Work and practices of nursing in Primary Health Care in the state of Paraíba – Brazil: professional profile and care practices in the care dimension

Nursing work involves care and management dimensions, reflected in the production of care actions in the care of individuals, families and communities. The objective was to analyze the Primary Health Care (PHC) nursing work process in Paraíba, considering the professional profile and individual daily practices developed by nurses in the care dimension. A quantitative approach study, carried out at the PHC services in Paraíba between November 2019 and August 2021. The analysis of quantitative data was performed using the SPSS® software (Statistical Package for the Social Sciences), version 21.0 for Windows®, using descriptive and inferential statistical analysis. The results showed, among other aspects, that 93.3% professionals are female; with regard to professional training, specialization was the most common type of degree among the professionals surveyed; among the practices analyzed, prenatal consultations were considered the most resolute, according to the perception of 388 (84%) professionals surveyed. It is concluded that, regarding the sociodemographic profile, the female sex predominates among the nurses surveyed, regarding training, there is a need for qualification at residency and stricto sensu postgraduate levels. In the care dimension, the nursing consultation in prenatal care, as a problem-solving practice of care in PHC in Paraíba.


Introduction
The conception of work shows that its process takes place from the relationship between man and nature, and man's action mediates the work process; "with the help of the means of work, the human being transforms the object of work according to a conceived purpose" 1(55-56) .
Based on Marxist theory, the work process has three components: work, an activity aimed at overcoming a need; the material or object of the work; and the instruments of work, such as the means of production.These components are stages of a whole -the work -and only in this way does the process take place 1 .
The health work process is better understood from the thinking of Mendes-Gonçalves 2, 3 .It is worth mentioning his valuable work, which addresses the theory of the work process in health; it is an essential theoretical contribution to studies on the health work process, a construction that is based on studies in Basic Health Units (UBS).
Mendes-Gonçalves analyzed the following components: the object of work, the instruments, the purpose and the agents, emphasizing that they need to be examined in an articulated way, and not separately, since only in their reciprocal relationship they configure a specific work process 2-4 .
Starting from the technosocial consubstantiality of health practices, Mendes-Gonçalves developed a conceptual framework that, based on premises of historical materialism and genetic structuralism, provided fruitful bases for a range of health studies, notably for the construction of the field of collective health in Brazil.On the one hand, there are efforts to bring history, in its radical materiality, into social thinking in health; on the other hand is the determination to do so without ever losing sight of the ethical meaning of this historical rescue and of scientific praxis in general 5 .
The debate on the work process has been important for understanding the organization of health care and its transforming power, particularly when we focus on the micropolitics of work organization.There is a work potential of all professionals that can be used for direct care with the user, thus increasing the resolution capacity of the services.This is done, above all, with the restructuring of work processes, the potentialization of 'live work in action' and the valise of relationships as sources of imaginative and creative energy in the configuration of the health care model 6 .
In nursing, the work process has its pioneering spirit in the studies of Cecília Puntel de Almeida; Her work 'Nursing knowledge and its practical dimension' constitutes a milestone for Brazilian nursing.Adopting the Marxist framework of work, the author analyzed nursing as a social practice and part of the process of division of labor in health, articulated with other practices in the way of organization of the capitalist society 4, 7 .
Nursing is part of a collective work process with the purpose of producing health actions through specific knowledge, articulated with that of other team members in the politicalsocial context of the health sector 8 .
The characteristics of the nurse's work process in Primary Health Care (PHC) and in the Family Health Strategy (ESF) involve five dimensions -care, management, teaching, research and political participation -, which are complementary and interdependent 9 In Brazil, there are several ways in which nurses work in PHC, configuring 'various scopes of nursing work', various practices and a division of classes articulated to the work process.This means that we can have different practices and work processes, according to the way we perceive the field; the multi and interprofessional relationship; the design of PHC; technical and political skills; management models; and the processes of training and Permanent Education in Health (EPS) 10.
Nursing work in PHC has its practices established by Law No 7,498/86 and by regulatory ordinances of the Federal Nursing Council (Cofen)/Regional Nursing Councils (Coren), as well as by the National Primary Care Policy (PNAB), legal framework, normative and institutional policy that defines the managerial and care competencies of nurses' work.In clinical-assistance practice, this includes, among other actions, nursing consultation, request for complementary exams and prescription of medicines, according to protocols, clinical and therapeutic guidelines or other technical regulations established by managers in the federal, state, municipal or the Federal District manager, observing the legal provisions of the profession 11, 12 .
In PHC, nursing practice has care and management dimensions focused on the individual, reflected in the production of nursing care and in the management of therapeutic projects and, for the collective, through monitoring the health situation of the population and management of the nursing team and health services.Its essential function is to assist people, families and communities, developing activities for the promotion, maintenance and recovery of health 8, 13 . .

Material and methods
Study with a quantitative approach, characterized as a sample of voluntary response, and data collection was done through a standardized and structured electronic questionnaire, with variables distributed in different dimensions of the nursing work process in PHC.The questionnaire was disseminated on social networks and on the websites of Nesp/Ceam/ UnB, Cofen and other partner institutions through the survey link (https://ecos.unb.br/pesquisapraticasdeenfermagem) 14 .
In the state of Paraíba, 1,635 nurses are registered in the PHC/ESF 19 ; among these, 462 responded to the data collection instrument in the quantitative study stage.
.Research participants signed the Free and Informed Consent Term (FICT).Thus, the ethical and legal precepts required for research with human beings were fulfilled.As there was no intervention or intentional modification in the physiological or psychological and social variables of the participants, there were no risks to the professionals who collaborated with the research.

Sociodemographic profile of PHC/ ESF nurses in the state of Paraíba, Northeast, Brazil
Knowledge of the profile of professionals can support programs to readjust work processes, in order to improve service to the population and ensure quality care that meets the needs of the assisted clientele and the implementation of public health policies.Identifying the professional's profile, their qualifications and their work process become important for the adaptation of the PHC model 21 .
Among a set of characteristics that outline the sociodemographic profile of the PHC/ESF nurses that participated in this research, in this article is possible to find the results related to to age and sex and those about marital status, about residing in the city where works and about years of experience in PHC in the city where currently works.The data are distributed in table 1.
It was found that, of the total of 462 (100%) professionals, 93.3% are female, corresponding to 431 nurses.As for the age group, it was evidenced that the largest number of professionals are aged between 36 and 40 years, with 109 female and 9 male.
The second and third highest frequencies are those aged between 31 and 35 years (94 professionals) and 26 and 30 years (78 professionals), adding up the amount of both genders.It is worth noting that only one nurse is in the age group of 70 years or older.
The female predominance in nursing is historically recognized; It is worth remembering that the pioneering spirit in the profession was due to women such as Florence Nightingale, in Europe, and Anna Nery, in Brazil.
The infographic presented by the Pan American Health Organization reveals the 'Situation of nursing in the Region of the Americas' 22 .The percentages related to the sex of the group of professionals -percentages extracted from the World Health Organization (WHO) report on 'The State of Nursing in the World' -show that, of the nursing professionals in the Americas region, 89% are women 23 .
Regarding the distribution by sex, of every 10 nursing professionals in the world, 9 are female.There are important regional variations: 95% of professionals in the Western Pacific region and 76% in the African region are women 24 .
The results of our study, which show a high percentage of nurses working in the PHC in Paraíba (93.3%), corroborate the findings of several other studies already carried out at the national level, which also found female hegemony in nursing.Examples of these studies are the survey with family health nurses in the five regions of Brazil, 25 the Cofen study on the 'Profile of Nursing in Brazil' 26, 27 and a more recent survey, also carried out by Cofen, on the 'Nursing Practices in the Context of Primary Health Care', which registered a percentage of 88.4% of women in this field of action throughout the national territory 14 .
It should be noted that, in the national survey on 'Nursing Practices in the Context of PHC' 14 , females predominated in all regions of the country.When observing the frequency and percentage of professionals participating in the study, analyzing the age group according to sex, the predominance occurred in the same age groups: 36-40 years (24.3%),followed by nurses aged between 31-35 years (21.7%),considering the totality of participants distributed in different age groups.
The predominance of females in these two age groups is also strong evidence in the research developed with the PHC in Paraíba.Thus, there is a considerable amount of young nurses working in that state.
The young age among nursing professionals is also confirmed by WHO data, in a report published in 2019, referring to the global distribution by age group, highlighting that the nursing workforce is relatively young: 38% of professionals are aged less than 35 years old -considered those who are at the beginning of the profession -, compared to 17% aged 55 and over, who have already been working for a long time.There are regional disparities, with considerably older age groups in the Americas, with 24% of professionals aged 55 and over, and in Europe, with around 18% 28 .
Table 1 shows that, in terms of marital status, 218 are married, representing 47.2% of the total of 462 professionals surveyed; of this number, 301 (65.2%) reside in the municipality where they work.When asked about the length of time they worked in the PHC in the municipality where they currently work, 42.2% of the nurses reported that they had worked in the municipality for a period of 0 to 4 years.Those who work in the municipality for a longer period, that is, for more than 12 years, represent a percentage of 20.1%.
When one seeks to investigate the place of residence of PHC/ESF nurses in relation to the municipality in which they currently work, one sees the importance of inserting and linking these professionals to the municipality to broaden the view and the knowledge of the health territory in which they work, so that they can get to know, understand and experience the daily lives of the people who live there.Thus, it is possible to know the culture, habits and customs of the communities, the locoregional singularities, in order to understand the complexities of the populations residing there and their health and illness processes in the face of situations of social and sanitary vulnerability.This proximity also allows for a greater bond with users of health services, promoting a better development of care practices in health units and in the community environment.
In this sense, we agree with other researchers that the expansion of the perspective of PHC/ESF professionals about the territory contributes to overcoming the limits of the health unit and the practices of the conventional care model.It also contributes to the (re) construction of the link between professionals and the health system with the space, for the adaptation of health actions to the uniqueness of each specific socio-historical context and for the effective incorporation of the paradigm of health promotion and participation 29 .

Professional training profile of PHC/ ESF nurses in the state of Paraíba, Northeast, Brazil
Considering the nature of the institution in which they graduated in Nursing, of the 462 (100%) participants in the research, 282 (61%) studied in a private institution; 171 (37.0%) in a public institution; and 9 (1.9%) did not respond.It was found that 453 professionals (98.1%) are graduates of Brazilian Higher Education Institutions (HEIs).And, taking into account those who did not answer the question about the nature of the institution from which they graduated, the same frequency (9) and percentage (1.9%) of professionals did not inform the country of the institution from which they graduated in Nursing.Based on these results, it is clear that most nurses working in the PHC/ESF are graduates from private institutions and trained in Brazil.
The predominance of private institutions in the training of nurses was also an evident finding in the study carried out on the 'Profile of Nursing in Brazil', which recorded a percentage of 57.4% of nurses graduated from these institutions 27 .
The survey results showed that, for the most part, the nurses working in the PHC/ESF in the state of Paraíba completed their training from 2001 and on, with 193 (41.8%) between 2001 and 2010; 100 (21.6%) between 2011 and 2015; and another 100 (21.6%) between 2016 and 2021.Among all the participants, 41 (8.9%) concluded during the 1990s, that is, between 1991 and 2000, and 9 (1.9%) did not respond.Thus, when analyzing the period in which professionals completed their courses, it appears that, for the most part, PHC/ESF nurses in Paraíba have been working for a maximum of 20 years.
The professional training profile related to the frequency of qualifications is analyzed based on the results distributed in graph 1, which presents different postgraduate levels: lato sensu (residence and specialization) and stricto sensu (master's, doctorate, postdoctoral and 'Livre Docência').Predominantly, nurses stated that they had completed specialization courses, with a total of 336 professionals (72.7%); 117 (25.3%) have no specialization.The frequency of those who do not have a residence is significant, since they total 438 (94.8%);only 15 professionals (3.2%) have this kind of training among all those surveyed.When analyzing the frequency and percentage of stricto sensu graduate courses, it is evident the high frequency of professionals who do not have any degree at this level, with numbers of 417 and percentages above 90%.It is noteworthy that only 36 (7.8%) have a master's degree; 3 (0.6%) have a doctorate; 13 (2.8%) completed their 'Livre-Docência' degree; and none have a postdoctoral degree.Taking each degree level, 9 (1.9%) nurses did not answer whether they have them or not.
Analyzing the profile of PHC nurses, particularly those working in the ESF in the five Brazilian regions, researchers found that 82.5% of the participants completed residency or specialization courses.It is considered that better training contributes to achieving the efficiency, efficacy and effectiveness desired for achieving comprehensive care 25 .
However, the rate of professionals with postgraduate degrees in the residency modality is still low, and the number of specializations is high, which are often disconnected from what the country's health system really needs.
Research carried out on the sociodemographic and professional profile of PHC nurses found that, regarding the initiative to seek professional improvement through continuity of studies, a significant portion of professionals (73.4%) reported having a graduate degree at a lato sensu level.However, no professional declared to have a postgraduate degree at the stricto sensu level (master's and/or doctorate).Based on this evidence, the authors ensure that the analyzed results have significant potential to contribute to the process of diagnosing the functional situation of nurses working in PHC, as well as the planning of actions to be implemented by municipal management. in the sense of qualifying professionals, with a view to better preparing them to work at this level of care, which requires technologies of high complexity and low density.The data collected point to the need for investments by local managers in the continuing education of nurses 31 .
Managers do not understand that, without training and continuing education projects for PHC/ESF professionals, municipalities will continue to face difficulties in having an adequate and qualified profile for sociosanitary responsibility with a view to inverting the health care model, reproducing the high turnover, precariousness and dissatisfaction of health workers 32 .
The authors emphasize that the barriers to the organization of training and permanent education projects aimed at PHC personnel continue to be an issue to be faced as a State policy capable of carrying out ongoing changes in training, especially that of nursing professionals.It is sought that these professionals are prepared and committed to practice comprehensive, family and community health 32 .
We highlight, in the results of this study -although in a small number 13 (2.8%)-the presence of nurses who reported having completed their 'Livre-Docência' degree, an important degree for those working in higher education.
Bearing in mind the development of the country, the formation of doctors for teaching is fundamental, as well as the stimulus to the continuous formation of leaders.In this context, the 'Livre-Docência' enters as a strategy for recognizing those whose trajectories are committed to teaching, research and extension.The search for the highest degree in the Brazilian academic career can constitute a moment of individual and collective advancement, contributing to the consolidation of areas of knowledge 33 .
It is believed that the presence of nurses with this degree, working in the PHC/ESF in the state of Paraíba, may be the result of university professors who, although already retired from their academic career, have established a new employment relationship in certain municipalities to work in PHC/ESF.

Assistance dimension of the work process of PHC/ESF nurses in the state of Paraíba, Northeast, Brazil
Nurses are part of a collective work process whose purpose is to produce health actions through specific knowledge, articulated with other team members in the political-social context of the health sector.The performance of these professionals in PHC in Brazil has been constituting an instrument for changes in the health care practices of the Unified Health System (SUS), responding to the proposal of a new care model, focused above all on comprehensive care, on intervention in the face of risk factors, disease prevention and health promotion and quality of life Considering the total number of professionals participating in the research, 462 (100%), and the frequency with which they perform care practices, it is possible to verify that the highest frequency of daily activity is that of practice A1 -'Nursing consultation', with 368 (79.7%); in second place, the practice A4 -'Request for exams', with 299 (64.7%).As for practice A5 -'Prescription of medication', 223 (48.3%) said they performed it daily, thus approaching half of those who participated in the research.
When checking the frequency scale of activities, shown in table 2, it is clear that, for all the practices analyzed, the percentages of nurses who perform them daily are considerably higher than those who perform them 'three or more times in the week', 'between once and twice a week', 'eventually' and 'never', and are higher especially when compared to the percentages of those who did not respond.
In the work process of the PHC/ESF, the nurses have been developing care practices with autonomy in relation to the attributions under their competence, supported by the Professional Practice Law 11 and based on the approval and implementation of clinical protocols by the Ministry Health and by the Coren, in addition to municipal protocols, documents and regulations that guide nursing care in order to meet the needs of users.
The implementation and updating of nursing protocols by health departments, with the support of the Coren, expands users' access to the PHC/ESF health units.With regard to nursing consultations, researchers have reported an increase in the amount of this practice, especially when analyzing the implementation of protocols and the improvement of care flows 34 .
As for the present study, in the analysis of the care practices of PHC nurses in the state of Paraíba, significant percentages of consultations performed daily are recorded, which helps to confirm the evidence found in the research of the authors 34 previously referenced.
The nursing consultation is a resource for welcoming and linking the family with the health service and these components are interrelated, that is, as nurses welcome the family, they improve the frequency of consultations and the evaluation of the service, implying its proper use and valorization 35 .
It is known that, among the consultations in the daily work of PHC, nurses perform lowrisk prenatal care; follow-up consultations for hypertensive and diabetic patients; childcare; consultations with people with communicable diseases; monitoring and management of mental health cases; and other activities governed by legislation, clinical protocols and other technical regulations that ensure nursing practice.
The scope of these professionals' competences is associated with the prescription of medicines and the request for exams, actions that they have been exercising with autonomy, contributing to the care and quality of care in health units.These actions, listed in table 2, also present significant numbers of daily frequency of performance.
In Paraíba, Lima36 identified that none of the municipalities in his field of investigation had specific legislation on requests for exams and prescription of medicines by nurses.He realized, therefore, that the health secretariats are based on the standards offered by the ministerial protocols and Cofen documents.The request for exams and the prescription of medication, as elements of analysis in this study, contributed to characterize the individual assistance provided by nurses to users of PHC/ESF services in Paraíba.As can be seen in table 3, with regard to the request for exams, of the total number of participating professionals (462), most register being able to request a blood count (381, 82.5%), other blood tests (351, 76.0 %), ultrasound (309, 66.9%) and mammography (249, 53.9%).It appears, therefore, that the blood count has been the exam that PHC nurses in that state have most requested.Among the nurses surveyed, more than 70% said they did not request X-rays and electrocardiograms.In the analysis variable for each of the exams, only 14.7% of the professionals did not give an opinion.
When analyzing the criterion 'can prescribe medication', the highest frequency of professionals who responded positively -that is, 372 (80.5%) -is related to the prescription of ferrous sulfate and other supplements.The second and third highest frequencies concern the prescription of analgesics, with 230 (49.8%) professionals, and antiparasitic drugs, with 221 (47.8%).Among the nurses surveyed, 264 (57.1%) reported not prescribing antibiotics and only one reported prescribing anxiolytics.
In Paraíba, Coren, from the perspective of equipping professionals to work in PHC, recognizes that -in the context of comprehensive health care -care must be organized to meet the real needs of the population, through the use of existing technical-scientific knowledge and the most adequate and available means and resources.Therefore, in order to meet the SUS guidelines and the legal requirements of the profession, the 'Nurses' Protocol in the Family Health Strategy of the State of Paraíba', prepared by that council, has guided professional conduct, supporting and subsidizing care practice, in addition to standardizing the work process, seeking, through the Systematization of Nursing Care (SAE), to strengthen the implementation of nursing diagnoses and interventions, as well as the prescription of medications in the nursing consultation, based on the 'Primary Care Notebooks' 39 .
The prescription of medications in nursing is an element that contributes to the profession in PHC; in Brazil, this practice has taken on clearer contours in recent years, through the PHC notebooks and the protocols established by the Ministry of Health 36 .Table 4 presents frequencies and percentages concerning the perception of the professionals surveyed about the resolution of care practices developed within the scope of PHC/ ESF in Paraíba, analyzing whether they are 'sufficient' or 'insufficient'.It is clear that all practices have high frequencies and percentages of resoluteness, highlighting prenatal consultation, which 388 (84%) professionals consider to be the most resolute, followed by monitoring of child growth and development, mentioned by 344 (74.5%) nurses surveyed.In all practices, the percentages were above 65%.
Carrying out prenatal consultations was also the activity best evaluated by PHC nurses, nationwide, in terms of resolution, with percentages of 73.7%, according to the research report 'Practices of Nursing in the Context of Primary Health Care' 14 .
Regarding the work of the nurse, the Code of Ethics for Professionals establishes that the professional, when acting in the promotion, prevention, recovery and rehabilitation of people's health, must exercise the profession with autonomy and resolution 40 .It is noteworthy that throughout the development of the study, which included, among other developments, the preparation of this article, no limitations were observed; which enabled the entire process of carrying out the research and achieving the results presented, discussed and analyzed.

Final considerations
The work process of nurses working in the PHC/ESF in the state of Paraíba was analyzed in this study with emphasis on the sociodemographic profile and training of professionals, as well as the care dimension of care practices and the scope of individual actions.
Regarding the sociodemographic profile, the majority is female; the professionals surveyed have an age group that characterizes a set of relatively young nurses working in PHC in that state, most of whom live in the municipality where they work and have been working there for less than 4 years.
The analysis of the professional training profile of the nurses surveyed makes us reflect critically on the importance and need for qualification for the work processes of the PHC/ESF in the municipalities of the state of Paraíba, since only specialization has been the most common type of degree.
The care dimension of the work of PHC/ ESF nurses in the state of Paraíba made it possible to understand how individual competence actions have been developed in the daily work in health units and in the community environment.The care practice most frequently performed daily is the nursing consultation, followed by requesting tests and prescribing medications.The most requested tests are blood count, other blood tests and ultrasound; the most prescribed medications are ferrous sulfate and other supplements.For all practices analyzed, the predominant problem-solving capacity concerns prenatal consultations.

Collaborators
Alvarenga JPO (0000-0002-7170-7498)* contributed to the conception and design of the study, analysis and interpretation of data, analysis and discussion of the results and preparation of the manuscript.Sousa MF (0000-0001-6949-9194)* contributed to the critical review of the final version of the manuscript.s *Orcid (Open Researcher and Contributor ID).

Table 1 .
Frequency distribution of nurses in terms of marital status, residing in the municipality where they work and years of experience in the PHC/ESF in the municipality where they currently work(Paraíba, Northeast, Brazil)

How many years have you been working in PHC in the municipality where you currently work?
Source: Self elaborated.
Graph 1. Frequency distribution of degrees completed by nurses from PHC/ESF(Paraíba, Northeast, Brazil)

Table 2 .
Individual daily practices developed by PHC/ESF nurses according to their role in care(Paraíba, Northeast, Brazil)

Table 3 .
Characterization of the care provided by PHC nurses according to the request for tests and the prescription of medication(Paraíba, Northeast, Brazil) Source: Self elaborated.

Table 4 .
Frequency and percentage of perception of care practices developed by nurses from PHC/ESF in terms of resolution(Paraíba, Northeast, Brazil) Source: Self elaborated.