Las prácticas de enfermería en un ambulatorio en la perspectiva de la integralidad1

AIM
to analyze nursing care practices at a Specialized Outpatient Care Center from the perspective of an integrative health care activity.


METHOD
Interviews with 24 nursing professionals were undertaken. For data analysis, Thematic Content Analysis as proposed by Bardin was applied, resulting in the following themes: the team size and its commitment to health care; professional practices and activity of the nursing team.


RESULTS
The size of the nursing team was considered insufficient, which compromises the quality of care and results in work overload and dissatisfaction of the nursing professionals. On the other hand, they were satisfied with the tasks performed day-to-day and related integrality to individual care, considered it essential and usually practiced it daily.


CONCLUSION
It is considered that the nursing team has the potential and commitment to develop their care practice combined with the integrative perspective, and therefore providing quality health care to the population.


Introduction
The Brazilian Constitution, introduced in 1988, can be identified as a turning point in health care in Brazil, since it permitted the establishment of the Unified Health System (SUS) and resulted in the consolidation of ethical-doctrinal and organizational-operative principles, such as universality, equity, integrality, decentralization, regionalization, hierarchy and social participation.
Semantics show integrality as a multi-semantic term, with different meanings and applications.The legal definition states "integrality is the integration of preventive, corrective, individual and collective measures pertaining to each case and degrees of complexity".From the patients' point of view, integrative action has been often associated with a quality treatment that is decent, www.eerp.usp.br/rlaePinto IC, Marciliano CSM, Zacharias FCM, Stina APN, Passeri IAG, Bulgarelli AF. respectable, receptive and bonding.These meanings are similar to the idea of integrality used herewith: a plural term, ethical and democratic (1) .
Integrality is the second essential guideline of the SUS (2) .The development and implementation of this guideline, as an attribute, will result in a change in the care model and may be the biggest challenge for the health sector in Brazil in present times (3) .
It is known that a work team whose care is based on an integrative perspective must be capable of identifying the disease causing the pain, providing immediate response to the pain and recognizing the need for other interventions related to the promotion of good health and the prevention of diseases, that is, integrality is obviously distinguished by the care applied to the patients' needs (4) .Health care, when directed and organized by integrality, tends to be more effective in response to the patients' needs, their families and communities.
Integrality has at least three sets of meanings: 1) the feature of health policies or government responses to certain health issues; 2) the set of meanings relating to the aspects of health care organization and 3) the attributes of health care practice (4) .
Nursing, in the interdisciplinary construction of health care, must take on the core of its duty and responsibility: the care.This care necessarily has a target that goes beyond individual and collective subjectivities.
With this in mind, Nursing has the potential to shift into various areas of knowledge or, in other words, the nursing professional focuses on the person to be cared for and can thus establish interaction channels with other parties more intensively, with the intention to seek out technologies needed for care, keeping relationships with the work team and also with the family, and this includes acting in the reality transformation process (5) .
The purpose of this study is mainly the orientation based on the third meaning of integrality and directed towards Nursing practices, which is based on the population needs and has an integrative perspective of health care activities.

Objectives
To analyze nursing care practices at a Specialized Outpatient Care Center from an integrative perspective of the health care activity.

Method
This is a descriptive study with qualitative analysis of the data, collected through semi-structured interviews, which were taped and transcribed, carried out with the team of the Specialized Outpatient Care Center in 2011.The interviews involved the participation of twenty-four (24) nursing professionals working in that center and who promptly agreed to answer the questions.Concerning the data analysis, thematic Content Analysis (6) was applied and involved three

Results and discussion
In relation to the sex of the participants, 91.6% were female.The average age was 35 and it varied from 28 to 56 years of age.Concerning educational background, 15 (62.5%) completed secondary school, 3 (12.5%)were undertaking tertiary studies and 6 (25%) completed tertiary education, amongst these 3 (12.5%)specialized in Nursing.From the 24 nursing professionals participating in this study, 5 (20,83%)   worked as Baccalaureate Nurses, 9 (37,5%) as Nursing Assistants, 3 having the function of Nursing Technicians, and 10 (41,66%) worked as Nursing Technicians, 2 of whom were undertaking a Nursing degree and 1 completed the degree but was working as a technician.
In relation to the period of time working at the Specialized Outpatient Care Centre, 5 (20.83%) had worked from 1 to 3 years in their jobs, 3 (12.The participants interviewed were asked about the areas they worked in, and 17 (70.83%)stated that they worked in a permanent area, that is, they worked in only one area of the Specialized Outpatient Care Centre and 7 (29.16%) in more than one area according to work needs.Concerning remuneration, all of the participants stated their last month's salary (excluding the thirteenth salary) which was, for Baccalaureate Nurses, on average 5.8 times the minimum wage, varying from 3.3 to 7.8; for Nursing Technicians, the average remuneration was 4.2 times the minimum wage, varying from 2.3 to 5.1; and for Nursing Assistants, the average was 3.1 times the minimum wage, varying from 3.1 to 5.5 in the month the study was undertaken.
After the data analysis, three themes characterizing the actual results emerged and are as follows: 1) Dimensioning from the nursing professionals' point of view and their commitment to heath care; 2) nursing team activities at the Specialized Outpatient Care Centre and 3) nursing practices: potentialities and difficulties to achieve integrality.
Based on these thematic contexts, it can be concluded that Nursing, as a subject that is part of health care work, is also a subject that creates collective health.
The Nursing intervention project is moving towards the creation of a social action, which can be one of reality conservation or transformation.In relation to the nursing care process, and particularly Collective Health Nursing, the employee applies a series of technologies, including equipment and the necessary instruments for work to be performed, as well as technologies involving the relationship between the parties, which is related to supporting people by listening to them, to providing humanized care and to bonding (5) .Amongst other factors, humanized care possibly depends on listening, on bonding between professional and patient and on integral care, from which the essence of the patients' needs can be noted, who seek quality care from the professionals involved.
The process of practice humanization assumes that professionals develop an ethical care position that unifies with the health needs of the human being and that this factor is present in the professionals' work process.For this to happen, it is important that health institutions and policies also motivate these professionals.SUS has been presenting policies that emphasize and contextualize the actions for the humanization of health care practices, which are clearly observed in the National Humanization Policy (7) .
It is important and urgent that practices are introduced and encourage nursing professionals not only to be involved with the humanization policy and with the integrality of practices but also with the permanent education at work, which can be allied to the creation of integral care.First of all, appropriate staff dimensioning is perceived as essential.
Institutions, which are always mindful of the improvement of the service provided and the innovation of care methods, have addressed this theme to adjust their costs to a new reality, under more insufficient resources (8) .
Another aspect that is considered of utmost importance in staff dimensioning, in the scope of the nursing team, is the rate to cover for staff absence at work, also known as absenteeism and absence, which indicates staff absence at work and the percentage to cover for these absences (9) .

Dimensioning from the nursing professionals' point of view and their commitment to heath care
According to the professionals' statements in this study, the human resource structure of the health care service is insufficient for the health care team to provide quality care.The following excerpt confirms this conclusion: In reality, it is not that we have few days, but that there are few people for too many patients (A5).
In a study undertaken by the Health Department's Human Resources Observatory in 2002, with the participation of management, the Local Authority Health Secretary and the staff, the need to work with management in the creation of quality service and to achieve patients' satisfaction was analyzed, taking into consideration that human resources are an essential element to achieve good management in health care and, also, that staff performance management is a tool to increase productivity and a quality service (10)(11) .
Regarding the organization of the nursing activity, therefore, besides considering the organizational human resource policies, there is also a need to consider these professionals' perceptions, since it will permit their participation with a view to identifying the problems relating to staff dimensioning and the structure of the nursing service.
As for humanized care, the participants' statements In a study undertaken at 11 Family Health Care Units, in the town of São Carlos, SP, Nursing Assistants participated in semi-structured interviews and the same result was found.An overload of daily tasks was noticed at the Family Health Care Units, resulting from the large demand (12) .
In another study undertaken with Nursing students, soon to be nursing professionals, it was found that, when students face the suffering of sick people, their fragility brings up the students' own human dimensions, which encourages them to provide care under a humanized perspective.In order to provide humanized care, however, professionals need to provide quality care, which means that there is a need for staff to assist patients´ real necessities within a human resource policy directed at Nursing, and therefore permitting compliance with SUS principles (13) .
When dealing with the analysis of the professionals' commitment, it can be noted that many of them are dissatisfied with the type of work they perform.They affirm they like what they do, but not under pressure, which is the current condition in which they always perform their work, according to the following statement: I like working here, we sometimes say that we are dissatisfied, but it is because nobody deserves to work under pressure.Sometimes, I have to collect blood from 80, 90 patients alone, and this is not human… I even find the physical structure good, there had been divisions that seemed to work in a different way according to the way they were allocated.But it needs to be increased because the workload is increasing with time and the building is the same, the team is the same (N17).
Concerning the size of the nursing team, criteria and methods must be used to allow human resources to be adjusted to actual care needs, so that patients can receive quality care, which offers them security (8) .
Team dimensioning determines and establishes parameters to quantify the nursing staff working in care units, Health Institutions and similar places.If this is done inadequately, it entails implications for the quality of care provided to patients, as the quantitative and qualitative aspects of staff are directly related to the final product of their work, which is the quality of the care provided to patients (14) .

Care Center
The above-mentioned theme results from an analysis of the statements' contents which, within the care scope, reflect strenuous activity, involving multiple work functions.One study identified that baccalaureate nurses perform various daily tasks such as shift change, nursing notes and progress, patient file reading and nursing report, in addition to information exchange with the health team (15) .
The work conditions of the nursing team involve long working hours with strenuous shifts (afternoons and nights, Sundays and public holidays).During the shifts, there is a multiplicity of tasks, causing anxiety in the nursing professionals due to excessive repetitions and rhythm of the work, supervisory control, physical efforts, uncomfortable positions caused by the separation of manual and intellectual work, resulting in accidents and sickness (16) .
According to the professionals, the activities performed in outpatient care are, in general, related to the admission: reception, selection, checking of vital signs and anthropometric measures, orientations, immunization, exam collection and data registration.

While presenting the activities performed, they include integrality aspects into the individual care scope. (…)
Providing welcoming care takes time and I think that we have to see the patient as a whole, not only to arrive and say hi… I think that providing this type of care is insufficient… they want to be seen as human beings, that is what I think (A2).Some of the team members believe that the person should be seen as a whole.The participants suggested that integrality must be a priority in health care to patients, and this relates to what has been reported: "people recognize the bio psycho social and spiritual human being as the subject of care" (17) .
This supports the research findings in which the nursing professionals working at the Specialized Outpatient Care Center reinforce integral care in its individual scope.It is important to mention that, in nursing, the health needs are directed not only towards the patients' individual aspects, but also to the collective, taking into consideration that the nursing has the duty and responsibility to seek technologies, in order to act together with the heath team, the family and the population.When relating the integrality scope to the health care levels, the nursing team needs to understand the complexity and technological density of each person, aiming to assist the patients' demands.
Therefore, in this survey, these professionals understand the power of integration in the development of nursing practices concerning health care services, in order to attend to the needs the patients present, since they mention the Unit's internal and external services in their statements.
When services are provided as a network, it is essential to consider the organizational structure directed towards the production of services, as well as towards the dynamics of actors in permanent renegotiation of their roles, thus providing new solutions for old problems in the context of changes and mutual commitment (18) .

Nursing practices: potentialities and difficulties to achieve integrality
It is imperative to recognize the manifestations of Nursing practices (4) in the scope of health care attributes, considering the potential difficulties in their experiences at the Specialized Outpatient Care Centre with a view to changing the practices towards integrality.
In the statements shown below, integrality is seen as something crucial to the nursing team's actions and they recognize that this principle strongly influences their work.(…) integrality is related to availability… Look, it is very broad… availability of health care actions… To see the patient as a whole, not to focus only on their complaints, I mean, not to restrict your assistance to their current complaints, to make a general evaluation of the patient, to provide assistance in an integrative way, to make a general evaluation, it is hard to explain this, we know it but we cannot explain (…) (N7).
It is noted that the participants understand the meaning of the word integrality in the sense of nonfragmentation of the patient and its relation with Nursing practice.Integrality searches for the totality of the individual, avoiding fragmentation and reduction (19) .
It means the integration of all services that assist the patients, not to divide them, and each part of their body to be seen by a different person.Integrality means that all services are connected in relation to the same patient who is being assisted It should be pointed out that one of the participants mentioned that integrality is also related to mutual respect between staff and patients but that this does not often happen, according to the statement: Integrality, integration, respect from my part and their part too; however, here at work we deal with a lot of rudeness from the patients, not all of them, but they end up generalizing the staff, they  (20) .
Despite the fact that the nursing team has countless activities and that this job is not light, the statement described below points out that it is possible to develop a plan in order to avoid physical and psychological overload.It is important to have this plan in order to provide balance to the professionals and to encourage them to assist the patients with integral care.Nursing itself, when you really involve all variable factors of this job, it is not a light one, because it involves a psychological factor, it involves a physical factor, but I think that you can become overburdened, I think if you are able to plan then you do not become so overburdened (N19).
One of the potentialities of Nursing practices the participants in this study mentioned is related to aspects of training activities and permanent education.that could change the environment.A large part of the staff, however, complains about the lack of workers, since the demand is large when compared with the number of workers.
One of the main objectives of professional qualification is recycling and improvement, due to the constant changes in the scientific and technological fields, with a view to attending to the needs the professionals present in their work processes (21) .
In a study, it was noticed that the courses are offered sporadically and the themes often do not correspond to the real needs of the professionals (14) .In the sentences below, similar statements are seen: Work satisfaction as a category of analysis compulsorily refers to two essential elements that are part of this universe: the organization and the individual, which in this study refer to the health institution and the nursing professionals (22) .Therefore, in this study, the participants also bring up matters related to the organization of the health institution and their perception of the aspects that make their work easier or harder, both in daily health care and in Nursing.

Final Considerations
The purpose of this study was to analyze Nursing practices at a Specialized Outpatient Care Centre of a District Health Unit, in the town of Ribeirão Preto, Brazil, from an integrative perspective of health care activity, with a view to contributing to the construction of new knowledge, as well as to structure new care models, thus resulting in integrated nursing practices.
In regards to the nursing team size, the human resource structure is insufficient to provide quality care, which results in work overload and dissatisfaction.It is believed that the following changes are needed to improve the conditions of the service: adjustment of the physical area, organization of the Unit as a whole, as well as closer proximity of supervisors, aiming to identify and solve care-related matters and, mainly, staff dimensioning.
In general, the nursing team in outpatient care was satisfied with the tasks performed daily, however, they proposed future adequate courses, taking into consideration that, based on their own experience, the courses often do not relate to the real needs of the practice.The professionals' proposal was the periodic listing of the themes to be addressed within their own team and the development of a schedule of educative meetings, flexible to the daily activities of the divisions, in order to increase communication and decrease the distance between team members.
It is considered that the nursing team has the potential to develop a practice combined with the principle of integrality, hence providing quality care to the health needs of the population.
stages: organization of the data, examination and classification of data, which was combined into different themes.These themes were allocated in the context of SUS, focusing on nursing activities, on the principle of health care integrality, and on the individual and collective scope.The project received approval from the Research Ethics Commission where the study was carried out, under registration number 287.To ensure the anonymity of the participants, they were identified by letters and numbers referring to the interview, being A for Nursing Assistants, T for Nursing Technicians and N for Baccalaureate Nurses.
show the difficulty resulting from the current number of staff because of the excessive demand for health care.Many of the staff members show appreciation for their work, even though they are not satisfied with the low number of staff in the workplace and the fact that Pinto IC, Marciliano CSM, Zacharias FCM, Stina APN, Passeri IAG, Bulgarelli AF. one person may have to do the work of three people, leading to decreased productivity, and this is noted in the following statement: (…) I think that a lot more staff is needed so we work like this, to quickly finish attending people because there are other people to be attended, it has even got good quality, information, courses are offered but you cannot take the time to provide the service… I am satisfied with my job but not with the shortage of staff, I am doing the work of three people, I like what I do but not under these conditions (T11).
www.eerp.usp.br/rlaeRev. Latino-Am.Enfermagem 2012 Sept.-Oct.;20(5):909-16.One of the nursing team's activities relates to the referral to internal and external services at the Specialized Outpatient Care Center.When the patients need social services, specialized clinical, psychological and other types of care, the nursing team refers them to the services related to their real needs.(…) we have a specialized outpatient care center and we have our supporting services, such as the social service, the psychological service, physiotherapy, dentistry, therefore we do have social resources which we can refer to (N19).
mix up ES (emergency service) with outpatient care service, I rarely have a problem with a patient, sometimes the patients want to vent due to other problems, I see patients as a whole, sometimes the elderly patients want to talk, you have to give a lot of attention and we often do not have time as a result of the work (T23).The nursing team often has a heavy workload and this reflects in the integral care."The nursing team´s work tends to fall into vertical organizational charts and into the work activity fragmentation.The performance of actions related to planning, organization, and care supervision is the baccalaureate nurses' responsibility.The execution of these actions is the responsibility of the nursing technicians and assistants" Therefore, in relation to the courses offered, a large part of the staff states that some courses and seminars are offered but the working hours are long and, many times, it is not possible to attend them, and other times, they are not even aware they are being held.Staff mentions recycling courses, family assistance program and permanent education.The team states that there are not enough microphones and chairs, accessories www.eerp.usp.br/rlaePinto IC, Marciliano CSM, Zacharias FCM, Stina APN, Passeri IAG, Bulgarelli AF.
(…) the courses and seminars offered by the local council have been practically absent lately, it has been years, I always try to find information and, as I work 40 hours per week, I cannot leave the unit to attend courses, but I try to find answers to my questions in secure websites, during the time I have (…) (N7).
The following are identified as activities generally performed in outpatient care: admission, reception, selection, checking of vital signs and anthropometric measures; orientations; immunization, exam collection and data registration.Integrality was related to individual care without an accurate definition, and the professionals themselves nevertheless linked both and considered them as essential and usually practiced at the Health Service.