Public health nursing and public health policies: a case study

Abstract

Objectives

to characterize the interventions of specialist nurses of community health and public health of a Group of Health Centers, to identify the main facilitating factors for the performance of competences, and the contribution to public health policies.

Method

this is a case study carried out with nurses specialized in community health and public health nursing. Data were collected through interviews from October to December 2019. Analysis was guided by two strategies: starting from the theoretical propositions and working the data from the ground up; and two techniques: pattern matching and explanation building.

Results

from the constructed matrix, ten theoretical propositions, ten emerging evidences, five patterns and five explanatory hypotheses emerged. There are interventions for epidemiological surveillance, planning and project management. Personal training and communication stand out as facilitating factors.

Conclusion and implications for practice

the intervention of the nurses of these specialties presents a dimension centered on project planning and management identifies and reflects the facilitating factors of the performance of their competencies, as an applicator of public health policies.

Keywords:
Public Health Nursing; Public Health Nurses; Public Health; Public Health Policy; Case Study

Resumo

Objetivos

caracterizar as intervenções do enfermeiro especialista de saúde comunitária e de saúde pública de um Agrupamento de Centros de Saúde; identificar os principais fatores facilitadores para o desempenho das competências, e a contribuição para as políticas públicas de saúde.

Método

estudo de caso, com enfermeiros da especialidade em enfermagem de saúde comunitária e de saúde pública. Coleta de dados por meio de entrevista, no período de outubro a dezembro de 2019. A análise foi guiada por duas estratégias: partir das proposições teoréticas e trabalhar os dados emergentes; e duas técnicas: combinar padrões, “pattern matching” e construir explicações, “explanation building”.

Resultados

a partir da matriz construída, surgiram dez proposições teoréticas, dez evidências emergentes, cinco padrões e cinco hipóteses explicativas. Sobressaem intervenções de vigilância epidemiológica, planeamento e gestão de projetos. A formação pessoal e a comunicação destacam-se como fatores facilitadores.

Conclusão e implicações para a prática

a intervenção do enfermeiro dessa especialidade apresenta uma dimensão centrada no planeamento e gestão de projetos, identifica e reflete os fatores facilitadores do desempenho das suas competências, enquanto aplicador de políticas públicas de saúde.

Palavras-chave:
Enfermagem de Saúde Pública; Enfermeiros de Saúde Pública; Saúde Pública; Políticas Públicas de Saúde; Estudo de Caso

Resumen

Objetivos

caracterizar las intervenciones del enfermero especialista en salud comunitaria y salud pública de un Grupo de Centros de Salud, identificar los principales fatores facilitadores para el desempeño de competencias, y la contribución a las políticas públicas de salud.

Método

estudio de caso, con enfermeros especialistas en enfermería de salud comunitaria y de salud pública. Recolección de datos realizada por entrevista, de octubre a diciembre de 2019. El análisis estuvo guiado por dos estrategias: partiendo de las proposiciones teóricas y trabajando con los datos emergentes; y dos técnicas: combinación de patrones, “pattern matching” y construcción de explicaciones, “explanation building”.

Resultados

De la matriz construida surgieron diez proposiciones teóricas, diez evidencias emergentes, cinco patrones y cinco hipótesis explicativas. Se destacan intervenciones de vigilancia epidemiológica, planificación y gestión de proyectos. El entrenamiento personal y la comunicación se destacan como factores facilitadores.

Conclusión e implicaciones para la práctica

La intervención del enfermero en estas especialidades presenta una dimensión centrada en la planificación y gestión de proyectos, identifica y refleja los factores facilitadores del desempeño de sus competencias, como aplicador de las políticas públicas de salud.

Palabras clave:
Enfermería de Salud Pública; Enfermeras de Salud Pública; Salud Pública; Políticas Públicas de Salud; Estudio de Caso

INTRODUCTION

This study focuses on specialist nurses’ actions in community health and public health as a co-participant actor in the definition of public health policies, in the context of the case of a Health Center Group (ACES). It is an understudied and valued area, as we concluded through a literature review¹. In 2020, the international year of nurses, it is important to emphasize that they are particularly well placed to advise people to make healthier choices, as they establish an effective therapeutic relationship through proximity².

As per the American Public Health Association, Public Health Nursing Section^3:2, “public health nursing is the practice of promoting and protecting the health of populations, drawing on knowledge from nursing, social and public health sciences”. The Portuguese Nursing Association states that:

nursing proposes new views on healthcare in Portugal, which should focus on proximity to patients and their families, on the supervision and training of increasingly trained professionals, on the reorganization of healthcare in the community and on the consequent profitability of human and material resources^4:1.

From the current public health policies of the XXII Portuguese Government, we emphasize that they value public health as an area of intervention, the good management of the alert systems and timely response of the services, the diagnosis of problematic situations and the elaboration of strategic action plans with the community, prioritizing respect for health professionals in new models of cooperation, even with regard to division of competences and responsibilities⁵. The competence of collaboration in epidemiological surveillance is highlighted, within the scope of its competences, namely through the Portuguese National System of Epidemiological Surveillance (SINAVE - Sistema Nacional de Vigilância Epidemiológica)⁶.

The present work has as a research problem the intervention of a specialist nurse in community health and public health from an ACES in the Lisbon region in the context of the contribution to public health policies. We set out as objectives to characterize the interventions of an ACES community health and public health specialist nurse, to identify the main facilitating factors for their performance and the contribution to public health policies. This study is justified in the search for the relevance of nursing interventions in the specific context of public health, highlighting the most effective ones, not only so that the political decision maker can choose them in times of public resource constraints¹, but also for nurses to demonstrate their knowledge and skills in their area of intervention.

METHOD

Study design

It is a qualitative approach through a case study⁷, dedicated to the knowledge of the complex phenomenon in its depth⁸. This is used in an investigation, constituting the method to choose, when the phenomenon under study is not easily distinguishable from its context. It uses multiple sources of evidence for data collection, such as document analysis, direct observation, interviews, among others, in order to increase its understanding. For this study, we used only interviews. It focuses on the circumstances, dynamics and complexities of a single case, or a small number of cases, in which interventions are described in a concrete context⁷, as is the case.

Population and setting

The option lies in the single, holistic or global case of an ACES in the Lisbon region, which integrates the indirect administration of the State endowed with administrative, financial and patrimonial autonomy, with a view to guaranteeing the population residing in the geographical area allocated access to quality health care through available resources adjusted to the population’s health needs, in accordance with what is established in the Portuguese National Health Plan⁹ and, especially, implemented in the Local Plan of Health¹⁰. It is characterized by a cohesive geographic environment, stable population, differentiated by a high social level and relevant education, notorious health indicators, with a birth rate above the national average and mortality below national average.

ACES, in addition to Family Health Units, the Personalized Health Care Unit and the Community Care Unit, also includes a Public Health Unit. The latter is responsible, in the ACES geodemographic area of which it belongs, the joint exercise of attributions, provided for in Art 12, 1, of Decree-Law 28/2008, of February 22¹¹, prepare information and plans in the fields of public health, carry out epidemiological surveillance, manage intervention programs in the field of prevention, promote and protect the health of the population in general, or specific groups, collaborate, in accordance with the respective legislation, in the exercise of health authority functions.

This study has been developed since the second half of 2019, in an ACES with about 160 nurses. All ACES community health and public health specialist nurses were included. Nurses who were on long-term sick leaves were excluded. It resulted in a total of 31 nurses, all of whom accepted to participate, with no exclusions. Data collection, in the form of an interview, took place between October 21 and December 19, 2019.

Data collection

Interview was the option selected among several sources of evidence most used in the case study⁷. Previous contacts were made by email, to schedule the day, time and place at the workplace. With each interviewee, an interview was recorded, lasting about forty minutes. After transcribing the interviews, the respective validation was requested by the interviewees, also by email. The interview was based on the application of a semi-structured interview protocol, consisting of thirty-one open questions. Moreover, there is also the documental consultation of public health policies on official websites for dissemination of such policies, namely governmental ones.

We used all interviews (n=31), carried out by the first author, as a doctoral student, who attended a specific curricular subject for this purpose, and did not personally know the interviewees, nor did they know her, and an appointment was made with a brief presentation.

Data analysis and treatment

The organization of data for analysis was performed based on a matrix composed of two strategies and two analysis techniques, proposed by the author, for the case study⁷. The initial strategy derives from previous theoretical propositions, which direct the case in concrete, and the second strategy aims to work with emerging data. To these are added two analysis techniques, pattern matching and explanation building⁷.

The application of this matrix was operationalized through the collection of relevant data in the interviews after the systematic elaboration of Excel spreadsheets, with all the data obtained, also using the qualitative analysis software MAXQDA 2020, which supported us in data coding and in the creation of categories of analyze.

The first strategy is based on the fact that the propositions delineated the data collection plan, leading to analytical priorities, and the second directly contrasts with this one, as, instead of thinking about any theoretical propositions, it simply invites “walking between the data” or to “play with them”.

The first analytical technique compares patterns based on empirical data with those predicted, expected even before data collection⁷. To this end, we resorted to formulated hypotheses, based on a Systematic Literature Review (SLR)^12-14, carried out by us, and with published results, with the research question: “What has been published about competencies and interventions of community health and public health nurses?”.^12-14 According to the author⁷, it is about looking for how’s and why’s, in order to verify or disprove them. The second analytical technique, constructing explanations, aims to analyze the case study through the construction of an explanation of it, following the author’s footsteps⁷.

Public health policies are approached descriptively from the sources. The respective document analysis was carried out by reading the official texts and selecting those relevant to the case under study.

Ethical aspects

The assent of the Institutional Review Board of the Regional Health Administration of Lisbon and Vale do Tejo was obtained, by resolution on May 10, 2019, with Reference 4547/CES/2019. In order to comply with the ethical principles of protection of participants, free and informed consents were prepared, presented and accepted, individually, before each interview, as well as the guarantee of confidentiality and anonymity. In order to protect the information, without registering personal data, it was decided to use an alphanumeric code. Considering the academic and scientific purpose, participants’ consents were also obtained for the presentation of their perspectives in the study results and in the respective publications.

RESULTS

Participants are nurses, mostly female, with an average age of 48 years. From the interviews, some are particularly relevant for the objectives of this study.

Based on the described matrix, we organized the results into four groups, each corresponding to one of the strategies or analysis techniques.

1. I

   The first group results from the first analysis strategy. It is about resorting to theoretical propositions, unfolded from the two objectives and concretized in questions that were included in the interview script. We organized the first results, emerging from the ten theoretical propositions, which we list below.

   • 1^st. Proposition - Activities that shape nurses’ interventions.

[…] responsible for SINAVE, participation, management, monitoring and evaluation of projects (E05); […] participation, elaboration, monitoring, implementation of plans (training, vaccine management) (E02, E08); […] participation, group management, participation in programs; partnership meetings (E01).

• 2^nd. Proposition - Nurse’s contribution to the unit’s schedules.

For the team (multidisciplinary) (E01, E02, E05); […] for jobs and projects; with the view of nursing (E01); […] project proposals, indicators (projects) belong to the team (E05); […] with the core of projects (E08).

• 3^rd. Proposition - Nurses’ practice.

Information management (E01); […] project activities management, verification of patient data, articulation with health equipment (E02); […] articulate with other colleagues, articulate with patients, investigations through consultation of the clinical file (E05); […] support, collaborate and guide colleagues, organize preventive procedures (E08).

• 4^th. Proposition - The importance of nurses’ intervention.

Skills, know how (E01); […] elderly area, school health area, the entire life cycle (E02); […] epidemiological surveillance of the community, contributes to completing the whole (E05).

• 5^th. Proposition - Nurses’ problems and dilemmas.

Communication, unit structure, lack of well-defined procedures, lack of access to platforms (E01); […] the computer part, communication with the computer, problems with telecommunications (E02); […] lack of a nurse responsible for nursing (E05); […] change creates dilemmas and constraints (E08);

• 6^th. Proposition - Benefits and advantages of nurses’ presence.

The holistic view, looking in a broader, more global way (E01); […] know how and professional experience (E02); […] basic and specific training (E05); […] a whole process that has to go through nursing (E08).

• 7^th. Proposition - Facilitating factors for nurses.

Permanently researching new knowledge, new skills, doing my homework (E01); […] better equipment, flexible hours, multidisciplinary team with more people (E02); […] good communication between us, physical work conditions, leadership (E05); […] clear notion of our competences (E08).

• 8^th. Proposition - Factors that hinder nurses’ work.

Not being valued by peers and other professionals (E01); […] inexperience, impact of a new situation, difficulties in the functioning of the organization itself, organizational difficulties (E02); […] lack of a nearby nursing coordinator (E05); […] mismatch between the expected and the real (the expected and the real competences) (E08).

• 9^th. Proposition - Changes to help nurses.

Focus more on increasing your knowledge (E01); […] improve the system and IT support (E02); […] create a strategy, procedures and information manuals, have written procedures manuals (E05); […] more training in the areas in which they are working, more human and financial resources (E08).

• 10^th. Proposition - Organizational changes.

Give more value to public health (E01); […] more meetings, journeys to exchange experiences; more human resources (E02); better definition of the projects and intervention of each professional, meetings for evaluation and presentation of proposals, having a head nurse, going to the field to evaluate and implement measures, publicizing more public health in other units (E05); […] keep the population informed; plan teaching in the community; greater intervention in the community (E08).

1. II

   The second group results from the second strategy, the analysis of emerging data, from which new data emerge, directly related to the same theoretical issues.

   • 1^st. Nurses’ activities are articulated with the medical coordination, they can be changed. Nurses carry out activities within the team in which he is integrated (E05).

   • 2^nd. Nurses’ contributions are diluted in the multidisciplinary team, which makes it difficult to assess the actual activities of nurses (E05), and plays a key role in public health, without great decision-making power (E08).

   • 3^rd. There are changes to nurses’ plans (E02), that may leave them discontented, especially if they are limited to working at the desk, wanting to go to the community to carry out field research (E05). Nurses have a protocol, because it is important for everyone to follow the same thing (E08).

   • 4^th. What nurses are and their history is important (E01). It would be advantageous for nurses to go to the community to continue their studies. The activities of nurses could be more valued and used (E05) and it meets the objectives, than expected (E08).

   • 5^th. Nurses feel that inadequate material resources lead to poor use of human resources (E02).

   • 6^th. Nurses with their skills and qualities greatly enrich the unit, with a sensitivity to assess and care in a different way (E05).

   • 7^th. It would facilitate the existence of a nurse coordinator to define roles in projects (E05) and intervene in an articulated manner in each situation (E08).

   • 8^th. The lack of appreciation may hinder the nurse’s role (E01). Difficulties in information resources waste time (E02). The inexistence of a responsible nurse, coordinator, can hinder the articulation with the medical coordinator, and with the team (E05), as well as the recognition of the geodemographic area (E08).

   • 9^th. It would make it easier to have execution teams identifying specific people (E05), to be able to know all the projects and actions (E08).

   • 10^th. It would change, disclosure and impact (E01), teams increasingly reduced (E02), and the development of public health action (E05). Nurses feel they could go out into the field to assess and implement measures (E08).

2. III

   The third group is formed from the first analysis technique, pattern matching, using five patterns designed based on SLR^12-14. These were the ones chosen, as they are the most representative, being confronted with those resulting from the evidence of empirical data in Chart 1.

   Chart 1
   - Relation between patterns resulting from SLR and empirical data.
   

   Patterns	Empirical data
   1. The main commitment of most public health nurses is centered on vaccination.	1. We did not find any correspondence to the first pattern, related to vaccination, we found out that it is an activity among others, as we will explain below.
   	2. The same happened with regard to the second pattern, as we did not obtain data to confirm the provision of individualized services, rather than community ones.
   	3. For the third pattern, we have already found combinations with our empirical data, assuming the following dimensions:
   2. Most services are provided on an individual rather than community level.	[…] nurses’ contribution is diluted in the team, nurses are involved in many activities, lack of peer recognition and appreciation of nurses’ role, lack of recognition and lack of public disclosure of nurses’ interventions (E01).
   	4. Regarding the fourth pattern, several evidences stand out in our data, in different formulations: nurses do not feel well if they are limited to working at the desk (E05); hence the desire for the model to include more the presence and intervention of nurses in the community (E05, E08); expresses the need for a nurse coordinator, as the existing model only provides for a medical coordinator (E05); inclusion of more human resources and definition of roles (E02); manuals of procedures (E05); proposal for various changes, such as meetings and conferences (E02).
   	5. The fifth pattern concerns the facilitating factors for the performance of skills: we found that nurses also underline the importance of continuous updating (E01), more training (E08), but above all more and better human and material resources (E02, E08).
   3. Public health nurses are involved in many activities to prevent disease and contribute to the health of populations. However, their activities are not always visible to the public and policy makers.
   4. The need for a different model of community health services that implements collaboration and finds common denominators among public health team members.
   5. The demonstration of a fruitful alliance between academic work and professionals, in the sense of being able to provide effective, quality services, as well as the existence of new resources.

3. IV

   The fourth group is based on the second analysis technique, explanation building. It is intended to explain the phenomenon through a presumed causal sequence, from it, the how and why some results occur.

Given the results and patterns obtained, we built five explanatory hypotheses and their corresponding correspondence to the data, presented in Chart 2.

Chart 2
- Explanatory hypotheses and empirical data.

Explanatory hypotheses	Empirical data
1. The type of intervention of public health unit nurses does not only provide for an individualized relationship with the user/client, and their action will not focus solely on vaccination.	For the question of the hypothetical prevalence of the vaccination activity as the most important for public health nurses12-14, we found that this is an activity in the interventions of our nurse as:
	[…] responsible for vaccination at ACES […] make the flu vaccination session for homes and other institutions (E02). Another that, […] until last year I participated in the vaccination, (E05). And yet another one, […] I collaborate in the management of the vaccination project, […], and as I am with vaccination, it includes the management of flu and flu vaccines, in the various units (E08).
	This reality reinforces a large arsenal of interventions, in which this nurse is involved, such as:
	[…] epidemiological research I have partnerships, partnership meetings. I have two groups, one of them is a social intervention group from a certain geographic area, […]. The other group of social intervention is the group of the support center for the homeless, […] I have in teamwork, the management, I am part of the management, the inspection of homes and dangerous establishments. […] mental health project management (E01). […] I do epidemiological surveillance […] I am part of the seasonal health contingency plan, winter module (E02). I am responsible for SINAVE […] I do epidemiological surveillance by geodemographic area. […] health literacy project […] the diabetes intervention area (E05).
2. As a result of the above, we also did not identify a prevalence of individualized services rather than community services.	With regard to services at the community level, we obtained some evidence, such as the fact that nurses are:
	[…] working in the smoking field, whether in the community area, for the smoke-free community, outdoor spaces, as well as in the health areas, […] area of school health, which we also developed a manual, […] to support school health teams […] (E02). And coordinates […] vaccination and the management of the school health program (E02). And also, I go to the field, support, collaborate with colleagues, guide colleagues in the vaccination, as just last week we were in the units to support, guiding a little some procedures (E08).
3. Nurses perceive little visibility of their interventions, taking into account that they are part of a multidisciplinary team, to which they belong.	For the issue of (in)visibility for the public and policy makers, we have already found evidence of this reality in the data, as follows:
	[…] nursing activities that end up being included in a multidisciplinary team. In the multidisciplinary team, at this moment, it is not possible to assess what are the concrete activities that nurses performed (E05).
	[…] Professionals around us do not value us as much as we would like it to be possible. Many times, even our peers (E01).
	[…] ask what do you do in public health, besides vaccination? (E08).
	And lastly...
	[…] the work of public health is not highly valued, which is immense. On the other hand, sometimes, the coordination does not properly publicize or market what we actually produce in public health. And so, in terms, outwards, there is not the impact that there should be (E01).
4. Nurses are available to see their operating model changed, in the sense of being more on the ground, and facing the community, but also in the organizational dimension, with a nurse coordinator, definition of functions, human resources and procedure manuals.	On the implementation of a different model of community service, several testimonies illustrate this desire:
	[…] that there was a greater intervention in the community, that public health nurses were more on the street, closer to the population, closer to the communities, because that’s the only way we can always have gains in health (E08).
	[…] After carrying out all this field work on computers, it is necessary to effectively go out into the field, evaluate and implement measures (E05).
	And, with regard to human resources,
	[…] teams are increasingly reduced to the geographic areas we have (…) we can’t even respond to the work we have daily (E02). […] often, when you have to intervene, at the level, outside of public health, sometimes it was important that we all speak the same language, and sometimes that doesn’t happen (E01).
	The presence of a nursing coordinator is also noticed and, apparently, desired, thus,
	[…] put a fifth element of nursing, to have an internal head. This is strategy number one for me (E05).
5. Nurses are aware that it is important to continue their education, but they also recognize that other factors facilitate their performance, such as good communication, well-defined functions, better facilities and working conditions.	Regarding the facilitating factors of performance:
	[…] One of the very important things in performance is not thinking that the knowledge you have is enough (E01).
	[…] contributes better equipment, flexibility of time, multidisciplinary teams, that we had more people, and even good communication between us (E02). […] it is very important to define functions, prepare manuals of procedures (…), and then give visibility to the work (E05).
	[…] If I have internalized my skills well, in each area, I will give the right answer (E08).

DISCUSSION

Based on theoretical propositions and emerging data, a “portrait” of public health nursing, carried out by specialist nurses in community health and public health, stands out from the results presented. It develops a plurality of interventions, which it represents as relevant, although it does not always, apparently, have autonomy in its definition. It faces some difficulties, such as better defined intervention procedures, or even organizational ones, such as the absence of a head nurse. It recognizes the benefits and advantages of its presence, resulting from its holistic vision and its specific training, which facilitate its performance. Not feeling sufficiently valued, in their performance and social recognition, or by their peers, points out strategies, how to define the roles and roles of each one in the multidisciplinary team that integrates; but also at the level of dissemination of their work and investment in human and material resources that allow nurses to go further into the field to implement and evaluate measures.

This “portrait” looks something different from what is planned for this area of nursing or in other health systems, as is the case in the United Kingdom², with areas of action such as health promotion and prevention of early mortality. However, it is perceived to be in line with other realities, in which nurses also seek to affirm their status, challenging the current “status quo”, through structural changes that enable their shared leadership in the health system¹⁵.

We then start from the patterns designed, based on SLR, in the scoping review¹ modality, which has already been published. Given the patterns that emerged from this review, we built our explanatory hypotheses, in order to deepen data analysis, building a possible explanation of the case under analysis in this case study. Based on the how and why, we tried to find explanations for the results found through a presumed set of causal links about them⁷.

In contrast to our first explanatory hypothesis that nurses do not seem to have only an individualized relationship with the public/user/client, nor only centered on vaccination, a national study was carried out in Israel¹⁶. About 80% of public health nurses will have participated in it, providing a detailed and updated description of their work and areas of practice. They state that one of the key results is that the main commitment of most public health nurses is focused on vaccination.

In line with our second explanatory hypothesis of not identifying a prevalence of individualized services rather than community services, an article carried out in the United States¹⁷, with visiting public health nurses, having as its main objective to describe the action of this nurse in home visitation, in this specific case, to carry out nutritional interventions, it presents a public health nursing centered on the community and individuals.

In the same sense as our third hypothesis, that nurses perceive little visibility of their interventions, even because they are diluted within the multidisciplinary team to which they belong, we can highlight the position of authors, in a study in North America¹⁸. Having resulted from two national surveys, with questions focused on the activity of public health nurses, to promote their visibility, identifying activities and exploring their impact on the community, it basically mirrors the same feeling. It states that it is evident that public health nurses do many activities to prevent disease and contribute to the health of populations, and that they are not always visible to the public and policy makers. Many of its interventions, which strengthen the social determinants of health, are invisible.

An article from Portugal, in the form of a review of published and unpublished literature, and document analysis, to analyze the health workforce composition in Portugal, illustrates the issue of the fourth explanatory hypothesis, of strong evidence that nurses want to see changed its operating model to be more on the ground and in the community, lack of a coordinating nurse and even human resources. In this study, it is stated that there is some normative space to expand nurses’ skills, in order to improve the health system’s work. However, it is noteworthy that such a change needs a social consensus “and that, in Portugal, some partners express reservations regarding the expansion of the field of action of the nursing profession” ¹⁹.

In line with our fifth hypothesis, of the factors that facilitate its performance, such as good communication, well-defined functions, better facilities and working conditions, we cite, as an example, an israeli study²⁰. It points to a fruitful alliance between academic research and health professionals working together to provide high quality services to users. The publication from the United States²¹ supports the existence of common bases between the level of competences of public health nursing and in-service learning principles: community’s experimental knowledge; work with key partners and policy makers; reflection and knowledge; professionalism and compassion; cultural competences; and civic engagement. These principles, in the development of experiences in public health, will increase the chances of success.

We present, as a possible explanation for the product of the analyzed data, the type of intervention planned for this nurse, which may be closer to planning, in the important control of users’ epidemiological and clinical data through computer applications such as SINAVE, used to: identify risk situations; collect, update, analyze and disseminate data relating to communicable diseases and other public health risks; prepare contingency plans for emergency or public calamity situations⁶; and also the fact that they are dedicated to the design and management of projects in addition to interacting with individuals, groups and communities. They are aware that ongoing training and the resources at their disposal are the main factors that facilitate their skills.

For public health policies and nurses, it should be noted that, according to Tedros A. Ghebreyesus, Director General of the World Health Organization, “Nurses are the backbone of the entire healthcare system: by 2020 we invite all countries to invest in nurses and midwives as part of their commitment to health for all”^22:1.

Also, in Brazil, a recent publication draws attention to the importance of nurses in the development of primary control actions for diseases such as tuberculosis²³. The current pandemic situation has highlighted the need to plan and put into action material and human resources in sufficient quantity and quality to support health services, in particular with regard to nurses²⁴, even questioning the safety of these professionals²⁵ as a counterpoint to their indispensable contribution.

Foreseeing the XXII Government of Portugal’s program⁵ in health policy as a fundamental policy, recover the central role of the primary health care network and even expand and improve its capacity in the management of human resources, valuing health professionals through new forms of cooperation and sharing of responsibilities, in health professions⁵, the role of nurses, in practice, executes and reflects public health policies, but questions whether they should also have an effective participation in making them.

Although the numbers suggest that nurses will have little political activity in Portugal, as was seen in the electoral process that led to the last legislative elections, in 2019, four nurses were candidates, i.e., 2.27% of the total, and the forecast was for there to be between 2 and 5 nurses, in a total of 230 deputies. We confirmed the presence of one in the current Assembly of the Republic, the country’s legislative body²⁶.

To support this concern, the position of nurses in the Azores, which they already underlined in 2016, individually and collectively took on an informative and awareness-raising work with political decision-makers to influence the definition of health policies²⁷. It is also important to emphasize that, given the ongoing reforms, in the context of primary health care in Portugal, new opportunities are opened for nurses to gain greater relevance, since, as the authors argue²⁸, in other similar health systems, the possibility of developing broad skills for these professionals is foreseen, or in practice.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The interventions identified by specialist nurses in community health and public health seem to be located more in epidemiological surveillance, planning and project management, with relevant contributions to public health and health policies. They are aware of the factors that facilitate the performance of their competences, and, like most of their peers, they are implementers of public health policies, with a vocation to also be actors in their design and elaboration.

As a possible limitation, we can point out the fact that we only focused on one health unit. However, the data collected and the results that emerge from the analysis are very important for the knowledge of this nurse, given the scarcity of studies on this reality, which translates into an advance for nursing science in its dimension of research and new knowledge, as well as leveraging a broader investigation even towards an expansion of its competences.

Although the study data collection refers to a temporal phase, immediately prior to the current pandemic (COVID-19), we certainly cannot imagine its fight without the relevant contribution of community health and public health nursing, which, as it seems to emerge from this investigation, dedicates a large part of its work to epidemiological surveillance.

REFERÊNCIAS

• ¹
  Cunha C, Costa A, Henriques MA. The public health nurse’s interventions and responsibilities in Portugal: a scoping review. Rev Enferm UERJ. 2019;27:e37214. http://dx.doi.org/10.12957/reuerj.2019.37214
  » http://dx.doi.org/10.12957/reuerj.2019.37214
• ²
  Wild K, McGrath M. Public health and health promotion for nurses at a glance. UK: Wiley Blackwell; 2019.
• ³
  American Public Health Association, Public Health Nursing Section. The definition and practice of public health nursing [Internet]. 2013 nov [citado 2020 jan 15]. Disponível em: https://www.apha.org
  » https://www.apha.org
• ⁴
  Ordem dos Enfermeiros. Participação dos enfermeiros na definição de políticas de saúde domina debate entre ministério, entidades e deputados da área da saúde [Internet]. 2013 [citado 2020 fev 3]. Disponível em: https://www.ordemenfermeiros.pt/arquivo-de-p%C3%A1ginas-antigas/participa%C3%A7%C3%A3o-dos-enfermeiros-na-defini%C3%A7%C3%A3o-de-pol%C3%ADticas-de-sa%C3%BAde-domina-debate-entre-minist%C3%A9rio-entidades-e-deputados-da-%C3%A1rea-da-sa%C3%BAde/
  » https://www.ordemenfermeiros.pt/arquivo-de-p%C3%A1ginas-antigas/participa%C3%A7%C3%A3o-dos-enfermeiros-na-defini%C3%A7%C3%A3o-de-pol%C3%ADticas-de-sa%C3%BAde-domina-debate-entre-minist%C3%A9rio-entidades-e-deputados-da-%C3%A1rea-da-sa%C3%BAde/
• ⁵
  Portugal. Programa do XXII Governo Constitucional para a saúde [Internet]. 2019 [citado 2020 mar 10]. Disponível em: https://www.sns.gov.pt/institucional/politica-de-saude/
  » https://www.sns.gov.pt/institucional/politica-de-saude/
• ⁶
  Direção-Geral da Saúde. SINAVE MED [Internet]. 2020 [citado 2020 mar 10]. Disponível em: https://www.dgs.pt/servicos-on-line1/sinave-sistema-nacional-de-vigilancia-epidemiologica.aspx
  » https://www.dgs.pt/servicos-on-line1/sinave-sistema-nacional-de-vigilancia-epidemiologica.aspx
• ⁷
  Yin RK. Case study research and applications: design and methods. 6th ed. Los Angeles: SAGE; 2018.
• ⁸
  Creswell JW. Research design: qualitative, quantitative, and mixed methods approaches. 3th ed. Los Angeles: SAGE Publications; 2009.
• ⁹
  Direção-Geral da Saúde. Plano Nacional de Saúde, revisão e extensão a 2020 [Internet]. 2015 [citado 2020 abr 5]. Disponível em: https://www.dgs.pt/a-dgs.aspx
  » https://www.dgs.pt/a-dgs.aspx
• ¹⁰
  Administração Regional de Saúde de Lisboa e Vale do Tejo. Plano Local de Saúde do ACES de Lisboa Ocidental e Oeiras [Internet]. 2016 [citado 2020 abr 5]. Disponível em: https://www.arslvt.min-saude.pt/uploads/writer_file/document/1034/Plano_Local_Sa_de_v4-_Vers_o_Final.pdf
  » https://www.arslvt.min-saude.pt/uploads/writer_file/document/1034/Plano_Local_Sa_de_v4-_Vers_o_Final.pdf
• ¹¹
  Portugal. Decreto-lei nº 28/2008 de 22 de fevereiro. Cria os agrupamentos de centros de saúde do Serviço Nacional de Saúde. Diário da República [periódico na internet], 2008: I Série (Nº 38 de 22-02-2008): 1182-9 [citado 2020 abr 5]. Disponível em: https://dre.pt/pesquisa/-/search/247675/details/maximized
  » https://dre.pt/pesquisa/-/search/247675/details/maximized
• ¹²
  Cunha C, Costa A, Henriques MA. Competências e intervenções do enfermeiro de saúde comunitária e de saúde pública: uma revisão de literatura. Atas CIAIQ2019 [Internet]. 2019; [citado 2020 abr 5];2:361-70. Disponível em: https://proceedings.ciaiq.org/index.php/CIAIQ2019/article/view/2038
  » https://proceedings.ciaiq.org/index.php/CIAIQ2019/article/view/2038
• ¹³
  Cunha C, Henriques MA, Costa A. Investigação e inovação em saúde: intervenções do enfermeiro de saúde comunitária e de saúde pública. Rev ROL Enferm [Internet]. 2020; [citado 2020 abr 5];43(Suppl 1):32-42. Disponível em: https://e-rol.es/rol_2020/IC_RESEARCH_INNOVATION_DEVELOPMENT_NURSING_2019.pdf
  » https://e-rol.es/rol_2020/IC_RESEARCH_INNOVATION_DEVELOPMENT_NURSING_2019.pdf
• ¹⁴
  Cunha C, Costa A, Henriques MA. Community health and public health nursing: a systematic literature review. Gestão & Saúde. 2020;11(2):80-96. http://dx.doi.org/10.26512/gs.v11i2.29414
  » http://dx.doi.org/10.26512/gs.v11i2.29414
• ¹⁵
  Varghese J, Blankenhorn A, Saligram P, Porter J, Sheikh K. Setting the agenda for nurse leadership in India: what is missing. Int J Equity Health. 2018;17(1):98. http://dx.doi.org/10.1186/s12939-018-0814-0
  » http://dx.doi.org/10.1186/s12939-018-0814-0
• ¹⁶
  Haron Y, Honovich M, Rahmani S, Madjar B, Shahar L, Feder-Bubis P. Public health nurses’ activities at a time of specialization in nursing-a national study. Public Health Nurs. 2019;36(1):79-86. http://dx.doi.org/10.1111/phn.12578
  » http://dx.doi.org/10.1111/phn.12578
• ¹⁷
  Horning ML, Olsen JM, Lell S, Thorson DR, Monsen KA. Description of public health nursing nutrition assessment and interventions for home-visited women. Public Health Nurs. 2018;35(4):317-26. http://dx.doi.org/10.1111/phn.12410
  » http://dx.doi.org/10.1111/phn.12410
• ¹⁸
  Schaffer MA, Keller LO, Reckinger D. Public health nursing activities: visible or invisible? Public Health Nurs. 2015;32(6):711-20. http://dx.doi.org/10.1111/phn.12191
  » http://dx.doi.org/10.1111/phn.12191
• ¹⁹
  Temido M, Dussault G. Papéis profissionais de médicos e enfermeiros em Portugal: limites normativos à mudança. Rev Port Saude Publica. 2014;32(1):45-54. http://dx.doi.org/10.1016/j.rpsp.2013.11.002
  » http://dx.doi.org/10.1016/j.rpsp.2013.11.002
• ²⁰
  Kagan I, Shachaf S, Rapaport Z, Livne T, Madjar B. Public Health Nurses in Israel: a case study on a quality improvement project of nurse’s work life. Public Health Nurs. 2017;34(1):78-86. http://dx.doi.org/10.1111/phn.12261
  » http://dx.doi.org/10.1111/phn.12261
• ²¹
  Brown CL. Linking public health nursing competencies and service-learning in a global setting. Public Health Nurs. 2017;34(5):485-92. http://dx.doi.org/10.1111/phn.12330
  » http://dx.doi.org/10.1111/phn.12330
• ²²
  United Nations. Year of the nurse and the midwife highlights ‘backbone’ of health systems. Un News. [periódico na internet], jan 2020 [citado 2020 abr 5]. Disponível em: https://news.un.org/en/story/2020/01/1054531
  » https://news.un.org/en/story/2020/01/1054531
• ²³
  Bertolozzi MR, Takahashi RF, França FOS, Hino P. A ocorrência da tuberculose e sua relação com as desigualdades sociais: estudo de revisão integrativa na base PubMed. Esc Anna Nery. 2020;24(1):e20180367. http://dx.doi.org/10.1590/2177-9465-EAN-2018-0367
  » http://dx.doi.org/10.1590/2177-9465-EAN-2018-0367
• ²⁴
  Soares SSS, Souza NVDO, Carvalho EC, Varella TCMML, Andrade KBS, Pereira SRM et al. De cuidador a paciente: na pandemia da Covid-19, quem defende e cuida da enfermagem brasileira? Esc Anna Nery. 2020;24(spe):e20200161. http://dx.doi.org/10.1590/2177-9465-ean-2020-0161
  » http://dx.doi.org/10.1590/2177-9465-ean-2020-0161
• ²⁵
  Santana N, Costa GA, Costa SSP, Pereira LV, Silva JV, Sales IPPM. Segurança dos profissionais de saúde no enfrentamento do novo coronavírus no Brasil. Esc Anna Nery. 2020;24(spe):e20200241. http://dx.doi.org/10.1590/2177-9465-ean-2020-0241
  » http://dx.doi.org/10.1590/2177-9465-ean-2020-0241
• ²⁶
  Macedo MA. As legislativas vistas pela enfermagem [Internet]. Shifter Editorial; set 2019 [citado 2020 abr 2]. Disponível em: https://shifter.sapo.pt/2019/09/legislativas-enfermagem/
  » https://shifter.sapo.pt/2019/09/legislativas-enfermagem/
• ²⁷
  Pereira SM, Hernández-Marrero P. A decisão e desenvolvimento de políticas de saúde, o contributo central dos enfermeiros no desenvolvimento de políticas de saúde. Açoriano Oriental [periódico na internet], 26 jun 2016 [citado abr 4]. Disponível em: https://www.ordemenfermeiros.pt/media/3723/junho16.pdf
  » https://www.ordemenfermeiros.pt/media/3723/junho16.pdf
• ²⁸
  Cunha C, Henriques MA, Costa A. A enfermagem de saúde pública: regulação e políticas públicas de saúde. Rev Bras Enferm. 2020;73(6):e20190550. http://dx.doi.org/10.1590/0034-7167-2019-0550
  » http://dx.doi.org/10.1590/0034-7167-2019-0550

Edited by

ASSOCIATE EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  30 July 2021
• Date of issue
  2021

History

• Received
  10 May 2021
• Accepted
  02 June 2021