Normative grounds of health care practice in Brazilian nursing

Objective: to understand the normative grounds of health care practice in Brazilian nursing. Method: qualitative study with the use of document research, carried out based on resolutions of the Federal Nursing Council. From a total of 263 resolutions, in the period from 1975 to 2015, 38 which were in accordance with the objective of the study were selected. Results: three analytical categories were systematized: Normative grounds of health care practice by the nursing team, under coordination/ supervision of the nurse; Normative grounds of the care performed privately by the nurse; and Management and administrative aspects which affect and permeate the practice of health care in nursing. Conclusion: the set of normative grounds of health care practice by the nursing team leads to the refl ection on the possible overlapping of attributions between professional levels and requires expansion to the other fi elds of nursing which are coherent with the health care network model. Descriptors: Professional Practice; Nurse; Resolutions; Nursing Assistance; Standard of Care. RESUMO Objetivo: compreender como se defi nem os fundamentos normativos para a prática do cuidado realizado pela enfermagem brasileira. Método: estudo qualitativo, do tipo pesquisa documental, realizado com base nas resoluções do Conselho Federal de Enfermagem. De um total de 263 resoluções, no período de 1975 a 2015, foram selecionadas 38 que atenderam ao objetivo do estudo. Resultados: foram sistematizadas três categorias analíticas: Fundamentos normativos para a prática do cuidado realizado pela equipe de enfermagem, sob a coordenação/supervisão do enfermeiro; Fundamentos normativos para o cuidado realizado privativamente pelo enfermeiro; e Aspectos gerenciais e administrativos que condicionam e permeiam a prática do cuidado de enfermagem. Conclusão: o conjunto dos fundamentos normativos da prática do cuidado da equipe de enfermagem conduz à refl exão sobre a possível sobreposição de atribuições entre os níveis profi ssionais e requer ampliação para os demais campos de atuação da enfermagem, coerentes ao modelo de rede de atenção à saúde. Descritores: Prática Profi ssional; Enfermeiro; Resoluções; Assistência de Enfermagem; Padrão de Cuidado. RESUMEN Objetivo: comprender cómo defi nir las bases normativas para la práctica de los cuidados proporcionados por la enfermería brasileña. Método: estudio cualitativo de la investigación de tipo documental, basado en las resoluciones del Consejo Federal de Enfermería. En un total de 263 resoluciones en el período 1975-2015, se seleccionaron 38 que cumplieron el objetivo del estudio. Resultados: fueron sistematizadas tres categorías analíticas: Bases normativas para la práctica de los cuidados proporcionados por el personal de enfermería, bajo la coordinación/supervisión de un enfermero; Bases normativas para los cuidados proporcionados exclusivamente por los enfermeros; y Los aspectos administrativos y de gestión que infl uyen e impregnan la práctica de los cuidados de enfermería. Conclusión: el conjunto de bases normativas de la práctica de los cuidados del personal de enfermería lleva a la refl exión acerca de la posible superposición de responsabilidades entre los niveles profesionales y requiere la expansión a otros campos de la actividad de enfermería, en consonancia con el modelo de red de cuidado de la salud. Descriptores: Práctica Profesional; Enfermero; Resoluciones; Cuidados de Enfermería; Atención Estándar. Normative grounds of health care practice in Brazilian nursing Fundamentos normativos para a prática do cuidado realizado pela enfermagem brasileira Bases normativas para la práctica de los cuidados proporcionados por la enfermería brasileña Selma Regina de Andrade E-mail: selma.regina@ufsc.br CORRESPONDING AUTHOR


INTRODUCTION
The National Health Policy, exercised through the Brazilian Unified National Health System (SUS), guides the conduction of promotion, protection, prevention, recovery and rehabilitation practices, based on a universal, total and equitable access model.The organizational arrangement made to put the model into effect has incorporated the concept of health care networks as a strategy to overcome the fragmentation of health care and management, considering its attributes for improvement of the quality of the care provided to the users of the system (1) .
Brazilian nursing, in its condition of largest work force in the health field, acts in most scenarios of the network of provision of health practices and services, and may contribute decisively to the effectiveness of the SUS, through the articulation between care, management, education and investigation processes, axes that compose the professional practice (2) .
As a profession that is responsible for human, individual and collective health care, nursing care involves the performance of direct assistance to human beings and management of the provided services and assistances by the nursing team.It is guided by ethical and legal provisions, in order to ensure quality to the welfare of people and/or restoration of their health (3) .
Understanding nursing care as an intentional phenomenon that is essential to life, and that occurs in human interaction (4) , health care practice is associated to the ethical responsibility that accompanies the professional duties.It goes beyond the common sense of punctual and episodic care to be configured as continuous, systematized and contextualized care (1) .
Under a perspective of adherence to the health care network model, the improvement of the practices of nursing care demands an internal look towards the normative outlines that regulate the profession.In that sense, as a profession, nursing is regulated from vocational training up to its competencies and fields of expertise, its professional practice being policed by a competent body.
The Brazilian Nursing Association (ABEn), the first entity to represent the profession, was responsible for creating a Professional Council to perform the role of an advisory body of public authorities in all that concerned it (5) , which occurred in 1973 with the creation of the Federal Nursing Council (Cofen) (6) .
The Professional Councils are autarchies, public law entities with administrative and financial autonomy that are responsible for ensuring the quality of professionals and for the legal fulfillment of professional practice (7) .In the condition of collegiate bodies, the Professional Councils have their decisions registered through Resolutions, a type of normative act with the force of Decree, adopted with the fundamental purpose of making them public to the people to whom they are destined.
In light of the reality of the activities of nurses and of the nursing team in the organizations which compose the health care network, it is possible to say that the political-professional guidance concerning nursing care, which is outlined by the body related to the field, is still fragmented.
Considering that nursing regulation -including professional qualification, competencies and fields of expertise -is made by Cofen; that it is through it that the attributions of the nurse and of the nursing team are defined; and that there is a normative dispersion regarding the policy which is basis for the health care practice performed by the profession, this study is justified by the necessity of deepening the understanding of the set of resolutions adopted by this body, which concern the normative grounds of the practice of nursing care in the country.
Based on these considerations, this study aims to answer the following research question: how are the normative grounds of health care practice in Brazilian nursing established?Objectively, and based on the resolutions from Cofen, this study aims to understand how the normative grounds of the health care practice performed by Brazilian nursing are defined.

METHOD Ethical aspects
For this research project, presentation in a Research Ethics Committee was not necessary, since it was based on online public documents.However, the project received the approval of the Federal University of Santa Catarina and the ethical aspects of authorship were considered during the processes of selection, organization, analysis and reference of the documents addressed in this study.

Methodological referential
Document research is a modality that allows the indirect investigation of a determined issue, through the study of documents produced by human beings, which reveal their way of being, living and understanding a social fact (9) .It uses a comprehensive and complex set of data as basis for the selection of elements that can be manipulated, in order to establish relations and obtain conclusions (10) .

Type of study
Qualitative approach study, of exploratory-descriptive nature, with use of document research, performed based in the Resolution from Cofen, from its first edition in October 4th 1975 up to the last edition available in December 17th 2015, resulting in a 40 year period of this type of normative production.

Study scenario
In a broad manner, the scenario encompasses the virtual identity of Cofen, which can be seen in the web portal that has the legislation which guides the exercise of the profession of nurses, technicians and assistants in nursing.

Source, collection and organization of the data
The source of data encompassed the legislation contained in the Cofen web portal, available online (www.cofen.gov.br/categoria/legislação/resoluções).Regarding the organization of the document database, the adopted criteria for inclusion were the Resolutions from Cofen, which are integrally available in the Internet, publicly accessible for free, and the exclusion criteria included the resolutions which were revoked, barred, or that did not relate to the objective of the study.The search for documents was concluded in February 2016, and 263 resolutions were found.Following this survey, all the documents were individually read by two researchers, and 38 were selected.Figure 1 presents the flowchart of the selection of documents.

Data analysis
The documents were analyzed through the document analysis technique, which consists of two phases: document systematization and information synthesis (10) .
In the first phase, systematization, a table was created in Microsoft Word® in order to preliminarily evaluate the documents, considering context, author, authenticity and reliability, nature, key concepts and internal logic of the text (10) .In this case, it was considered that the author is represented by the advisory board of Cofen, which is the legal and legitimate body that represents the profession, and also the producer of the published resolutions, which establish regulations for guidance of processes in Brazilian nursing.For resolutory texts, focus was given to their content, considering what are known as key concepts for the practice of nursing care.
In the second phase the synthesis of the information from the documents was obtained, by extracting contents (key concepts) and comparing them to the elements contained in the document corpus, which allowed recognizing similarities, relations and differences.The document syntheses were analyzed with the support of the MaxQDA ® software, and three categories resulted from it: Normative grounds of health care practice by the nursing team, under the coordination/supervision of the nurse; Normative grounds of the care privately performed by the nurse; and Management and administrative aspects which affect and permeate the practice of health care in nursing.

RESULTS
From a total of 263 resolutions available on-line in the period from 1975 to 2015, 38 were selected.Of those, 15 serve as basis to the exercise of health care practiced by the nursing team, the nurse being the coordinator/supervisor of the care performed by the team, 13 establish the private attributions of the nurse for the practice of health care and ten define management and administrative norms that condition and permeate health care in nursing.Thus, based on the similarity and relation between their contents, three categories were originated: Normative grounds of health care practice by the nursing team, under the coordination/supervision of the nurse; Normative grounds of the health care privately performed by the nurse; and Management and administrative aspects which affect and permeate the practice of health care in nursing.
Normative grounds of the health care performed by the nursing team, under coordination/supervision of the nurse The normative grounds that guide the functions of nursing teams are the ones over which competences and responsibilities are shared.The performance of health care performed by the nursing team is understood based on the grounds which define its attributions and field of expertise, guiding the care provided by it.It includes specific designations for the professionals with secondary and higher education.Regarding the latter, it includes those which are private to the nurse, characterized by planning, execution, coordination, supervision and evaluation of the care and of the nursing team for which they are responsible.Box 1 presents the 15 resolutions that regulate health care practice by the nursing team.
To be continued Normative grounds of the health care practice privately performed by the nurse This category addresses the set of normative grounds which define the private attributions, competences and responsibilities of the nurse regarding the care of individuals and population groups.The forms of care performed privately by the nurse are those of higher technical complexity, which require scientific knowledges and immediate decision-making to their performance.13

DISCUSSION
The regulation and normalization of the nursing activity contributes to the expansion of the professionals' field of expertise, considering that the nurse and the nursing team begin to legally act in many sectors due to it.The normative grounds defined by the Cofen guide the practice of health care performed by the nursing team, under the coordination of the nurse, assigning specific activities to them.Many other roles are privately attributed to the nurse, besides all the practices performed by the other members of the staff, which have been published in exclusive resolutions or alongside norms that are directed to the entire team.In this regard, it is clear that, when establishing the health care practices to be performed by the team, save for the clauses of exclusivity of actions to the professional of academic qualification, turmoil could be caused by the assigning to these professionals, in addition to their private functions, of integral care in daily services.
Nursing consultation, which is included in the private activities of the nurse both in private and public institutions, utilizes components of the scientific method to identify conditions of the health-disease process and, based on clinical decisions, proposes promotion, protection, and recovery measures.It is an activity that is performed in a deliberate, systematic and individualized manner, according to the patient's characteristics (11) , and is part of a process carried out in variable intensities and modalities in the many locations where the practice of health care in nursing is present.As an example, nursing consultation in urgency and emergency services is performed through risk assessment methodologies.About the application of one of those methodologies, a study concerning the perception of the nurses in the South region of Brazil has revealed benefits such as improvement in flow organization and in the quality of the provided care, despite the precariousness of the flow of referral to the health care network (12) .
Systematization of Nursing Care (SAE) is the currently adopted name for the terminologies of nursing process, care process, care methodology, assistance process and nursing consultation, synonym terms that assign the same goal to the nurse's work: applying a scientific method in the planning of nursing actions.Despite Cofen making the implementation of SAE in health institutions mandatory, there are still many difficulties for its execution, difficulties that involve not only lack of resources, but the way the professional assimilates knowledge.Even with the efforts of the nursing field, it is a form of knowledge that, despite being introduced in Brazil in the 1970s, still has a large gap between its production and applicability in the daily practices of the nurse (13) .
Home care represents one of the many scenarios of performance of the nursing team; regulated by Cofen, it may be supported by the analytical logic of the SAE, in order to comprise a set of actions in health promotion, prevention and treatment of diseases and rehabilitation that are provided at the patient's house (14) .This assistance modality offers new production modes for health care and intervention at different points of the network, enabling the continuity and integrability of care.However, it still has frailties to be faced, mainly in what concerns the complementarity of services and their interdependency, revealing that the network is an organizational strategy that is not yet completely effective (15) .
Besides distinct assistantship levels, the nursing team acts in situations with patient profiles of different complexities.Of the health care practices by the nursing team that are regulated by Cofen, the attributions and procedures in hemotherapy services, organs and tissues procurement and transplantation, parenteral and enteral nutrition, antineoplastic chemotherapy and wounds care stand out.
In what concerns the attributions in hemotherapy, it is necessary to consider that this service has been growing in the country for the last few decades due to new findings and technological innovation.Such evolution is a challenge for the nursing team, because it requires specialized knowledges on the blood cycle process, which includes from transfusion performed in a general hospital to blood donation in a blood center (16) .In Paraná, a study has demonstrated that the nurses know very little about the regulating norms of this service and that they do not receive training on the subject, reasons why the development of qualification programs on transfusion therapy are recommended, as strategy to qualify assistance and comply with the legislation (17) .
As in the donation of blood products, the nursing team, especially the nurse, provide care to organ and tissue donors.The nurses' contribution to the success of transplantations has been acknowledged, especially in what concerns their private role in planning, executing, coordinating, supervising and assessing the programs for procurement of donors.A literature review has shown that nurses acting in organ and tissue transplantation care need comprehensive scientific knowledge and that their participation alongside multi-professional teams contributed to a complete assistance to donors, recipients and families undergoing organ donation processes (18) .
The nursing care for people unable to orally ingest enough nutrients also requires a joint action by the nursing team and other health professionals.The nurse and the nursing team are the ones responsible for administering and monitoring the diets of people who depend on feeding, within the hospital environment or not, being also responsible for assuring the access to the gastrointestinal tract, its maintenance and for the response to complications inherent in therapy (19)(20) .Regarding the work of the nursing team in nutritional therapy, a study performed in Paraná revealed deficiency in professional enhancement, asserting the importance of implementing care protocols in order to prevent complications (21) .
The necessity for qualification and assessment of the developed actions was also demonstrated in relation to the administering of antineoplastic drugs, presented in an integrative literature review, which recommended measures aimed at education not only of nurses, but of all professionals involved with the area.Antineoplastic chemotherapeutic administering is a relevant practice of the nursing team in the oncology field, and it requires a team that is qualified and able to perform validation, preparation and dispensing of chemotherapeutics (22) .
An important field of expertise in nursing has been established through the regulation concerning the competence of the team in wounds care.The access to adequate supplies, to specific training and to the development of an interdisciplinary effort was considered an indispensable factor to the viability and establishment of therapeutic actions that are effective for wounded individuals (23) .
Institutional scenarios may require the performance of nursing professionals under very specific work conditions.Some of these conditions are normatively covered, including environments with ionizing radiation, surgical instruments, pre-hospital and inter-hospital care, orthopedic care and orthopedic immobilization procedures, mechanical contention of patients and transportation of patients in environments that are internal to health services.Attributions of peripheral and central catheter insertion and request of routine and complimentary examination were privately delegated to the nurse.An integrative literature review revealed the importance of the supervisor nurse in the work environment as a facilitating health care practice agent, who is responsible for the continuous guidance of the team (24) .
Finally, Cofen has regulated a set of attributions for the health care practice performed by the nursing team in emerging fields, such as, for instance, specialization in alternative therapies, authorizing the nursing professionals to include acupuncture in their professional conducts.
In the analyzed Resolution, there is solid regulation over the performance of the nurse in health care for women and children, specially in what concerns the collection of material for oncologic colpocytology; the care of women in the pregnancypuerperal cycle; genetic counseling; collection of blood from the umbilical and placental cord; venous access via umbilical catheterization and the utilization of the therapeutic toy technique.
Nursing has become an entrepreneurial profession, made viable through socially relevant practices, collaborating with the reversion of health indicators, such as mother and child mortality.In order to improve these indicators, the nurse works with the aspects of health promotion and prevention within the context of prenatal, parturition, puerperial practices and care of newborns, despite the emphasis still being attributed to the performance of technical procedures (25) .Nurses are considered key professionals in the health care for mother and child populations since, besides technical qualification and legal support, they contribute to ensuring the quality in prenatal care and assess obstetric risk, from a holistic, educational, management and assistance perspective (25) .
In child care, the performance of complex procedures that impose risks to the patient and which require technical-scientific abilities are the nurse's responsibility.For the performance of procedures in pediatric patients, which differ in level of cognitive development, the nurse may apply the therapeutic toy technique as a way of communicating with the child.A study performed in a children's hospital in Paraíba evidenced the technique as a communication skill that is developed during the process of child care, assisting on the child's recovery and promoting care individualization, minimizing the stress of the hospitalization process (26) .
The health care practice performed by the nursing team or privately by the nurse is affected and permeated by management and administrative aspects that provide support so that the care may occur in a systematized and safe manner.
Besides establishing the ethics code, the resolutions guide the constitution of the minimum staff, based in the dimensioning of personnel, as well as the recording of professional actions in the patient record and the adoption of the manual procedure for standardization of routine services.
Ethical professional practice is enforced through guiding principles for the exercise of nursing in its many field of action, involving teaching, research, management and assistance (27) .Thus, the importance of quality in the nursing record is evident, being it an ethical-legal duty of the professionals.The records are documentation sources for the actions performed by the nursing team, becoming a way to ensure and prove both the provision itself and the quality of the care provided.Adverse situations such as the incorrect filling of a patients' identification data, absence of prescription verification, absence of signature and incomplete notes (28) , are worth of reflection on the ethical-professional commitment.The manuals for norms, routines and procedures, as well as the clinical assistance protocols, are fundamental for the assessment of services and, therefore, for the quality of care.The nursing protocol are technological products that enable systematization, facility of the work process, guidance and, specially, humanization of health care (29) .
Other attributions that are private to nurses have been regulated, making evident their competence as technical managers of nursing services in all the assistance environments, in waste management, birth centers and material and sterilization centers, as well as in auditing and management of health institutions.It is noted that, in these cases, nursing practice is focused on the management of care and of service, processes that mainly encompass the management of human and material resources to meet organizational goals.In that sense, the health care practice by the nurse is revealed as a broad process, which encompasses actions in health care, management, education and research, which are shared with the nursing team, converging to the patient's benefit.This practice is not transferable and requires professional criteria from planning to execution, in compliance with ethical, legal and technical-scientific standards (27) .

FINAL CONSIDERATIONS
The results of this study enabled the understanding of the way Brazilian nursing is regulated by the respective Professional Council in demonstrating the normative grounds of the health care practice performed by the nurse and the nursing team.The analyzed documents define the normative grounds, specifying the care performed by the nursing team, of which the nurse is coordinator/supervisor, the private attributions of the nurse and management and administrative norms that affect and permeate nursing care.
A critical take on the set of normative grounds of the health care practices by the nursing team, as they are described, leads to the reflection on a possible overlap of designations between professional levels, with exception to what concerns determined procedures and management-administrative roles, which are private to the superior level.In what concerns the private attributions of nurses, they are responsible for the execution of high-complexity procedures that require technical-scientific knowledge for rapid and effective decision-making.Among them, nursing consultation stands out, which is performed during the nursing process, and the health care related to women and children.
The normative grounds require expansion to other nursing fields of expertise, since the resolutions refer to health care practice in specific fields.That way, it is relevant to consider the promotion of a debate to consolidate, in a unified manner, the assistance policy of the profession, integrating assistance, management, teaching and research processes with the health care levels and with the assumptions and guidelines of the health care network model.

Figure 1 -
Figure 1 -Flowchart of the selection of documents

Box 1 -
Normative grounds of the practice of health care performed by the nursing team, under coordination/supervision of the nurse, 1975-2015 performed by the nursing team 197 1997 Establishes and recognizes alternative therapies as a specialty and/or qualification of the nursing professional.210 1998 Concerns the performance of nursing professionals who work with antineoplastic chemotherapeutics.211 1998 Concerns the performance of nursing professionals who work with ionizing radiation.214 1998 Concerns surgical instrumentation.
resolutions that regulate this practice have been selected and are presented in Box 2. a network of volunteers, composed of professionals in nursing, to provide care for populations affected by climate catastrophes or that are experiencing post-war calamities.Management and administrative aspects which affect and permeate health care practice in nursingThe category of management and administrative aspects concerns the normative grounds that guide the actions of the of the nurse in the collection of blood from the umbilical and placental cord.3262008Authorizes the autonomous use of acupuncture by a nurse in his/her professional practice, after the approval of his/her specific technical qualification by the Cofen.the scope of the Cofen system/regional nursing councils, the participation of the nurse in the activity of classification of risks.468 2014 Concerns the performance of the nurse in genetic counseling.477 2015 Concerns the performance of nurses in care for pregnant, parturient and puerperal women.
427 2012 Regulates the nursing procedures for deployment of mechanical contention of patients.464 2014 Regulates the performance of nursing teams in home care.501 2015 Approves and establishes the regulation over the competence of the nursing team regarding wound care.Box 2 -Private attributions of the nurse for health care, 1975-2015 258 2001 Decides that the insertion of central peripheral catheter by the nurse is licit.295 2004 Concerns the utilization of the therapeutic toy technique by the nurse in the care of hospitalized children.nursing team in relation to the regulations that permeate the provided care, so as to ensure a safe, legal, and systematized practice.10 resolutions compose this category, which are presented in Box 3. Box 3 -Management and administrative aspects that affect and permeate health care practice in nursing, 1975-2015 458 2014 Regulates the conditions for recording of technical responsibility by the nursing service and defines the attributions of the technician nurse manager.478 2015 Regulates the performance and civil responsibility of the obstetrician nurse in birth centers and provides other measures.Rev Bras Enferm [Internet].2016 nov-dec;69(6):1020-8. Normative grounds of health care practice in Brazilian nursing