Innovation in nursing health care practice : expansion of access in primary health care

Objective: analyze the reorganization of the health care practice of nurses as an innovative strategy for expansion of access in primary care. Method: qualitative and quantitative study, which interviewed 32 management and care nurses and collected documentary data from public reports of production of nursing consultations from 2010 to 2014, in a municipality in southern Brazil. Data processing for textual analysis was performed by IRAMUTEQ software; for simple descriptive statistical analysis, the program Excel 2013 was used. Results: in the innovative care practice class, associated with awareness of change, related to implementation of the FHS, its challenges and advantages, the following subclasses were identifi ed: reorganization of schedules, nursing consultation, physical restructuring of BHUs, and shared consultation. Final considerations: the need to expand access to and valorization of care practice encourages the development of innovative strategies. The protagonism of care needs to be discussed in the various spaces so that each professional carry out the respective role with competence and effi cacy. Descriptors: Organizational Innovation; Primary Health Care; Access to Health Services; Health Care Practice Management; Nursing. RESUMO Objetivo: analisar a reorganização da prática assistencial do enfermeiro como estratégia inovadora para ampliação do acesso na atenção primária. Método: estudo qualiquantitativo, tendo sido entrevistados 32 enfermeiros gerenciais e assistenciais e coletados dados documentais de relatórios públicos de produção de consultas dos enfermeiros de 2010 a 2014, num município sul-brasileiro. O processamento dos dados para análise textual foi realizado pelo software IRAMUTEQ; para análise estatística descritiva simples, o programa Excel 2013. Resultados: na classe prática assistencial inovadora, associada à sensibilização para a mudança, relacionada à implantação da ESF, seus desafi os e fortalezas, foram identifi cadas as subclasses: reorganização das agendas, consulta do enfermeiro, reestruturação física das UBS e consulta compartilhada. Considerações fi nais: a necessidade de ampliar o acesso e valorização da prática assistencial incentiva o desenvolvimento de estratégias inovadoras. O protagonismo do cuidado precisa ser discutido nos diversos espaços a fi m de que cada profi ssional desempenhe seu papel com competência e resolutividade. Descritores: Inovação Organizacional; Atenção Primária à Saúde; Acesso aos Serviços de Saúde; Gerenciamento da Prática Assistencial; Enfermagem. RESUMEN Objetivo: evaluar la reorganización de la práctica asistencial del enfermero como estrategia innovadora para proporcionar un mayor acceso a la atención primaria. Método: estudio cualitativo y cuantitativo, en el que contó con entrevistas de 32 enfermeros de gestión y de la asistencia, y con datos recolectados de informes públicos de consultas de enfermeros entre 2010 y 2014, en un municipio brasileño. Se emplearon el software IRAMUTEQ para el análisis textual de los datos y el Excel 2013 para el análisis estadístico descriptivo simple. Resultados: desde la categoría práctica asistencial innovadora asociada a la apertura al cambio relacionada a la implantación de la Innovation in nursing health care practice: expansion of access in primary health care Inovação na prática assistencial do enfermeiro: ampliação do acesso na atenção primária La innovación en la práctica asistencial del enfermero: mayor acceso a la atención primaria


INTRODUCTION
Primary health care (PHC) has the role of entry and of continued care for most clinical situations of a population defined in a given health system.Access is characterized in one of its central attributes as a condition to the achievement of the other attributes, such as continuity, comprehensive supply of services, and coordination of care of situations that pass through other health services (1) .The Pan American Health Organization establishes as one of its strategic lines the expansion of access to health services, fairly and focused on people (2) .
In the Unified Health System (SUS), designation of the Brazilian public system, PHC is organized in different ways, with multiprofessional teams of basic health units (BHUs) who work in the Family Health Strategy (FHS).These teams are composed of general practitioners for about 4,000 people, which enables care to families.In other units, called traditional BHUs in this study, doctors are specialists in gynaecology, paediatrics, and general practice.Since 1993, with the creation of the Family Health Program, later renamed as Family Health Strategy, there was an increase in the number of family health teams, reaching more than 36,000 in Brazil, which in itself represents an expansion of the Brazilian population's access to PHC and to the SUS (3) .In addition, the mode of work of BHUs with FHS leads these to be prominent in relation to traditional BHUs in the various attributes of PHC (4)(5) .
The nurses' work in the FHS stands out due to its general profile, to its comprehensive understanding of the individual as a whole, to the integral care, identification of the users' needs and expectations, in addition to the mutual interaction between the population and the health professionals (6) .According to the National Policy for Basic Care (7) , nurses in the FHS conduct a wide range of clinical care activities, with care being the object of their work, composing their health care practice (8) , in addition to their management practices.Proper balance between these activities can be a significant difference in relation to the matter of access, since each team needs to provide health care to an assigned population.
The nurses' presence in the identification of the needs of care, as well as their work in the consolidation of the SUS principles and guidelines have been highlighted in the PHC.Nursing consultation, regarded as one of the main actions of the nurses' health care practice and a space for bonding and caring, has potential for expansion of access and enhancement of efficacy in PHC (9) .A study conducted in Spain on the differences in the use of nursing consultations in PHC observed that the necessity criterion has been the most frequent in the use of nursing services; however, access has a significant weight in the use of the service (10) .
Improvement in the quality of care is one of the elements that favor good results in health care, which includes changes in the health care provision process.Therefore, innovation in primary health care aims to meet its principles and promote quality in health care (11) .
This study is justified by the need for recognition of the innovative strategies that expand access to PHC through organization of the service that comprises the nurses.

OBJECTIVE
Analyze the reorganization of nursing health care practice as an innovative strategy for expanding access in primary health care.

Ethical aspects
The study was approved by the Research Ethics Committee of a Brazilian University.The feasibility for the research field in the SMS was approved by its Research Ethics Committee and all participants signed voluntarily the informed consent form.
Theoretical-methodological framework and type of study This is a qualitative and quantitative research, of the descriptive and exploratory type.

Study scenario
The municipality in Southern Brazil that was researched has 109 BHUs, of which 65 have family health teams and 44 are traditional.The six BHUs intentionally chosen for this research underwent an institutional change process in 2013, with implementation of the FHS.This change occurred in a context of physical restructuring of the BHUs and of reorganization of the team's work process, which strengthened the clinical practice of care nurses in the municipal sphere.In order to formalize the institutional support and legally support some actions included in the nursing consultation, the municipality designed a normative resolution that defines the prescription of medication, request of examinations, conducts and procedures of nurses, in addition to expanding the portfolio of services in order to increase the efficacy in meeting the users' needs.
Innovation in nursing health care practice: expansion of access in primary health care Lowen IMV, et al.

Data source
As inclusion criterion it was defined that participants should be the nurses of the family health teams of one BHU of each of the six health districts in which there was expansion of the FHS in the first half of 2013; the management nurses involved in this process should be from the BHUs, health districts, and departments of the Municipal Department of Health (SMS) and who remained in their positions until the data collection.Nurses who were not conducting their activities in the period of data collection were excluded.Therefore, the intentional sample was composed of 16 nurses (50%) working in the management and, coincidentally, 16 nurses (50%) working in care.

Data collection and organization
Qualitative data collection was conducted from January to April 2014, through interviews.The instrument employed addressed the FHS expansion process and the innovative practices related to the context of change in the FHS expansion process.Interviews were conducted by one of the researchers, recorded and transcribed later, with average duration of 25 minutes, in the participants' work site and shift, after scheduling through telephone contact.For identification of care nurses we used the word "assist."[care], while for management nurses we used "gest."[management].
Quantitative data regarding the number of nursing consultations of the BHUs were collected in October 2015, from the municipal production database of the period from January 2010 to December 2014, recorded in the SMS information system called "e-Saúde".The "e-Saúde" is an integrated system that, in addition to being the Patient Electronic Record, is also characterized as an Electronic Health Record System (RES) that provides management reports to monitor the production of health professionals (12) .The data were collected in the institutional site (13) and refer to the production of nursing consultations of the six BHUs researched, according to total consultations per year, and also comparing with the variation in this period for all BHUs of the municipality.

Data analysis
To support the textual analysis of qualitative research data, we used the IRAMUTEQ software (Interface de R pour lês Analyses Multidimensionnelles de Textes et de Questionnaires).This program is free and anchored in the R software.It was developed in 2009 in French, and use in Brazil started in 2013.IRAMUTEQ software enables different processing and statistical analysis of texts produced; in this research, we used the Descending Hierarchical Classification (DHC) method (14)(15) .
Based on the set of interviews and preparation of the corpus, the DHC estimated the elementary context units (ECU) -classified according to the words with highest frequency, understood as significant for qualitative analysis of data -and the highest Chi-square values in each class -as they have greater association of their ECUs with their class (16) .These classes "present similar vocabulary between them, and different vocabulary in relation to the ECUs from the other classes" (15) .The class that showed innovative nursing care practice was associated with awareness of change and, this, was related to the implementation of the FHS and its challenges and advantages.In this change process, characterized as innovative, four subclasses emerged: reorganization of schedules, nursing consultation, physical restructuring of BHUs, and shared consultation.For the descriptive statistical analysis of quantitative data, we used the program Excel 2013.

RESULTS
Of the 32 nurses participating in the first stage of research, 24 (75%) were aged 30-50 years, the time since graduation of 22 (68%) of them was of up to 20 years.Eleven managerial nurses, of 16 (68%), had been for over one year in the position in the BHUs researched and all care nurses for less than one year, due to the relocation norms in force at the time.The 16 care nurses had longer experience in the FHS, 12 (75%) with three years or more and 8 managerial nurses (50%) with no experience in the FHS or with less than one year.As to professional qualification, 11 managerial nurses (68%) had postgraduate degree, specialization in management and collective/family health, and/ or master's degree, while 11 (68%) of the care nurses had one or more specializations in the area of family health or similar, ongoing studies, or residency in family health.
During the interview data processing by IRAMUTEQ software, 93.8% of the corpus was utilized; by means of a dendrogram of the DHC the software identified aspects of the FHS change process, including innovation in nursing consultation.In the analysis of innovation in nursing consultation we explored the following categories: reorganization of the professionals' schedule, nursing consultation, physical restructuring of the BHUs, and shared consultation.
As to the work process in the six BHUs researched, the participants mentioned aspects related to nursing consultation characterized by them as innovations.They addressed the expansion of access to consultations and its relation with the development of the nursing health care practice.The reorganization of the professionals' schedule to improve access was characterized as innovative: Then we were able to meet almost 100% of the demand because we didn't have a pre-scheduling, schedules so full.Whoever came to us we always received cordially and usually people who need medical consultation we were able to provide because these schedules were not so full [...].So they were ok with meeting all demand that came, within the limit, of course, there's a limit of the day, but nothing we can't negotiate.(Gest.14)   The promotion of nursing consultation emerges in the following interview excerpt: [...] there is no need for me to refer the person to a doctor's appointment, so I can renew that person's prescription and explain that, four months from now, you repeat it, diabetic cases repeat their test.[...] I adopted the Manchester protocol, provided that care always directing to the doctor.(Assist.4) The participants revealed aspects related to the physical restructuring of the BHUs to have clinics close and thus Results for the nursing consultation production show, through managerial reports monitoring the production of health professionals of the six BHUs researched and that implemented the FHS, that the care nurses' productivity related to nursing consultation had significant increase in 2013 and 2014, as shown in Figure 1.

DISCUSSION
Strengthening of the care role of health professionals of the municipality researched is guided by the universal right of using health services, by the need for expansion of access (17) and of the portfolio of services, with the promotion of nursing consultation, and the deconstruction of care according to criteria related to health problems or to priority groups (8) .To this end, practices regarded as innovative by the participants were used; practices which not necessarily need to be created.Innovation can also be characterized when a product, service, or improvement is transposed from a context to another (18) .
In-depth analysis of the access to services can contribute to further improve care and to meet the population's health needs.Due to the limitations imposed, not always the need of health advances to a demand, which needs to be analyzed in discussions on access.It must be considered that it is a universal right permeated by equity and that the State has the duty to provide it through concrete and responsible actions (19) so those who need it are provided a quality service (20) .In this context, the aforementioned changes propose increasing the nursing health care practice, aiming at efficacy.
One of the characteristics of the expansion of access is to analyze the reorganization of the professionals' schedules.The schedule of consultations, predominantly of physicians, was organized in order to achieve predetermined goals, that is, the number of consultations was generally predetermined and a large part was pre-scheduled, with prioritization for pregnant women, children aged up to one year, hypertensives, diabetics, and elderlies.For years the nursing assistant's evaluation for scheduling of medical consultation -which could be characterized as a preconsultation -had its space.Institution of the Manchester protocol (21) , so nurses evaluate every user with a complaint to prioritize or not medical schedule, as well as the decrease of the evaluative function of nursing assistants contributed so demand referred predominantly to medical consultation.In many BHUs nursing consultations were not part of the routine of work or were conducted in nonsignificant number.Others worked with an open schedule; however, this was not an institutionalized practice.By that logic, the choice to improve access proposes to meet the demand of the day, that is, users who go to the BHU will have their needs met within the real possibilities of the service, with no predetermined number of consultations for each professional (22) .The user's evaluation as to referral to the best suited professional to resolve the situation refers to the importance of the work of a multidisciplinary team capable of being efficient in resolution and not centering the referral of all demands to the doctor.
The FHS is considered as a possibility for the nurse to attain (re)acknowledgement as author of nursing care, integrated with a multidisciplinary team, in order to contribute to consolidate the Unified Health System (7) .
Promotion of nursing consultation and deconstruction of care -according to criteria related to health problems or to priority groups, including the hypertensive, diabetic, pregnant women, and children -aim to foster access by the entire population that has some health need (8) .Yet, in other contexts, the care practice still shows the organization of care geared primarily to certain groups (23) .
The physical restructuring of the BHUs included the proximity of the location of offices of nurses and doctors of each team, obtained by re-evaluation of the service flow, reforms, and through prioritization of rooms for nursing care.A study found that nursing consultation is considered a secondary action in relation to medical work, that is, it is performed when the doctor is not in consultation, and reflects in reduced access and reduced efficacy in solving the needs of users, in addition to compromising professional autonomy, generating dissatisfaction, uneasiness, and improvisation in the activities of the nurse (24) .It cannot be affirmed that adequate infrastructure  ensures the autonomy of nurses, but it contributes to their professional visibility.Sharing between professionals is experienced through the different practices; however, as occurs in the matrix support (25) , shared consultation between the nurse and the doctor also promotes both their integration and the exchange and use of knowledge, as well as of experiences in order to achieve an integrated view in care seeking resolution, which can be facilitated by the proximity of the rooms.In a study, the nurses recognize other activities shared with the team, including home visits and educational activities (23) : valorization of the multidisciplinary team focusing on the needs of the population, in the concept of including people are actions to be strengthened.
Figure 1 shows that there has been an increase of over 100% in nursing consultations in five of the six BHUs researched from 2010 to 2014 (13) .A Swedish study points to the importance of measuring productivity and quality in order to be accountable to taxpayers about the resources spent on health care and the evaluation of benefits for users (26) , which encourages an in-depth analysis about its quality, systematization of care, its financial impact, its efficacy, and its contribution to the training of future health professionals.
In this research, the legal support provided by the municipality to nursing consultations, to clinical management, can contribute significantly to the care provided to the user, to the family, and to the population.However, nurses usually do not plan or use and perform consultation because they were not trained, due to disinterest, among other factors (27) .However, a study conducted in a health center in Spain shows the importance of nursing consultation in order to improve the health system's efficacy (28) .

Study limitations
One of the limits of the research is the restriction in the information system which did not provide a specific icon for initial evaluation of nursing.Therefore, nurses registered their service sessions as "nursing consultation," and it might or might not be characterized as such.
Contribution to the field of nursing and health As contribution, the research indicates the review of the nurse's care role for the expansion of access in PHC.This practice of the nurse goes beyond the initiative of the professional, which occupies new spaces, since its support depends on institutional decision-making and the organization of the work process.

FINAL CONSIDERATIONS
The interviews with the nurses and the consultation production data show a concern with the need for expansion of access in PHC.Among the strategies in seeking this expansion, it should be noted changes in the organization of consultation scheduling with increase in nursing consultation and in shared consultation that tend to acknowledge the nurse's health care practice in PHC.
Readjustment of physical space in the BHUs allowed that nurses could have their own offices and reorganization of patient flows favored the changes related to the production of consultations.The nurses' reports show a good perception about these changes, while highlighting a concern as to their skills and knowledge to face this challenge.Some participants pointed out other difficulties involved, such as excess demand for consultations and the difficulty of reconciling the care with the prior logic of prioritization of service to specific groups of people, which requires the reorganization of the work process of nurses and nursing staff.
The research demonstrates that the strengthening of the care dimension in the nurse work can occur by means of structural and organizational changes in the context of the FHS, impacting the expansion of access to health services by the population.
In addition to evaluating the number of nursing consultations, it is recommended other studies related to the quality of nursing consultations and to the readjustment of their managerial practice in this context.Furthermore, the protagonism of care inherent in the nurses needs to be discussed in the various spaces, aiming at competence and efficacy.This practice includes a critical reflection about the determinants that regulate the context of PHC professionals.

Figure 1 -
Figure 1 -Distribution of the number of nursing consultations, according to Basic Health Unit and mean consultations of the Municipal Department of Health (SMS) of Curitiba, Brazil, from 2010 to 2014 Innovation in nursing health care practice: expansion of access in primary health care Lowen IMV, et al.Every nurse, every doctor of the team with their own office, so they can work.That facilitated [...].(Gest.12)