Perception of primary healthcare management nurses on the nursing process

Objective: this qualitative study aimed to analyze the perceptions of primary health care management nurses on the nursing process. Methods: data were collected through interviews and analyzed by the Content Analysis proposed by Bardin’s theoretical framework. Results: managers recognize the importance of the nursing process, although its implementation was not a priority at the time of the interviews. A conceptual diffi culty and a lack of understanding that the implementation of the care methodology should be a cross-departmental action in the local healthcare management were clearly observed. Conclusion: managers should have their perspectives broadened concerning the relevance of the nursing process and the professional training. The active participation of legislative nursing bodies, local healthcare management and the federal government may open the way for the effective implementation of the nursing process. Descriptors: Primary Health Care; Nursing Processes; Healthcare Management. RESUMO Objetivo: analisar a percepção dos enfermeiros gestores da atenção primária à saúde sobre o processo de enfermagem. Método: estudo qualitativo em que os dados foram coletados por meio de entrevistas e analisados a partir da Análise de Conteúdo proposta por Bardin. Resultados: os gestores reconhecem a importância do processo de enfermagem, embora sua implementação não seja prioridade no momento. Existe difi culdade conceitual e não compreensão de que a implementação da metodologia de assistência deva perpassar pela gestão municipal. Conclusão: necessita-se de ampliação da visão dos gestores quanto à importância do processo de enfermagem e qualifi cação dos profi ssionais. Acredita-se na participação ativa dos órgãos legisladores de enfermagem, gestão local de saúde e governo federal para que a implementação do processo de enfermagem seja viabilizada. Descritores: Atenção Primária à Saúde; Processos de Enfermagem; Gestão em Saúde. RESUMEN Objetivo: analizar las percepciones de los gerentes de enfermería de atención primaria de salud en el proceso de enfermería. Métodos: estudio cualitativo; los datos fueron recolectados a través de entrevistas y analizados desde el Análisis de Contenido propuesta por Bardin referencial teórico. Resultados: los gerentes reconocen la importancia del proceso de enfermería, aunque su aplicación no es la prioridad en este momento. No hay ninguna difi cultad conceptual y la comprensión de que la ejecución de la ayuda metodología debe impregnar la gestión municipal. Conclusión: es necesario ampliar la visión de los administradores en cuanto a la importancia del proceso y la califi cación de enfermería. Cree en la participación activa de los órganos legislativos de enfermería, administración de salud local y el gobierno federal para la aplicación del proceso de enfermería es factible. Palabras clave: Atención Primaria de la Salud; Proceso de Enfermería; Gestión en Salud. RESEARCH Ieda Aparecida Diniz E-mail: ieda.diniz@yahoo.com.br CORRESPONDING AUTHOR Perception of primary healthcare management nurses on the nursing process Percepção dos enfermeiros gestores da atenção primária sobre o processo de enfermagem Percepción de directores de la enfermera de salud primaria en el proceso de enfermería Perception of primary healthcare management nurses on the nursing process 183 Rev Bras Enferm. 2015 Mar-Apr;68(2):182-9. INTRODUCTION The organization of the nursing care process in Brazil has been usually named under Nursing Care Systematization (NCS) by the majority of nurses. However, it should be highlighted that the verb “to systematize” means a specific set of organizing strategies, and not necessarily the mere employment of random actions originated from any given methodology aimed at structuring the nursing practice. In this sense, the Nursing Process (NP) becomes the most adequate terminology within any proposed healthcare context. The term is defined as the methodological instrument that orients the professional nursing care and professional practice papers(1). The purpose of the NP is to comply with scientific methodological principles, aiming at identifying health-disease conditions and providing individuals, families and communities with effective healthcare interventions(2-3). The application of such methodology as a nursing practice guideline provides nurses with autonomy in their work space and brings both higher professional recognition and higher care quality(4). Bearing in mind the relevance of the implementation of the NP as a nursing care guideline in all areas, as well as the current lack of its application, the Brazilian Federal Nursing Council (COFEN) released back in 2002 the Resolution 272/2002, which enforced the compulsoriness of the NP implementation in all public and private healthcare services. The resolution was later revoked and gave way to Resolution 358/2009. The 2nd article of another recent Resolution issued by the COFEN – 429/2012 – reinforces that the NP should be fully stored in the patient’s medical record. The stored information should record the phases of the patient’s nursing history, the nursing diagnosis, nursing actions or interventions carried out as a result of the identified nursing diagnosis, as well as the results achieved following the executed actions and interventions. Nevertheless, despite the importance of employing such care methodology, in addition to its legal compulsoriness, its implementation in the Brazilian context is still underrated, including the primary healthcare area. A spoonful of experiences has been occurring in quite a shy way and are often bound to more general hospital-related areas(6). Some authors point out that the major obstacles toward the implementation of the NP in primary health care are related to the health service management processes; moreover, they affirm that the identified difficulties are not only associated with the resistance of nurses, but also with political-administrative issues that oppose the professional practice(7). There still are plenty of remaining impediments toward the full implementation of this care methodology, among them the administrative conceptions of healthcare institutions, the autonomy of the professional nurse, power centralization within these institutions, and the consequences of these behaviors in the execution of the NP as a care methodology(4). The present study considers as “managers” the professional nurses who hold administrative positions at primary health care areas, as the issue raised and assessed here is related to this professional class. In this sense, this study understands that the role of such professionals is to provide a nursing care practice grounded on scientific tenets, resulting from the organization of the service framework, as well as to make use the NP to insert nursing care into the institution’s mission and philosophy. The encouragement toward the establishment of management-based strategies aimed at altering the care framework grants nursing professionals a strong support, and tends to generate a more intense involvement of nurses in the implementation of the NP(4,8). Although some authors(7) affirm that one of the major barriers toward the implementation of the NP in the primary health care are the managers themselves, Brazilian scientific publications do not reveal such perception and conception of management nurses regarding the implementation of the NP in this area. As such, the objective of the present research was to analyze the perception and conception of primary health care management nurses on the NP as a care methodology.


INTRODUCTION
The organization of the nursing care process in Brazil has been usually named under Nursing Care Systematization (NCS) by the majority of nurses.However, it should be highlighted that the verb "to systematize" means a specific set of organizing strategies, and not necessarily the mere employment of random actions originated from any given methodology aimed at structuring the nursing practice.In this sense, the Nursing Process (NP) becomes the most adequate terminology within any proposed healthcare context.The term is defined as the methodological instrument that orients the professional nursing care and professional practice papers (1) .
The purpose of the NP is to comply with scientific methodological principles, aiming at identifying health-disease conditions and providing individuals, families and communities with effective healthcare interventions (2)(3) .The application of such methodology as a nursing practice guideline provides nurses with autonomy in their work space and brings both higher professional recognition and higher care quality (4) .
Bearing in mind the relevance of the implementation of the NP as a nursing care guideline in all areas, as well as the current lack of its application, the Brazilian Federal Nursing Council (COFEN) released back in 2002 the Resolution 272/2002, which enforced the compulsoriness of the NP implementation in all public and private healthcare services.The resolution was later revoked and gave way to Resolution 358/2009.
The 2 nd article of another recent Resolution issued by the COFEN -429/2012 -reinforces that the NP should be fully stored in the patient's medical record.The stored information should record the phases of the patient's nursing history, the nursing diagnosis, nursing actions or interventions carried out as a result of the identified nursing diagnosis, as well as the results achieved following the executed actions and interventions (5) .Nevertheless, despite the importance of employing such care methodology, in addition to its legal compulsoriness, its implementation in the Brazilian context is still underrated, including the primary healthcare area.A spoonful of experiences has been occurring in quite a shy way and are often bound to more general hospital-related areas (6) .Some authors point out that the major obstacles toward the implementation of the NP in primary health care are related to the health service management processes; moreover, they affirm that the identified difficulties are not only associated with the resistance of nurses, but also with political-administrative issues that oppose the professional practice (7) .There still are plenty of remaining impediments toward the full implementation of this care methodology, among them the administrative conceptions of healthcare institutions, the autonomy of the professional nurse, power centralization within these institutions, and the consequences of these behaviors in the execution of the NP as a care methodology (4) .
The present study considers as "managers" the professional nurses who hold administrative positions at primary health care areas, as the issue raised and assessed here is related to this professional class.In this sense, this study understands that the role of such professionals is to provide a nursing care practice grounded on scientific tenets, resulting from the organization of the service framework, as well as to make use the NP to insert nursing care into the institution's mission and philosophy.The encouragement toward the establishment of management-based strategies aimed at altering the care framework grants nursing professionals a strong support, and tends to generate a more intense involvement of nurses in the implementation of the NP (4,8) .
Although some authors (7) affirm that one of the major barriers toward the implementation of the NP in the primary health care are the managers themselves, Brazilian scientific publications do not reveal such perception and conception of management nurses regarding the implementation of the NP in this area.As such, the objective of the present research was to analyze the perception and conception of primary health care management nurses on the NP as a care methodology.

METHOD
The background for this qualitative study was the primary health care area of the Local Department of Public Health (SEMUSA) of a mid-sized city located in the Center-West region of Minas Gerais, counting on a population of 213,016 inhabitants (9) .This city is considered as a healthcare cluster in the State's Western Macro-Region, and is also the headquarters for the Regional Healthcare Superintendence of the State of Minas Gerais.It is also a healthcare reference for 55 other municipalities in its surrounding areas.The city's mixed primary health care owns 15 Healthcare Centers, 17 Family Health Strategies (FHS), and three Community Health Agent Strategies (CHAS) distributed into 12 sanitary sectors (10) .The study's population comprised professional nurses occupying management positions at the SEMUSA, and who also worked in primary care.The involvement of the researchers with the main issue of this study results from the fact that the research team belongs to the Federal University of São João Del Rei located in the assessed municipality.The university shares healthcare partnerships with SEMUSA and such connection of the researchers with the Local Healthcare Department has provided new pathways toward the implementation of studies related to the current research.
In this sense, following the identification and mapping of managers, 11 nurses were selected to participate in the study, being one healthcare secretary, one primary health care director, five nursing technicians, and four area coordinators.Codenames were employed to the participants by associating the letter N -standing for Nurse -and numbers related to the sequence of interviews, aiming at preserving the identity of the interviewed nurses.
The data collection process was carried out by means of a semistructured interview comprised of a previously prepared script counting on four questions.The questions referred to the following issues: the Nursing Care Systematization (NCS) concept; the nurses' perception on the reality of the nursing care in the city; the hindrances toward the implementation of the NCS; and last, inquiries regarding the existence or lack of existence of the strategy or proposal to the implementation of the methodology.The interviews were individually carried out at the city's SEMUSA between July and October 2012 and lasted for an average period of 20 minutes each.
Although the literature points out the NP terminology as the most adequate term (1) , the interviews employed the expression NCS as the most disseminated terminology among Brazilian nurses.This study understands the difficulties the participants would have to comprehend the meaning of the term NP.Hence, we were also able to optimize the discussions regarding the NCS and NP conceptions.
The audios of the interviews were recorded and later transcribed, in order to keep the originality of the gathered information.Our choice for the interview as the applied instrument results from the fact that it stands out as a method that more broadly allows for a deeper understanding of viewpoints.Additionally, the rich and multidimensional interpersonal meetings generate plenty of verbal and non-verbal information, which may enable researchers to capture the distinct dimensions emerging from the proposed questions, as well as the defined objectives and presuppositions (11) .
Data were organized and analyzed by means of Bardin's content analysis (12) .In the qualitative research, the content analysis owns quite singular characteristics as an organizing and analytical method.One of its major aspects is the focus on qualifying the experiences of the subjects, as well as their perceptions on a given object and its surrounding phenomena (12) .Based on the method proposed by Bardin (12) , data analysis was performed at three distinct times: pre-analysis, analytical description, and reference interpretation.
The pre-analysis process, composed of the organization and general reading of the material, occurred at the same time of the data collection process.In the analytical description phase, the empirical material was submitted to a deepened reading.The next step was to gather excerpts from the statements and use them to build sense units.Such systematic process allowed for the recognition of empirical categories (12) .
The reference interpretation phase generated an articulation between the theory and the empirical result.This process was comprised of systematic procedures that generated a series of indicators, which allowed for a knowledge inference process (12) .
The study was approved by the Research Ethics Committee under protocol number 82113/ 2012.
The analysis of the interviews produced three analytical categories, as follows: NP/NCS: meanings, recognitions and responsibilities; NP/NCS: conceptual knots; and difficulties toward the implementation of the NP/NCS.This last category generated the following subcategories regarding: the Labor Process; the perception of the local management on the NP/NCS; and the professional, the institution, and the diversity of models.

RESULTS
Nursing Care Systematization/Nursing Process: Meanings, Recognitions, and Responsibilities Subjects recognize the relevance of the NCS/NP toward the organization of care and managerial processes related to the nursing teams working at primary care areas, as well as realize it enables the nurse's decision-making processes.

The systematization of any type of care stands out as an organization of the work process that may lead you to effective intended results [...] to systematize means to organize the nursing work flow in such a way that you can achieve intended efficacy or effectiveness in the nursing service. So, it presupposes the organization of both nursing administrative processes and care processes. (N1)
In my opinion, the most important thing in the systematization process is that it stands out as an exclusive activity to the nurse.This is the time when he/she carries out one of his/her rights, which helps a lot in decision-making and problem-solving processes within a healthcare center toward the patients and their families.So, I think it is extremely relevant.(N3) Nonetheless, interviewees also recognized that the NCS/ NP is not carried out in the city's primary healthcare area, despite being a legal demand from the COFEN.They deem the NP to be an action yet to be implemented in the long run.

(The NCS) is not operative yet (discreet chuckles). I think that this is the way, and it is a matter of time. It will eventually be incorporated in the routine of every professional. (N2) Concerning the central level here, we're trying to start implementing the systematization both in our work and in the work of different healthcare teams. But, I can't see yet an effective systematization process in the short term. It'll be implemented in the mid-term or long-term (chuckles). Unfortunately, I do not have a positive idea yet. (N5)
Managers do not understand the implementation of the NCS/NP as a managerial commitment and as such they delegate such responsibility either to the nurse or to other managerial levels within the managerial hierarchy presented by the Department of Public Health and the Healthcare Board of Directors.On the other hand, they point out a great concern with the nursing care and recognize the relevance of the nurse in the healthcare team.

Nurses have to be aware that they are the link that connects a work team [...]. When they are aware of that, they understand that it is all dependent on them [...]. I think that this is one of the major problems we face today, not only the lack of resources we speak about all the time, but the involvement of nurses, this level of perception of nurses. (N8)
[...] it's something to be developed at the correct department, the Healthcare Board of Directors, so that we are able to acknowledge how to proceed [...].This is quite an important work and, yes, it can be carried out by the managerial body.Consequently, this work, in one way or another, will be more intensely sought than it has been so far.
Look, the Healthcare Director is a nurse; as the Healthcare Secretary, I am a nurse myself.So, we have to have a clear understanding of the relevance of this process.(N2) Management nurses believe that the NCS/NP is important in the care process; however, at the same time, they report that its implementation is not a priority in the city's primary health care.They even regard the NP to be an extra task for care nurses, thus increasing their workloads.

.]. (N3)
Other care systematization processes perceived by the managers Managers comprehend that there are other ways of systematizing the nursing care.They affirm that the nurse does carry out, for instance, consultation processes, in a systematic way; however, their statements highlight that the care processes do not comply with the five stages of the NP, and are not grounded on a nursing theory.Therefore, it is not performed as proposed by the COFEN.
[it is not systematized], not in the general sense of the systematization process.If you look at the core of what the Nursing Council proposes for the care systematization process, we are definitely not replicating the system.And why not?Because of the diagnosis and treatment proceedings.Yet, throughout all procedures nurses usually carry out in the healthcare network, they perform nursing consultations, apply their assessment, and come up with diagnoses.(N1) [...] I can't tell that we are at ground zero of the nursing systematization process.We perform a considerable portion of it.Take the childcare as an instance.We carry out several procedures at the childcare area in quite an organized process of embracing, listening to, anamnesis, physical exam, diagnosis, prescription, referral to exams, and follow-up.This is a good example.(N1) I would say that this issue of incorporating the NCS in primary care [...] is quite rooted in already existing programs [...] such as, for instance, the hypertension and diabetes programs.All that methodology, the protocol per se, is aimed at assisting the hypertense or the diabetic patient, or even the pregnant woman.In a certain way, this already stands out as a care systematization mechanism.As soon as you adopt protocols, you are systematizing in a certain degree.[

...]. (N2)
As for the implementation of the NCS/NP in primary health care, interviewees point out that the creation of care protocols is one of the goals of the Department of Public Health toward addressing this proposal.Managers also say that in addition to the systematization of the nursing care, the use of protocols also organize the nurse's work process.
[...] The Health Department is on the move.We can't say (the NCS has not yet been implemented).Like I said, we do have a series of protocols.What we need is to put these protocols into action so that the systematization can work and start flowing in a better way.In my opinion, this is one of the major goals of the Health Department now.We are dedicated to make these protocols function in order to systematize the nursing process.(N8) Difficulties toward the implementation of the Nursing Care Systematization/Nursing Process Interviewees described some difficulties toward the implementation of the NCS/NP in primary care.These obstacles were divided into three subcategories, regarding the work process; the perception of the local management on the NCS/ NP; and the professional, the institution and the diversity of models existing in the primary care area of the city.

• Work Process
Managers point out that the nursing work developed in primary care was not focused on the care practice, but on bureaucratic activities.Such status was generating overloads to the nurses working in the city's primary care area.

The Nursing practice is quite aimed at responding to bureaucratic demands. It's all about organizing shifts, taking notes, and that's (phrase not completed) the bureaucratic service. It's not about that practical nursing anymore. [...]. (N8) I think that part of those difficulties is due to the nurse's work overload. The nurse has to solve all kinds of problems at all times in the healthcare center. Then, functions pile up and I think that the big problem related to our lack of capacity to implement the systematization process is a direct result of this primary issue. It is not an excuse, it is a real problem. [...]. The nurse has to act like a firefighter, a plumber, he/she does everything, and keeps putting fires out all the time. [...]. (N3)
Interviewees realize that the care quality is quite compromised as a result of the work overload piled up on the nurse's shoulders.They understand that the bureaucratization of the services related to the nurse's practices occurs due to the need for meeting previously defined goals.
We face a lot of problems.We know that the nursing practice is one of the most overloaded occupations, with all its programs, all its goals to be achieved, everybody looks at the nurse as the one that will sort every problem out.So

, I think that the quality of the services is quite compromised as a result of this do-it-all status. [...]. (N10)
From my perspective, we were reduced to mere accountrendering professionals.What is taken into account right now is only the level of production, and not the quality of the work.(N7) • The perception of the local management on the Nursing Care Systematization/Nursing Process Interviewees address the NCS/NP as quite a complex process.They point out that this complexity hinders the care practice and cause them to reduce the number of patients cared for.Management nurses still hold on to the belief that the applicability of the systematization process depends upon the profile of each department.

[...] We would have to reduce a great deal of patients due to the complexity of the systematization process. If you look around today and observe how the medical consultation and the medical diagnosis processes are performed, they are faster. On the other hand, if you take the NANDA, for instance, a process to which several steps have to be defined before you reach an effective approach, it takes much longer. (N1) [...] In my opinion, there are stages to be completed before we can reach the systematization process. I think it will succeed in a closed, smaller environment, with known patients [...]. (N6)
• The professional Managers report that primary care nurses show quite diverse profiles.Some are unprepared and others do not show any concern with the NCS/NP.Such aspects would restrict the implementation of the systematization process in the municipality.

One of the difficulties I see in the implementation (of the NCS) is the broad heterogeneity of the professional profiles of nurses acting in the field, and also their distinct professional backgrounds. They are very heterogeneous. (N2) [...] Another important issue is the knowledge status. I've been working here as a nurse for ages. I graduated 28 years ago, and I can feel the difficulty of the nurses who are just leaving college and coming to work in the network without (phrase not completed). They are just not prepared. (N8)
[...] I think that a huge portion of this issue lies in the will of the professional.It's much more up to him/her.Perhaps it's a lack of interest, or a lack of knowledge, I don't know.[...].We can do it, but there is a lot of resistance everywhere, especially from professionals working in the field.(N5) • The institution Political will, inadequate work conditions, lack of human resources, and absence of qualification processes were the most problematic factors pointed out by the interviewees regarding the institution.
[...] there is a series of them, starting in the political will, because there are issues that, yes, can be systematized, but we just can't implement them [...].We frequently do not have an adequate work environment.Sometimes the professional really wants to develop a good work, but there are no conditions for that to be done.(N5)

[...] I see a precarious environment. The number of workers in the network is insufficient today. We just can't cope with the care demands [...]. (N9) [...] In the present four-year administration no training process on the Nursing Care Systematization was carried out. So, those who started working in this administration do not have a clue of how to do it. (N1)
• The diversity of models Another difficulty toward the introduction of the NCS/NP management nurses highlight in their statements is the existence of other healthcare models in the city's primary care area, a fact that hinders the implementation of the NP, as it needs to be adapted to distinct profiles.

DISCUSSION
The construction of the first category highlights the management nurses' reports concerning their perception and recognition of the importance of the NP in the organization of a nursing-related work process in primary care, as well as their comprehension that such process is able to promote autonomy and professional recognition.On the other hand, it was also clear that they do not see the implementation of the NP as a priority right now.Such paradoxical findings raise the issue on the acknowledgement of the NP by the managers as a care methodology legalized by the COFEN.The COFEN Resolution 358/09 (13) is explicit about the necessary application of the NP in any public or private healthcare institution that renders nursing services.Therefore, it is not up to the institutions to determine priority levels for compulsory procedures.Some studies (14,16) have pointed out the knowledge of nurses regarding the NP as quite incipient.These authors (14,16) observe that the lack of knowledge on what the NP really is, allied to the lack of belief toward carrying out patient care processes under such methodology, hinder its implementation at the services.As such, it is essential that managers broaden their knowledge and recognize the meaning of the NP, as well as the existence of the legislation that grounds it.In addition to such recognition, managers need to fully grasp the proposal, so that they become potential collaborators toward a more comprehensive qualification of the nursing care.
Within such context, management nurses realize that the NP turns the care practice into a difficult process due to its complexity and specificity.Such reality may be identified in their concern with the time they spend to provide an NPbased care and also by the belief that such methodology is more effectively adapted to areas other than the primary care.
These findings point to the concern of managers at assisting a limited number of patients, even though such decision may disrupt the prioritization of the nursing care quality every now and then.A similar situation, yet related to care nurses, was described in a study carried out in two family health teams located in a city of Minas Gerais, where the implementation of the NP was triggered (17) .The time spent in the execution of the NP stands out as a real concern among professionals, as they need to fulfil several activities.This difficulty is commonly experienced by nurses in national and international healthcare institutions (14,17) .
Based on this initial perception, other potential hindrances may become only consequences, such as the lack of responsibility toward the implementation of the NP, which turns it into a mere inherent managerial obligation.
Nonetheless, it is up to the managers to enable the process by organizing the framework, enforcing the goals of the service, as well as the mission and the philosophy of the institution.The involvement of these professionals in the implementation of a nursing care methodology based on scientific guidelines is critical, as the accountability of the managers is directly translated into support to the nurses, facilitating their work and allowing for adherence to a new care model (4) .
It is widely known that if the nursing management does not work conjointly with all other areas, the creation of a healthcare project that encompasses the improvements in the care practice will not be possible, and consequently the insertion of a care methodology grounded on scientific tenets in healthcare centers will definitely not take place.This study shows that nurses do not carry out the NP especially due to the lack of institutionalization of this practice, associated with a lack of knowledge about it, which consequently characterizes the lack of preparation not only of professional nurses, but also the healthcare institution they are inserted into (16,18) .
A study (19) performed in Bolivia points out that the change into an NP-based nursing practice is not only dependent upon the nurse, but demands an active participation of managers.One of the reasons for the resistance toward the institutionalization of the NP in primary care in the municipality addressed by this study may be related to the lack of knowledge of managers regarding the power of this methodological tool toward the organization and qualification of the care practice.This fact points to the existing belief that the NP stands out as a proposal that would not bring about any degree of optimization to the work routine.
In face of such inference, it is important to reinforce the idea that a care practice based on a scientific methodology, such as the NP, enables the organization of the team's daily schedule, as it facilitates the medical records and the assessment of the rendered care.Additionally, it directs and quantifies care, controls costs, facilitates auditing processes, and allows for the achievement of goals related to care quality (4) .Therefore, the implementation of the NP stands out as a potential strategy toward nursing care systematization.
Another report that deserves attention is related to management nurses who deem the NP to be partially implemented in some types of care rendered in the primary care, based on a set of conducts defined by programs and manuals of the Health Ministry, besides those recommended by the municipal guidelines and protocols.The mere use of manuals and protocols does not necessarily imply the application of the NP.Such practice simply organizes the professional activity aimed at the clientele specified in those manuals.These programs and tools neither show the scientific foundations proposed by the nursing theories, rationale and diagnostic inferences, nor the establishment of goals and interventions aiming at a future assessment of the rendered nursing care, a status that would effectively point to an NP-based care methodology.
The lack of understanding that the implementation of the NP demands a clinical rationale based on a nursing theory reinforces the idea of either the lack of knowledge or the difficulty of understanding concerning the content described in the Resolution 358/2009.Its 3 rd Article clearly points out that the NP has to be grounded on a theoretical foundation that orients and subsidizes all necessary phases toward its implementation (13) .It should be highlighted that the lack of a unifying theory or an integrated conceptual framework has strongly contributed to a fragmented comprehension of the nursing practice and its care organization process.The theory, in essence, should ground the diverse facets of the care organization process (20) .
Several nuances were perceived as hindrances toward the implementation of the NP in the primary care area, according to the management nurses.The obstacles start in the nurse's work process and reach the personal limits of the professionals and the lack of knowledge on the practical application of the NP by those who manage the institution.Finally, adding to the already presented difficulties, another referred hindrance was the diversity of healthcare models observed and employed in primary care in the municipality, with its FHS, CHAS and traditional healthcare centers, each offering distinct care profiles.
More and more discussions regarding the meaning of care quality are constantly necessary.The mere fulfilment of governmental objectives does not leave ground for the planning of a nursing care based on scientific tenets and operationalized by means of the NP.Such care model demands a proposal that goes beyond quantitative care models and promotes opportunities for advancements in the quality of the nursing service, thus benefiting both the patient and the health team.
According to some authors (21) , the lack of interest of nurses in getting effectively involved in the change of care model is a hindrance toward the implementation of the NP, especially when such status is allied to the lack of qualification, as reported by several interviewees.It is important to take into account that the change in the care profile needs to be associated with the insertion of a permanent health education process and training programs that are able to qualify these professionals (22) .
The hindrances identified by the present study do not differ from those pointed out by other nursing services (14,23) .We need to take into account that the first step toward the redesign of the work process is composed of all the aforementioned factors, as the combination of all of them contribute to critical points and failures.Consequently, it is an essential step to employ continuing efforts toward eliminating or at least minimizing such conditions, so that the rendered care may generate quality and positive impacts both for the patient and for the nurse (23) .

FINAL CONSIDERATIONS
Management nurses responsible for primary care areas in the assessed city affirm to understand the need for the implementation of the NP; however, up to the present day, they deem such implementation to be irrelevant.The interviews also showed the difficulty nurses have to conceptually comprehend the scientifically-based methodological instrument.Additionally, they do not display the understanding that such methodology should be a cross-departmental practice in the municipal management.
Hence, first of all, the perspective of local nurses regarding the concept and the relevance of the NP as a care methodology must be broadened.Second, professionals in the healthcare network must be better qualified in order to be able to cope with each phase of the implementation of the NP, so that they can offer an excellence-based nursing care, as well as more clearly envision the care function of the nurse.
The decision for combined efforts toward the local implementation of the NP and for a broader approach of its perspectives in the national level, allied to the responsibility managers have to execute the model, as well as the conjoint actions between the Health Ministry and nursing legislative bodies, are able to optimize compliance with Resolution 358/09 and prompt the change of the nursing care profile in each and every healthcare service.Therefore, the active participation of three pillars -nursing legislative bodies, local health management and federal government -may generate the implementation of the NP.The involvement of this triad is crucial to lever the nursing practice from a mere legal resolution to an active process in the work of the nurse, thus providing the nursing practice with a scientific aspect and offering population a more qualified care.
the present, there is not an open discussion on the issue of the nursing systematization because there are other priorities that come first [...].You can't speak of organizing processes without organizing the whole framework first [...].In this construction time we should avoid speaking of the systematization process, or we'll generate confusion and even hinder the whole process, as we are, in fact, beginning this whole issue of organizing the work from the ground zero.(N6) It (the NCS) would not come as a support, but as an extra work the nurses will have to perform.So, they would not be able to turn the systematization process into a reality.This is what I think at this moment.[..