RESEARCH ARTICLES

Care practices: the role of nurses in primary health care

Sonia Acioli^I; Luciana Valadão Alves Kebian^II; Magda Guimarães de Araujo Faria^III; Patrícia Ferraccioli^IV; Vanessa de Almeida Ferreira Correa^V

^IPhD in Public Health. Adjunct Professor of the Public Health Department of the Nursing Course of the State University of Rio de Janeiro; E-mail: soacioli@gmail.com.
^IINurse. Master degree in Nursing. PhD in Nursing of the Post-graduation Program in Nursing of the State University of Rio de Janeiro.  E-mail: lucianavvalves@hotmail.com.
^IIINurse. Master degree in Nursing. PhD in Nursing of the Post-graduation Program in nursing of the State University of Rio de Janeiro. E-mail: mag_araujo@yahoo.com.br.
^IVNurse. Master degree in Nursing. PhD in Nursing of the Post-graduation Program in nursing of the State University of Rio de Janeiro. E-mail: ferracciolip@gmail.com.
^VNurse. Master degree in Nursing. PhD in Nursing of the Post-graduation Program in Nursing of the Nursing Course of the State University of Rio de Janeiro. E-mail: nessa_aferreira@hotmail.com.
^VIIt is a clipping of the research Care Practices in SUS: the role of the nurse in primary health care, linked to the Post-graduation Program of the Nursing Course in the State University of Rio de Janeiro and inserted in the Incentive Program Scientific, Technical and Artistics Production (Pro- science).

DOI: http://dx.doi.org/10.12957/reuerj.2014.12338

ABSTRACT: the objective was to know the care practices developed by nurses in primary health care in the city of Rio de Janeiro. Qualitative and descriptive study, developed between 2009 and 2013, with technical data collection of semi-structured interviews with 30 nurses from 04 Municipal Health Centres and 02 Basic Units of Family Health. Data were analyzed using content analysis. It was found that the nurse performs various care practices in primary care, in which there were: nursing consultations, home visits and educational activities. It is concluded that the nurse has some difficulty in defining the presence of caring in the performed practices, which demonstrates the need to discuss such practices and the role of nurses in primary health care.

Keywords: Public health nursing; Nursing care; Private nursing practice; Public health practice.

INTRODUCTION

The nurse has in the developed practice in basic health units (BHU) the challenge of implementing the nursing care in the construction of interpersonal relations of dialogue, listening, humanization and respect. This practice is therefore, for the nurse's understanding about the meaning of his professional doing, i.e. practicing of nursing care in the basic health care (BHC).

In the national scientific production, the nurse's care in the BHC is shown as a debate to be built due to reduced bibliographic production about the thematic, which indicates the need for further articulation of the practices performed by nurses and in care reflection. In BHC, the relevance of studies about care practices performed by nurses is evidenced by identifying that this practice is considered, by the Ministry of Health, the priority and the gateway to the user's access to the Unified Health System (SUS).

There is a tendency of nursing practices be focused on the disease, technical procedures and curative actions, not being highlighted the process of care that addresses the individual as center of attention, and this situation has been reflected also in the care developed at BHC¹. In this way, although the studies recognize the role of the nurse in addition to the technical dimension, it is realized that the core of competence and responsibility of nurses, which is care, is not usually addressed².

This study has as its objective the nurses' care practices in BHC, understanding the need for research focused on this issue. In addition, it is assumed that the analysis of nurses' care practices can strengthen the development of interdisciplinary and integral actions in line with the guidelines and principles of the SUS.
Thus, the objective is to meet care practices developed by nurses within the BHC, in the municipality of Rio de Janeiro.

LITERATURE REVIEW

Practice is the "product of dialectical relationship between a situation and a habitus, that is, the habitus while durable provisions system is perception, appreciation and action matrix, which takes place under certain social conditions"^3:19. Health practices are built through various habitus and guided by a range of institutional, family and influences concerning the social group of which they are part. These practices have "multiple senses, which mix elements of biomedicine, other medical and rationalities of the so-called traditional or popular medicine" and can be perceived as ways to do^4:155. In particular, practices related to care are the closest of the professionals of the health area. The care can be defined as watching, taking care, a set of actions that are designed to function and maintain the life of human beings with the purpose of facilitating the reproduction and perpetuation of the life of the group life⁵. He understands more than a moment of care and watching, as it represents an attitude of occupation, affective involvement and accountability with each other. Thus, concern, respect, trust, compassion and solidarity are some basic attitudes and behaviours of care⁶.

Health care is represented by the values of the touch, look and listen, exceeding the dimensions of technical practices. At this moment, the health professional gives space for dialogue, appreciating the history of life, belief and culture of each individual. "The care is expressive from the moment that ceases to be a task to be an action which will provide growth for who cares and who is cared"^7:194. Soon, for technical care be considered a human care, it is necessary the meeting between the expressive and technical.

Care is considered as the object and the essence of nursing, since this profession involves several knowledge, among them affective knowledge - the art of care^6.8. Knowing that the process of care relates to different acts, interventions carried out by the nurse are characterized as care when caring behaviors appear, such as respect, kindness, attention, solidarity and interest⁹.

Historically, health care has evolved from strictly curative and individualized techniques for integrals and collective practices. Health care were geared primarily for the cure of diseases, which created a dichotomy between being filled with anxieties, doubts and desires and the pathology that he was carrying. However, through the introduction of new concepts such as the Biopsychosocial Theory, started to be considered the importance of biological, psychological and social aspects of the individual and the collective and valuing personal relationships between client, family and healthcare professionals, thus making the practice a more complex health care¹⁰.

The process of care involves a relationship between the person who cares and the subject, in which the socio-economic context and the political and cultural singularities are closely present⁸. With that, it can be observed that the nurse care practices in the basic care gain significance as it is in this field that many contexts expressed clearly, reflected through the social and cultural approach with the population. Consequently, the health needs are identified in loco, which may provide the development of care practices more coherent and effective.

From the perspective of that care exceeds the dimensions of the technical practices means that stimulators of dialogue spaces, that value the history of life, belief and culture of each individual, provide the development of care practices. Thus, it becomes important to study how the nurse uses care spaces on BHC, since it proposes the approach of the health professional to the reality of life of the population.

METHODOLOGY

Study of qualitative nature, descriptive type, since this approach favors the construction of knowledge from the exchange of knowledge between interviewer and interviewee, the local and the global and between the collective and the individual.

The research's participants were 30 nurses who work in the BHU of Rio de Janeiro. The study scenario consisted in four municipal health centres (MHC) and two basic family health units of the (BFHU) of this municipality. The survey was developed between 2009 and 2013. The selection of nurses was randomly and sample closure by saturation was employed.

The research used semi-structured interviews as data collection technique, which were recorded and subsequently transcribed and typed into Word.

Data processing technique used in this research was the content analysis, proposed by Bardin¹¹. The steps used for processing of data were: pre-analysis, in which the reading of floating testimonials was performed, constituting in the corpus of analysis, then the exhaustive reading material; analysis, in which record units were selected (sentences) forming a clipping of the reports and subsequent organization. Then, the thematic axes grid was built emerging the following categories: nurses' care practices in BHU; and difficulties and facilities of the care practices of nurses in BHU. This article presents the results of the first category.

The interviews were conducted after reading and authorization according to the Consent Free Clarified Form that ensured the anonymity of the respondents. In addition, to preserve anonymity, the participating nurses were identified with the letter N (Nurse), followed by an identification number from 1 to 30. This study was approved by the Research Ethics Committee of the Municipal Health and Civil Defense of Rio de Janeiro, under the Protocol 32A/2008.

RESULTS AND DISCUSSION

From the data of this study it was possible to meet the care practices developed by nurses within the BHC, in the municipality of Rio de Janeiro, and realize that the nursing consultation, home visits and educational activities are the most important care practices. Thus, this study deepens the reflection on these care practices, but emphasizes that dialogue emerged several practices, such as reception, assistance activities (vaccination, realization of dressings, checking vital signs, among others) and administrative activities (organization of space, meetings and team trainings, among others).

Nursing consultations

The nursing consultation has been shown as a practice of care developed by the nurses. They associate the nursing consultation to the opportunity of carrying out educational activities, strengthen the bond, meet and listen to the user, besides being oriented to the conflicts, the difficulties and the problems of the patient within their social context.

My preventive [women's health consultation] is almost a psychology consultation, because people have an argument, everyone is talking about. I can't take preventive in 20 minutes, because she's talking about the subject of her husband [...]. (N5)

And here in our work people approach of this reality [the user], we seek to know what are the conditions, even when he's being assisted in the office. (N3)

It is very good, in such preventives [women's health consultation] I've discovered even diabetes. (N1)

Nursing consultation is seen as a space conducive to the development of the practices of care, because in this practice the nurse has the opportunity to listen to demands, evaluate physical health and psycho-emotional conditions, better understanding the user and guiding¹², since he can use it to understand the emotional context, social and family relationships. Thus, this space favors a care comprising more than a technical moment, but an attitude of affective involvement with each other, strengthening the professional-user bond¹³.

Home visits

Home visits were also identified as a practice of care developed by nurses in BHC. This practice is related to the investigation of health needs, assistance activities (implementation of dressings, collecting exams, checking vitals, among others), active listening, health education and physical structure observation, food and family relationships. It was identified as a care practice because it provides care, dialogue, assistance and bond.

You have to hear. What's bothering that person, what generated that, if that person is with some emotional problem in the family, whether it is a financial problem. [...] I think the key point there [home visit] is listening, it's not just talk but also hear. (N2)

Through home visits you might be watching the home of that person, is not the thing to fix, is to observe. Through this observation I see how the person is living, there are people who live with poor hygiene condition, this will be bring harm to health. (N6)

The nurse uses the home visit as a strategy of care, as well as plan the activity, evaluate family health conditions and propose behaviors, he develops actions of expanded mode, including the individual social context biological clipping in a longitudinal perspective of care¹⁴.

Despite the importance of this practice for planning activities aimed for care on BHC, there are still obstacles to the realization of the home visit. In this survey, it was identified as the main difficulty for nurses task overload on BHU, which consume a great deal of time and, consequently, interfere with the performance of the home visit.
The home visit is an area that if we don't fight for it, it doesn't happen. Because we have an extremely large overload of activities if you let you just stay inside the unit. (N7)

Productivity requirements and registration exceeded underestimating the number of families in the area collaborate to the work overload15. Due to the large number of tasks and the limited time many nurses choose to carry out other activities than home visits. This shows the need for reflection on which practices should be prioritized in the set of activities to be developed.

It is important to note that in several interviews the nurses reported their everyday professional practice without however, call them as care. However, it was identified the act of caring in the speeches addressing personal relations of dialogue and listening, valorization, humanization and respect among nurses and users. This issue also reflects the need to debate regarding how the nurse develops his care on BHC and add to the discussion the role of nurses in BHC.

Although the nurse develop several activities aimed at care home visit, it was found that he has developed more the assistance activities, i.e. the technical dimension related. Thus, he has stopped doing home visits to strengthen the bond with the families and promote education and health. However, in this space, the nurse seeks to meet the different needs of health, worrying since the home infrastructure until the family relations16 and therefore including the most diverse approaches and not only the assistance.

Educational activities

The educational activities were also identified as an important practice of nurses' care of basic care, which mainly relate to the guidelines provided by the nurses to different social actors. They give health promotion, prevention and control of diseases, self-care and technical guidance on procedures. All this activities are conducted through individual or collective nursing consultations, lectures and health groups, as noted in the following reports.

[...] our practice here consists in education with our customers that we assist, the vaccines and the importance of complying with the deadlines that we schedule the vaccines. (N16).

The group is up there, we're going to do the lecture, explain to them, see the level that each user has, it will depend on the level. The purchasing power is low, the whole thing. You always renews talks with them, the lectures of how's it going, if he's taking the right medication at the right time. (N11).

The reports presented seem to create contradictions concerning the practice of health education for care. If, on one hand, they demonstrate the possibility of a greater contact, more interactive and watching with the user, on the other hand, they reveal the difficulties of nurses in achieving such health education, in an emancipation way, there is the exchange of knowledge and, consequently, the nursing care.

There are ways to know that include the popular knowledge and lay people who would be on the side of the invisible line that separates the scientific distinction between true and false. The experiences made invisible are wasted and disregarded as legitimate experiences of construction of knowledge. In this regard, it is recognized the plurality of heterogeneous knowledge that go beyond scientific, and sustainable and dynamic interactions between them¹⁷. For interaction between these knowledge, we need both parties, users and health professionals being committed to listen and express their opinions.

There was also observed, in the context of the interviews, that within these educational activities, there is an emphasis on the technical dimension of care since even to promote a dialogue/listen, there is a preponderant targeting biological aspects, sometimes in vertical manner.

[...] as much as we talk about care of the feet they insist on wearing tight shoes, less than the number of the foot causing calcification, causing injury. (N23)

 [...] We went in with the care of the baby then I guided the mother give the bath,there was the speech therapist who spoke, the psychologist. (N25)

I see the care in my practice because I do the bandage on umbilical scar of the baby when arriving in the unit and make sure the patient by applying vaccines and medicines. It is the care in practice and not just in theory. (N26).

It was identified in reports that the technical dimension of care pervades, in addition to educational activities, by the most diverse activities of nurses in BHC, such as application of vaccines, dressing, measurement of vital signs, among others. These expressions indicate that nurses understand care as action while performing a procedure, assisting the individual care. They show also the possibility of the beginning of a therapeutic relationship between the health professional and the individual. Therefore, to identify the care as a technical procedure, the nurse extends the possibility of interaction and communication with the individual seeking health services.

Technological advancement has contributed to a care centered on technical procedures, still influenced by traditional hegemonic model, with mechanistic and fragmented social assistance practices that prioritize curative actions. However, it is necessary to go beyond curative care, once in a moment of caring we cannot forget the uniqueness, the completeness and context of the individual's life⁸. The care is "always an interaction between two people"18:652 and therefore it can not be separated from the technical procedure of interpersonal relationship, since the technology is controlled by people.

These inferences lead to reflection on the need to instigate nurses understand the development of care in their practices, their meanings and delimitations. Because the care, even though for a long time has been disregarded as a know and realize just as a do, it seems to be inserted into the nurses' practices today, even when not recognized. Therefore, care permeates and at the same time is before the various practices developed, in an indirect mode.

CONCLUSION

While researching the practices of care developed by the nurses in the basic care of Rio de Janeiro, it was perceived their diversity, such as home visits, nursing consultation, educational, assistance and administrative and reception activities. However, the ones that stood out were the nursing consultations, home visit and educational activities.

Generally speaking, the nurses' care practices in BHC are technical and to the biological aspects, with expressive/sensitive care it is presented little strengthened, which could compromise the integral care to user's health.

It was possible to identify, through the results obtained, the complexity of the practice of the nurse, the care that permeates this practice and the do as a daily action. However, it is seen some difficulty on these professionals to define clearly the presence of nursing care practices that perform under the BHC, which demonstrates the need to debate this issue and the role of the nurse in the BHC.

As a search limitation there is the restriction of study area in only four MHC and two BFHU of the city of Rio de janeiro, which, despite its relevance, it is not possible to generalize the results to other municipalities for a specific sample.

This research indicates the importance that are expanded studies on nursing care practices aimed at primary care level, identifying both the objective character as subjective of these practices. And, still, deepen understanding about the role of this professional care practices and the way that they attach to such practices and thereby corroborate the importance of nursing care in the area of basic care.

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