Integrative and complementary health practices in the nurses’ action of primary health care

Objective : to analyze the knowledge and use of integrative and complementary practices in the work of nurses in Primary Health Care. Method : a cross-sectional study carried out in 85 Basic Health Units in Curitiba-PR in 2021. The sample consisted of 195 recruits recruited using the Snowball technique. The were confirmed by means of an electronic data selection instrument and methods by electronic descriptive data methods. Results : 43 (22.1%) of the participants use integrative and complementary practices (PIC) in care, and 31 (15.9%) reported having training in some modality. The use of 17 PIC modalities was identified, 33 (47.8%) in auriculotherapy and 7 (10.1%) in reiki. The Ranking item on the theoretical knowledge of the average participants on the topic was >3.89, demonstrating agreement with the statements. About how participants experience the PIC, due to the recognition of nursing practices. Conclusion : the study contributes to the characterization of nurses’ performance in primary care based on integrative and complementary practices. The findings serve as a subsidy for professionals and managers to identify gaps in knowledge, in action, as well as in the management of primary care health services in order to strengthen the professional autonomy of those who use these practices in care.


INTRODUCTION
The use of Integrative and Complementary Practices (ICP) in public and private health services has grown significantly, especially in developed countries. It is a set of therapeutic actions and practices that complement and integrate health actions, stimulating a broad perspective of the health-disease process and valuing the promotion of human care. 1,2 In Brazil, approved and published in 2006, the National Policy on Integrative and Complementary Practices (NPICP) promoted the insertion of actions and services related to ICP in the Unified Health System (UHS) throughout the national territory. It sought, from there, to integrate and expand care in its biopsychosocial aspect, highlighting Primary Health Care (PHC) as the main setting for the production of these practices. 1 The construction of user autonomy in their health treatment, the stimulation of their self-healing potential in minor health situations are typical elements of PHC. Thus, the strengthening of the professional-user bond directs the assistance with a central focus on the person. Thus, it is possible to affirm that PHC assistance using ICP considers the multidimensionality and the multidisciplinary care needs of users. 3 Ordinance No. 971 of December 3, 2006, highlighted the guidelines that contemplated for the first time the ICP in UHS making available to the population the services and practices of Traditional Chinese Medicine/Acupuncture, Homeopathy, Medicinal Plants, and Herbal Medicine, Social Thermalism/Crenotherapy, and Anthroposophic Medicine. In 2017, 14 practices were added to the NPICP: art therapy, ayurveda, biodance, circular dance, meditation, music therapy, naturopathy, osteopathy, chiropractic, reflexotherapy, reiki, shantala, integrative community therapy, and yoga. Recently, in 2018, another ordinance was released that included aromatherapy, apitherapy, bioenergetics, family constellation, chromotherapy, geotherapy, geotherapy, hypnotherapy, hand laying, ozone therapy, and flower essence therapy to the NPICP. 1 According to data from the Ministry of Health (MH), the ICP have been expanded in health services, mainly in public ones, of municipal administration, concentrated in capitals mostly in the southern and northeastern regions. 4 According to partial data, in 2019 the ICPs were offered in 17,335 UHS services distributed in 4,297 (77%) Brazilian municipalities and, in all capitals, and 14,508 (90%) of the ICP used were offered in the PHC. Moreover, the supply of ICP in 2019 increased by 324% compared to 2017. 5 In Brazil, some systematic review studies have shown the effectiveness, quality, and safety of the use of ICP in the treatment of users in several specialized services, at all levels of health care. [6][7][8] Some clinical studies have shown that ICPs act positively in promoting the health of UHS users. 9,10 Despite the fact that the ICP have been developed in a multiprofessional context, it is worth mentioning that, in Brazil, Nursing was the first profession to recognize the PIC as a care practice, focusing on the person's autonomy over his/her health. 11 When considering the possibilities of application of ICP in health care by PHC nurses and the need to know how these practices have been developed by these professionals, the research question that guided the study emerged: how have PHC nurses in the city of Curitiba, Paraná State, Brazil used ICP in health care? Therefore, the objective of this study was to analyze the knowledge and use of ICP in the performance of PHC nurses.

METHODS
This is a cross-sectional research with a quantitative approach, carried out in 85 Basic Health Units (BHU) in the city of Curitiba, Paraná.
The sampling technique took into account the number of 405 nurses working in BHUs and Family Health Strategy (FHS). The selected sample was obtained through a finite sample calculation, considering a confidence level of 95% and a sampling error of 5%. Thus, 195 nurses participated in the study.
The inclusion criteria were: being 18 years of age or older and providing direct assistance to users. The exclusion criteria were: professional in a management position, on leave, on vacation, or failing to answer two or more questions of the survey instrument.
Considering the public health condition installed in the world, due to the pandemic of COVID-19 and the guidelines for social distancing, the participants were recruited through the snowball technique, in which the first participants recruited are those contained in the network of contacts of the researchers and, after their participation, indicated new participants belonging to the same target population, and so on, until the number determined in the sampling was reached. 12 The data were collected between February and July 2021, through an electronic structured instrument created in Google Forms®, sent through a link to the Virtual Social Networks (VSN), or email. The instrument was composed of questions organized in three sessions: I) identification and characterization of the participants, II) knowledge and professional practice of the participants concerning ICP, and III) questionnaire with 20 statements with response degrees to measure opinions, perceptions, and behaviors, based on the Likert scale, ranging from one extreme attitude to another: (1) totally disagree, (2) disagree, (3) no opinion, (4) agree, (5) totally agree. The questions formulated for the instrument were based on the theoretical reference about ICP available in the documents of the Ministry of Health (MH). 1 The data were stored and analyzed by the Statistical Package for the Social Sciences SPSS® 21.0 software, by statisticaldescriptive methods. Independent double entry of data into the software was performed in order to avoid inconsistencies.
For the analysis of data from Likert-type questions, the Average Item Ranking (AIR) was calculated using the formula AIR=∑(fr.ve)/TNA, where ∑=summary; fr=frequency of answers; ve=value of the Likert scale; TNA=total number of answers of the same item; in order to verify the agreement or disagreement with the questions, from the score assigned to the answers. Thus, values greater than three were considered as agreeing, less than three as disagreeing, and three as neutral. 13 The results from the numerical variables were presented in measures of central

RESULTS
A total of 195 nurses participated in the survey, of whom 174 (89.2%) were women, with an average age 44±7.8 years, ranging from 23 to 59 years. The time of training ranged from one to 35 years, 18±7.4 years. 104 worked in the FHS (53.3%) and 91 (46.7%) in BHU. The time of work in the service was 7±6.0 years, ranging from one to 25 years, and in PHC was 13±7.9 years, between one and 35 years.
It is noteworthy that 25 (12.8%) participants said they did not know about ICPs, and 86 (44.1%) did not know the NPICP. There were 43 (22.1%) participants who reported using some modality of ICP in their professional practice, 28 (14.4%) in one modality, nine (4.6%) in two, three (1.5%) in three, one (0.5%) in four and two (1.0%) in five, as shown in Table 1. Table 2 presents the results regarding the use of ICP in the professional scenario of PHC nurses. It is noteworthy that 12 (6.2%) participants reported not having specific training in ICP.
Among the participants, 120 (61.5%) said that other professionals, except nurses, use the ICP in their care. In addition, 117 (60%) said they had already received some professional care through ICP. Table 3 shows the distribution of the respondents to the statements referring to knowledge about the ICP. Table 4 presents the participants' experience with the ICP in the professional setting. Table 5 presents the participants' knowledge of the ICP

DISCUSSION
The implementation of the ICPs in Nursing practice by qualified nurses strengthens the therapeutic bond and, consequently, enables greater adherence of users to treatment, since they recognize the history of the community and value its culture. The result of this study showed a frequency of 43 (22.1%) participants with experience in relation to the use of ICP. However, in recent years, the strategy of professional training to work with the ICP is among the main actions carried out in the sphere of the NPICP, aiming at the need to expand the offers of these practices in health services. 4,14 The results of this study highlight that 47.8% of the participants have training in auriculotherapy, followed by reiki (10.1%), flower therapy (7.2%) and traditional Chinese medicine/acupuncture (4.3%), contrasting with the latest data from the MH, 4 in which the most frequently offered ICP in Brazil are body practices (53%) and acupuncture (20%).
There is a plausible justification for the higher frequency of training in auriculotherapy, considering that, between 2016 and    Integrative and complementary practices in primary care Mildemberg R, Paes MR, Santos BA, Dalmolin IS, Brusamarello T 2017, around four thousand health professionals were trained in this practice through an 80-hour semipresential course, funded by the MH with regional centers in 21 Brazilian states. 4 The use of auriculotherapy in nursing care is low cost, highly effective, does not cause side effects and is easily applied by trained nurses. A study showed that the use of auriculotherapy in pregnant women assisted in low-risk prenatal care in public service in Espírito Santo provided a decrease in stress and anxiety levels during the gestational cycle. 9 The improvement in the health condition of patients undergoing chemotherapy treatment was also observed in a study. 7 Although the national survey points out, that among the frequency of ICP in Brazil, acupuncture has 20% among health professionals, among the participants of this study it presented a low frequency (4.3%). The low demand for training and low frequency in the application of this practice can be justified by the restriction of health plans to register non-medical professionals to use this practice. Another barrier was the legal fight since 2001 between the Federal Council of Medicine (FCM) against the Federal Council of Nursing (FCN) to annul the resolution that recognized the qualification and performance of nurses as acupuncturists. Only in 2018, after FCN won the lawsuit, there were possibilities to ensure acupuncture as a specialty for nurses. 15 Given this, it is worth mentioning that studies have verified the effectiveness of acupuncture in the treatment of physiological dysfunctions. The improvement and increase of well-being, the acceptance and reduction of pain, greater self-care, and motivation in the search for effective coping strategies were observed in 64 people with chronic pain after being submitted to the use of acupuncture, yoga, chiropractic, and massage over three months. 16 From the data presented, it was possible to observe that 12 (6.2%) participants were not trained in ICP, but used them in their professional practice in the BHU. According to a study carried out with FHS nurses in Rio Grande do Norte, some professionals reported guiding the use of plants and other natural products, based on religious rituals and popular beliefs, passed on by their relatives. Therefore, the ICP implemented during health care by the participants may be based on cultural experiences and, together with the scientific knowledge acquired during their training as nurses. 17 As shown in Table 2, among the 43 participants with training in ICP, 31 use it in their professional practice. One study showed the existence of concern among professionals about the receptivity of the ICP, as an obstacle to its applicability, added to the superimposition of the biomedical model, absence or little support from managers, resulting in the precariousness of the planning of the ICP, lack of adequate spaces, and insufficient number of trained professionals. 18 As a private activity of nurses, the Nursing Consultation is developed to identify health-disease situations and prescribe and implement measures that contribute to the promotion, protection, recovery, or rehabilitation of the patient. Among the participants, 32 use ICP in this field of action. One study showed that the use of music therapy, dance therapy, and aromatherapy in childcare consultation with autistic patients helps to control psychological symptoms and brings benefits in social interaction, communication, and motor response. 19 Although only 11 participants used the ICP in home visits, according to Table 2, this field of professional practice shows itself as an efficient space for health education, and when allied to the ICP, it provides an exchange of knowledge and appreciation of the care process. The participants who underwent home auriculotherapy reported benefits from the use of the practice, according to the study. 20 From Table 3, it is possible to observe that the participants agree that the ICP promote integral care and self-care for users. The humanization of care resumes the users' autonomy over their own health. It is possible to notice in one study that the ICP are responsible for strengthening the professional/user relationship since the community has an interest in acquiring more knowledge about the theme. 16 Despite AIR=3.24, the results showed that the participants presented uncertainty about the legality of the use of ICP by nurses, it is important to highlight that currently, ICP are reaffirmed as a Nursing specialty through FCN Resolution no. 581 of 2018, ensuring the legal backing of this professional to act in this field, as well as to develop research in the area of ICP in general. 15 According to the data in Table 3, 28.2% of the participants had no opinion about the statement that the basis of ICP is subjective, and 18% agreed with the statement. ICP are used based on research about their safety and efficacy, and this knowledge has been stimulated since the declaration of Alma Ata by the  (2004). Thus, it can be said that these practices have sought to guide and be scientifically based. [1][2][3][4] The participants agreed that it is necessary to discuss ICP in the academic training process. However, it is noted that nurses demonstrated a great diffusion of knowledge related to ICP and participation in research and extension projects; nevertheless, there are weaknesses in the training of these professionals. 15 Therefore, in order to follow the recommendations of the NPICP, there is a need for a greater incentive to include subjects of interest to the UHS and the Policy in the curricula of undergraduate courses and specialization courses in the health area in educational institutions, both public and private. 21 It is important that the teaching be oriented to the various scenarios of the UHS, focusing on the PHC, as recommended by the NPICP. 4 Participants (41.5%) responded that they had no opinion regarding the increased demand for the use of ICP. Some studies have shown that the demand for ICP increased by 46%, from 216 thousand activities developed to 315 thousand between the years 2017 and 2018. 4 The high demand for ICP by users and positive health impacts, as well as the benefits in relation to chronic diseases and health promotion, have been identified in studies. [6][7][8][9][10]22 The research revealed a concordant AIR for the statements about the lack of dissemination and training on the ICP, through continuing education and little incentive to use the practices. This corroborates the literature, which has described the challenges in the implementation of ICP: the difficulty concerning the supply of material and acquisition of inputs used in some of the practices, the lack of support from local management, the lack of physical space, of available rooms, and a greater appreciation of the practices. 23 On the other hand, public administrators have cited as barriers to supporting the implementation of the ICP in health services: insufficient funding, lack of space to carry out the therapies, and also the difficulty in associating the ICP with the curative model, besides the few trained human resources, which are insufficient to meet the high demands. 11 Regarding training, the MH has offered five online courses on ICP in a virtual learning environment through the Open University System of the UHS (OUS-UHS). These courses are introductory, with the goal of stimulating health professionals in the public health system to become interested in the topic. In addition, the MH has promoted a face-to-face training course in Integrative Community Therapy for FHS professionals from all regions of the country. 4 The actions of continuing education in health services enhance specific training in ICP, but do not replace it. Some municipal health secretariats subsidize continuing education for their professionals and/or specialization courses in one or more modalities of ICP, specifically focused on PHC. 4 Table 5 shows that the participants disagreed with the statement that they have knowledge to prescribe and perform the ICP, as well as refer users to this service. This corroborates the literature, since the number of professionals who work with the practices and have the knowledge is still small, implying the impossibility to prescribe or apply them due to deficient knowledge. However, there is currently a movement, albeit slow, of professionals working in research and activities within universities and in the practice setting, which results in the spread of knowledge and dissemination of therapies to the community. 15

CONCLUSION
The UHS strategies for the implementation of the ICP in the assistance of Primary Care users, subsidized by public policies, have brought greater visibility and conditions for the professionals' knowledge and search for training for such practices.
Thus, it can be concluded that nurses demonstrated to have substantial theoretical knowledge about the principles that guide the use of the ICP in a care setting. Moreover, the participants recognized the importance of the insertion of ICP in health care, as important elements to strengthen the bond with the patient, promote integral care, and promote health.
Despite having knowledge, the nurses showed insecurity about the applicability of the practices, coupled with the participants' perception of the lack of greater dissemination of these practices and training actions by continuing education programs.
For the strengthening of the implementation of ICP in the care of users within the health system, it is essential to include this theme in the disciplines of nurses' undergraduate education, in order to instigate them to know such practices and understand their importance in the organization of favorable spaces for health promotion and self-care of users, with a focus on Primary Care. The management of Primary Care health services should increasingly promote actions of dissemination and training of ICP through continuing education, to empower primary care professionals.
Therefore, this study contributes significantly to the characterization of nurses' performance in Primary Care based on ICP. The findings may serve as a subsidy for Nursing professionals to identify gaps in knowledge, and performance, as well as in the management of health services in Primary Care, in order to strengthen the professional autonomy of those who use these practices in their care.
Thus, it is suggested that other studies be developed related to the implementation and management of the ICP, covering other health services, including specialized care, besides those of Primary Care, aiming at proposals to expand the dissemination and quality of the offer of ICP, contributing to the strengthening of the health system.
The limitations of this study include the regionalization of data collection, which occurred in only one municipality, and that the knowledge and practices may be different in other places of the country. In addition, the recruitment of participants due to the pandemic of COVID-19 was a challenge, which made it difficult to have direct contact with the participants due to social distance requirements. Thus, the data collection was done online, causing