing education, a resource that enables critical reflection on care and management practices and promotes educational processes applied to work, is not always adopted. The SUS police of continuing education approved in 2004 stresses education in service as a strategic resource to manage work and to recompose educational and care practices⁽¹⁴⁾.

The control aspect, a dimension of supervision, was identified and often displayed a strict focus of control: the work has to be performed as planned and exactly follow the established rules. We assert that such focus should be mitigated, since supervision could be practiced as a way to promote the involvement of workers according to the objectives of the project of which they are part, to share responsibility in relation to the production of care.

The second theme Teamwork in family health shows that the work of nurses is linked to the team in the production of care, demonstrating how the articulation of actions and interaction of workers occur. In this context, teamwork is one of the most important assumptions for the reorganization of the work process and can be a tool that enables a more integral approach with improved problem-solving capacity since it can be implemented in a way that coordinates the different actions of different professionals⁽¹⁵⁾.

The performance of nurses is represented by Teamwork in Family Health:

Nurses lead discussions of cases and create opportunities for workers to expose their knowledge; decision-making is centralized and vertical; they have the initiative to contact other care levels in order to obtain information concerning the users and their families and exchange experiences; evaluate risks and priorities, coordinate care so as to ensure continuity, intersectionality and integrality through the mobilization of the team; and they recognize that the work performed by the other team members is relevant.

We determined that the work of nurses is often connected and integrated to the team enabling the production of care, while many times the team meeting is an opportunity to foster such integration. Additionally, we observed that nurses seek to interact with physicians in certain situations, mainly to discuss actions directed to individual care, which enable us to infer a relationship between work and autonomy, indicating they adhere to the perspective that all health professionals perform their actions within a scope of autonomy and responsibility[...]⁽¹⁶⁾.

The third theme defined as Social control in the management process shows social control and participation as instruments that enable the construction of citizenship, and are present in the work of nurses and are related to the Local Committee of Health.

Nurses’ Performance in Social control in the management process:

Nurses understand the function and regulation of the Local Committee of Health. They reflect upon the specific problems found; they seek alternatives to negotiate with the community; and they recognize the Local Committee of Health as a space in which demands can be made, and the importance of worker participation in this council.

The fact that social control and participation is rarely seen in the routine of nurses in the FHS captures our attention because the Brazilian public health system encourages the action of society in the definition of the health system. Social control and participation appears only when linked to the work of nurses within the Local Committee of Health (a formal proceeding provided for in Brazilian law where social control and participation is enabled at the SUS local level), which somewhat contradicts expectations of the FHS official documents. Even though nurses show certain knowledge of social control, this study’s findings indicate that these workers may have difficulty acting as social subjects. They have difficulty promoting or triggering more participative management, planning and evaluation processes in which they can put their knowledge, skills and attitudes to the service of the population’s needs. Hence, we can verify that nurses know concepts of social control and participation but do not implement these into their routine, in the interlocution with the remaining subjects to make the participation of the community effective. Therefore, we infer that the nurses do not grasp social control and participation as dimensions present in their actions, that is, beyond the technical dimension of work.

The fourth theme The organization of work to produce care defines the organization of work as the appropriate selection of work tools to meet the needs that arise⁽¹⁷⁾ and shows that the work of nurses is developed guiding the organization of the flow of users and information both in the unit and among the services, and also to control infrastructure, human resources and material needs forecasts and provision.

Performance of nurses in The organization of work to produce care:

Nurses participate in discussions within the team, question behavior, explaining the reason of questions; they show the limitations of the professional role and worry about the access of users to the services and the continuity of care; they provide care based on care protocols, regionalization and the history of users taking into account bonds established with users; decisions are centralized hence do not share responsibility with the various subjects involved in the work process and do not organize the work according to the rationale of continuing education in health.

In relation to this way of organizing the work, we determine that nurses have developed actions focused on the mobilization of care, which indicates that the managerial and care dimensions are connected in the development of health work.

The last theme Work coordination and planning indicates that planning is directed to specific activities of health promotion and continuing education: to work scheduling and care. The coordination is related to the organization of work to produce care and initiatives to promote a more global planning directed to the territory and to the evaluation of individual, collective and organizational actions performed in the health unit are rare.

Performance of nurses in Work coordination and planning:

Nurses develop, coordinate and articulate planning; they identify resources (physical structure, information systems, location of documents within the unit) and factors (demographic and epidemiological profile of the enrolled population) involved with the plan; they develop activities to meet the health unit’s goals such as giving priority to families according to their classification by risks and diseases, care directed to risk groups, broadened clinical practice; they work jointly with other professionals; they reflect upon the forecast of situations and potential alternatives to make committed and responsible decisions; they identify potential problems and devise potential scenarios in an attempt to avoid intercurrences in the organization of service and be prepared in case these scenarios become a reality.

In terms of planning, considering it a tool that enables the scheduling, direction, coordination, control and evaluation of actions in the management of the work process, we verified that there is not a systematic process to evaluate activities developed by the services in the routine of the nurses in the FHS. This is a fact of concern since evaluation is a management tool and should support the decision-making process and the production of care and services. It should support planning in health from the perspective of care and promote the inclusion of users⁽¹⁸⁾.

We also highlight many contradictions in the work of nurses such as moments when vertical actions predominate, that is, imposed actions that do not allow dialog and negotiation and only accomplish the transmission of content. Similar to other studies, it indicates that nurses should develop communication skills to establish a dialogue with the team in which s/he is inserted, establishing bonds and trust aiming for a process of negotiation and the possibility to change practices⁽¹⁹⁾. However, we also identified some instances in which nurses attempt to alter the current care model: they allow talking and listening, which promotes bonds and education of the team and users.

CONCLUSION

We understand that the management of health services should enable relationships among people, structures, technologies, objectives/goals and environment and users’ satisfaction. The analysis of results indicates a set of attributes (knowledge, skills and attitudes) that nurses use and is still centered on the organization and management of work in health for individual care. It is rarely a systematized and continuous action involving all the stages of planning and evaluation of proposed actions in a more participative way, including other interested subjects.

We conclude that the work of nurses in the FHS may be in transition and hence it seeks to reorganize care in primary health care. We also identified that light and light-hard technologies predominate in the work of nurses and thus believe that this study can contribute to altering the current care model because it shows the potential of the work developed jointly by nurses and other workers in the health team, enabling the guidelines of primary health care, longitudinally, and showing that the coordination of care and integrality are effective.

We also assert that to sustain the process of change in the care model that has been implemented with the contribution of nurses at the primary care level investment in the education of nurses’ is required. These investments are being implemented to reach an education focused on a work environment in which objects of learning are problematized. Therefore, students and workers inserted in this context can perceive reality and act on it with a greater control of attributes and skills: they are prepared for the work and to defend citizenship⁽²⁰⁾.

Finally, we stress that this study identifies relevant issues for the analysis of nurse performance that compose the field of management. However, the construction of this competence (which is not a list of tasks or a sum of tasks, is not directly observed but inferred through performance that is a combination of attributes to solve a given situation in professional practice) needs to be validated by the set of nurses who work in the FHS in Ribeirão Preto, which is a specific context that mobilizes specific care projects and leads to the work of nurses conforming but can also contributes to a broader discussion related to the competence of nurses in the FHS that takes place in other instances.

This validation reflects on the identified performance in a critical way in order to connect it with the FHS proposal in the city with the possibility of analyzing professional practice. In this context, the purpose of validation is to reveal the values, interests and ideologies of the social practice historically formed since it enables linking theory with practice.

REFERENCES

• 1. Fracolli LA, Zoboli ELCP. Descrição e análise do acolhimento: uma contribuição para o Programa de Saúde da Família. Rev Esc Enferm USP. 2004;38(2):143-51.
• 2. Mishima SM. A gerência de serviços de atenção primária à saúde como instrumento para a reorganização da assistência à saúde: o caso do Programa de Saúde da Família [tese livre- docência]. Ribeirão Preto: Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo; 2003.
• 3. Campos GWS. Subjetividade e administração de pessoal: considerações sobre modos de gerenciar o trabalho em equipes de saúde. In: Merhy EE, Onocko R, organizadores. Práxis em saúde: um desafío para o público. São Paulo: Hucitec; 1997. p. 229-66.
• 4. André AM, Ciampone MHT. Competências para a gestão de Unidades Básicas de Saúde: percepção do gestor. Rev Esc Enferm USP. 2007;41(n.esp):835-40.
• 5. Oliveira RG, Marcon SS. Trabalhar com famílias no Programa de Saúde da Família: a prática do enfermeiro em Maringá-Paraná. Rev Esc Enferm USP. 2007;41(1):65-72.
• 6. Wright LM, Leahey M. Enfermeiras e famílias: um guia para avaliação e intervenção na família. 3a ed. São Paulo: Roca; 2002.
• 7. Lima VV. Competência: distintas abordagens e implicações na formação de profissionais de saúde. Interface Comun Saúde Educ. 2005;9(17):369-79.
• 8. Merhy EE. Em busca do tempo perdido: a micropolítica do trabalho vivo em saúde. In: Merhy EE, Onocko R, organizadores. Agir em saúde: um desafio para o público. São Paulo: Hucitec; 1997. p. 71-112.
• 9. Ribeiro ECO, Lima VV. Competências profissionais e mudanças na formação. Olho Mágico. 2003;10(2):47-52.
• 10. Parfitt BA, Cornish F. Implementing Family Health Nursing in Tajikistan: from policy to practice in primary health care reform. Soc Sci Med. 2007;65(8):1720-9.
• 11. Minayo MC. O desafio do conhecimento: pesquisa qualitativa em saúde. 6a ed. São Paulo: Hucitec; 1999.
• ¹²
  Brasil. Ministério da Saúde. Departamento de Atenção Básica. Relatório de Gestão: 1998-2002. Brasília; 2002.
• 13. Silva EM. Supervisão do trabalho de enfermagem em saúde pública no nível local [tese doutorado]. Ribeirão Preto: Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo; 1997.
• ¹⁴
  Brasil. Ministério da Saúde. Portaria n. 198/GM/MS, de 13 de fevereiro de 2004. Institui a Política Nacional de Educação Permanente em Saúde como estratégia do Sistema Único de Saúde para a formação e o desenvolvimento de trabalhadores para o setor e dá outras providências [Internet]. Brasília; 2004 [citado 2009 ago. 15]. Disponível em: http://www.unifesp.br/dmedprev/planejamento/pdf/port_GM198.pdf
• 15. Almeida MCP, Mishima SM. O desafio do trabalho em equipe na atenção à Saúde da Família: construindo novas autonomias no trabalho. Interface Comun Saúde Educ. 2001; 5(9):150-3.
• 16. Peduzzi M, Ciampone MHT. O trabalho em equipe e processo grupal. In: Kurcgant P, coordenadora. Gerenciamento em enfermagem. Rio de Janeiro: Guanabara Koogan; 2005. p.108-24.
• 17. Teixeira RA. O trabalho da enfermeira na saúde da família: potência de (re)construção do modelo assistencial e (re)criação do trabalho da enfermagem? [dissertação]. Ribeirão Preto: Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo; 2002.
• 18. Tanaka OU, Melo C. Como avaliar serviços de saúde? Olho Mágico. 2003;10(3):79-82.
• 19. Chirelli MQ, Mishima SM. A formação do enfermeiro crítico-reflexivo no Curso de Enfermagem da Faculdade de Medicina de Marília - FAMEMA. Rev Lat Am Enferm. 2003; 11(5):574-84.
• 20. Leonello VM, Oliveira MA. Construindo competências para a ação educativa da enfermeira na atenção básica. Rev Esc Enferm USP. 2007;41(n.esp):847-52.

Correspondência:

Lauren Suemi Kawata

Escola de Enfermagem de Ribeirão Preto - Campus da USP

Avenida dos Bandeirantes, 3900

CEP 14040-902 - Ribeirão Preto, SP, Brasil

*

Extraído da dissertação “Os atributos mobilizados pela enfermeira na Saúde da Família: uma aproximação aos desempenhos na construção da competência gerencial”, Escola de Enfermagem de Ribeirão Preto da Universidade de São Paulo, 2007.

Publication Dates

• Publication in this collection
  26 May 2011
• Date of issue
  Apr 2011

History

• Accepted
  03 Aug 2010
• Received
  17 Sept 2009