ORIGINAL RESEARCH

Nursing protocols: motivation and methodology in the shared construction process

Marcia Cristina Cid Araújo^I, Sonia Acioli^II, Mercedes Neto^III, Alex Simões de Mello^IV, Paula Soares Brandão^V

^I Nurse. Master student, Graduate Program in Nursing, State University of Rio de Janeiro, Rio de Janeiro, E-mail: marciacid@globo.com
^II Nurse. Associate Professor, Department of Public Health Nursing, State University of Rio de Janeiro. Brazil. E-mail: soacioli@gmail.com
^III Nurse. Adjunct Professor at the State University of Rio de Janeiro, Brazil. E-mail: mercedesneto@yahoo.com.br
^IV Nurse. PhD student and Assistant Professor of the State University of Rio de Janeiro. Brazil. E-mail: axmello@gmail.com
^V Nurse. Assistant Professor at the State University of Rio de Janeiro. Brazil. E-mail: pbrandaofenf@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.27339

ABSTRACT

Objectives: to understand the motivation and methodological strategies for shared construction of nursing protocols. Method: qualitative, descriptive study using documentary analysis. The sources were the protocol construction process documents filed with Rio de Janeiro Regional Board of Nursing. Thematic content analysis was used. The study was approved by the ethics committee (Protocol #1.508.49). Results: the analysis indicated that the factors facilitating the protocol construction process were: the motivation of the professionals involved, the methodological strategies for collective construction, the protocols' being suited to regional needs, and nurses' participation in management and care, facilitating reflection and contributing to safer actions by nurses in primary care. Conclusion: interviewees pointed to collective construction, adaptation of protocols to regional realities, and exchange of experience as factors motivating study, reflection and introduction of changes in care practices.

Keywords: Nursing protocols; primary health care;nursing; public health.

INTRODUCTION

The Regional Nursing Council - Rio de Janeiro Zone (COREN-RJ) and other Regional Councils were created after the approval of Law nº 5,905, of July 12, 1973¹. During 20 years, the COREN-RJ was accused of numerous irregularities and, after an action of the Federal Police, it was submitted to an intervention by determination of the Federal Public Prosecutor's Office. An intervention board was then assigned on May 15, 2008, through Decision nº 22 of the Federal Nursing Council (COFEN)² to assume the lead of the council; this board now was responsible for the Autarchy for a period of 18 months.

During the intervention process, there were different attempts of approximation between the Autarchy and the nursing professionals, who had sought distance from the Council due to the history of frequent denunciations of illegal deviation of finances and persecution of COREN-RJ's directors.

Thus, projects were developed in different sectors of the COREN-RJ as a way of listening to the needs of the members of the nursing teams, which reported difficulties faced by nurses in several municipalities in the State of Rio de Janeiro, conflicts of autonomy in the actions of nurses in the hospital area, in the Primary Care and in the Family Health Strategy (FHS).

These conflicts were mainly related to the prescription of medications and request of exams in protocols, nursing consultation in care lines, and high complexity procedures in the hospital area such as: wound treatment, peripheral insertion of central venous catheter (PICC), and obstetric care.

Situations of embarrassment of nursing professionals caused by corporatism of representative bodies of physicians were reported, including records of police reports against nurses from the FHS and from basic health units (BHU) because they had prescribed medications listed in health programs, and pressure exerted on health secretaries in the sense of limiting nursing actions.

Thus, the present article has as object the methodological and motivational path taken to the construction and agreement upon nursing protocols. The objective of this study was to understand the motivation and the methodological strategies of the shared construction of nursing protocols.

LITERATURE REVIEW

Since 1997, the Regional Council of Medicine of Rio de Janeiro (CREMERJ) had been publishing resolutions defining what was considered by them as a medical act, and they often stated that the diagnosis and the prescription of treatments and medicines were private activities of the physician, and this was the content of Resolution CREMERJ nº 121/98³. In 2008, the Regional Councils of Medicine of several states sent false news, replicated through the electronic website of the Federal Council of Medicine, on changes in the attributions of nurses established in the National Basic Attention Policy (NBAP) and in Administrative Rule 1,625/2007⁴, which stated that nursing consultation and prescription of medications established in health programs by nurses were no longer allowed.

These situations of conflict and lack of autonomy of nurses generated a situation of insecurity that contributed to the creation of a culture of restraints in the actions of nurses. Thus, even nurses who did not experience this circumstance were influenced by reports and these were reflected in their actions, imposing restrictions.

In the meetings with nurses, the COREN-RJ began to register requests from the municipalities of the State of Rio de Janeiro for the formalization of a protocol that would to back the action of nurses in basic care.

Prescription of medicines and request of exams are carried out within the framework of nursing consultation, in the context of integral health care for the individual, in compliance with article 11, paragraph II of Law 7.498/86, which determines "prescription of medicines established in public health programs and routinely approved by the health institution" ⁵.

After discussing the matter with the nurses of different municipalities, the Intervention Board defined as strategy to face these issues the elaboration of a model of ordinance by the municipality that would be sent to the municipalities for adequacy and publication. This document was prepared by the head of the council and had the objective to rule on the institution and standardization of the nursing consultation and the activities arising from this procedure within the scope of the units belonging to the service network of the Municipal Health Department of the municipality.

The legal and ethical bases for the professional practice of nurses were listed in this document, emphasizing the request for routine and complementary exams, and the prescription of medications that could be prescribed by nurses based on health care protocols of the Ministry of Health (MOH) in the different lines of care/health programs.

The document suggested the publication of its contents from the creation of an ordinance and recommended the wide dissemination to the local community, in meetings of Municipal Health Councils, and other spaces of participation. This document also alerted to the need to adapt the forms as prescriptions and guides of referrals for use by the multiprofessional team.

The document was released to the 92 municipalities of the state and its objective was to support the action of nurses in the face of the questions and conflicts that were happening in the municipalities among nurses, managers and medical professionals, and that limited the action and autonomy of nurses in health programs.

In the period from 2009 to 2011, the analysis of municipal protocols was under the responsibility of the Technical Advisory, who received protocols organized by the nursing managers and/or nurses acting in the BHUs of the municipalities of Araruama, Cabo Frio, São Pedro da Aldeia, Japeri, Nova Iguaçu, Itaperuna, Casimiro de Abreu, and Paraíba do Sul. Among these, the municipalities of Petrópolis, Cabo Frio, Rio das Ostras and Silva Jardim were analyzed and attended to the flow suggested by COREN-RJ, with publication of an ordinance in an official municipal newspaper.

Five technical boards were created by the Decree nº 1710/2010, among them the Technical Board of Nursing Management and Assistance (CTGAE/COREN-RJ) ⁶ which began its work in September 2011 and started to follow up the requests regarding nursing protocols from debates with nurses who worked in primary care units and members of the CTGAE/COREN-RJ

The management of the Intervention Plenary was active from November 2009 to December 2011 and, after elections, a new management was established from January 2012 to December 2014, during which time the process of construction of nursing protocols took place.

METHODOLOGY

This study was developed in a descriptive perspective with qualitative approach in 2016. The documents produced and registered by 14 nurses who participated in the process of construction of protocols were used, and the sample included documents from the nurses advisors of the COREN-RJ, also members of the CTGAE/COREN-RJ, supporters of state management, municipal management and the FHS units operating in Metropolitan Regions I and II.

The sources were documents filed by the Technical Board of Nursing Management and Assistance, many of which were in the possession of the General Secretariat and later passed on to the CTGAE/COREN-RJ and copied by the researcher throughout the process in which she was coordinator of the CTGAE/COREN- RJ. The scenario of the study comprised the State of Rio de Janeiro.

The analysis took place in stages from the perspective of Bardin ⁷. Firstly, the phase of textual exploration was carried out, identifying the elements of clarification of the text and the organizational structure. A quick reading was carried out, aiming to delineate the themes present in the text. Then, the second phase of the thematic analysis of the content was started, focusing on the themes, expectations and arguments elucidated. At this stage, we sought to demarcate the nuclei of meaning and their main categories. The last stage of the analysis, the interpretive phase, was aimed at establishing critical relations between the ideas present in the documents.

The Research Project was approved by the Research Ethics Committee of the State University of Rio de Janeiro (UERJ), as established by Resolution 466/2012, and approved under Opinion nº 1,508,499, issued on June 8, 2016.

RESULTS AND DISCUSSION

In order to understand the path taken to construct the nursing protocols, it is necessary to analyze the categories of the study - the motivation and the methodological strategies.

Motivation as facilitator of the process

In relation to the motivation for the proposed work, the initial demand was identified: the confrontation of the situations of impediment of the professional practice by managers and pressures coming from physicians linked to the management or to representative entities of the medical category.

The questioning regarding the actions of nurses in primary health care (PHC) is old and based on medical corporatism that has its roots in the importation of the Flexnerian medical model, linked to the general relations of economic dependence and political subordination of Brazil to the North-American interests⁸.

Law 12,842 of July 10, 2013, centered the health actions in the hands of the physicians and limited the field of action of the various health professionals, reducing their autonomy, under the argument a necessary regulation of the medical practice. The repercussion of these facts in the media generated conflicts between health professionals and other segments of the population⁹.

The demand to start the construction was the issue of professional practice, but what the nurses mentioned as more important was the possibility of regionalization of the protocols, that is, the adequacy to local actions. The proposal of elaboration of a regional protocol, rather than municipal, was designed by the CTGAE/COREN-RJ in partnership with the Superintendency of Basic Attention (SBA) of the State Health Secretariat (SHS) for a greater extent involving more municipalities. Coordination boards and professionals of each municipality would adapt the protocol to local realities. This agenda was discussed with the nurses during the workshops and was well accepted.

The regionalization process, a guideline of the Unified Health System (SUS), was defined as the structuring axis of the Health Pact 2006, with the objective of strengthening the processes of agreement among the management of the three spheres of the system, recognizing loco-regional differences¹⁰. The importance of the protocols for security in the development of the professional practice, previous experiences with protocols and the perception of improvement of existing protocols is also highlighted as motivation.

Group work, recognition, safety and group integration, among others, are decisive factors for human motivation. The act of involving people, creating an environment of participation and integration with managers, leading them to understand that they are expected to do their best in actions and activities, means that they are considered capable of achieving the best results¹¹.

Another aspect that emerged from the interviews (presented in the documents examined) as a motivating factor for the involvement and permanence in the process was the possibility of collective construction, which involved service professionals, managers, primary care coordinators and even secretaries of health, as well as the exchange of experiences that was reported by all the participants.

The valuation of the exchange of experiences and their connection with their work reality and that of professionals of other municipalities, increasing their knowledge in relation to the work of the region as a whole, emerge in the contents. The documents mention that the work in the groups had as starting point the experiences of nurses involved in care and management, and sought knowledge of the health and infrastructure reality of their municipalities, their possibilities and limitations.

The methodological strategies of the process

The FHS is a proposal designed to change the care model, with potential to comply with the constitutional principles of 1988. It was implemented in the late 1990s and has been expanding throughout the national territory. The fragmented work, with hierarchical practices and inequality between the different professional categories, usually with subordination of several professions to the knowledge and practices of medicine, persists as a major challenge in its political-operational dimension, that is, in the area of ​​care practices^12,13.

In this sense, it was a construction process based on the reflection and revision of the practices and experiences, whose overcoming was based on the knowledge and experiences of the nurses involved.

Nursing has learned its activity in practice, doing and learning, and later incorporating the knowledge from other disciplines, mainly the biological sciences. The first organized and systematized manifestations of nursing knowledge were constituted by nursing techniques¹⁴.

Rationality is the brand in the modern world and presents itself in many ways: technique, art, science, philosophy and knowledge. All these ways constitute the human praxis in the daily life of nursing, the dimensions of knowledge/knowing and praxis, which involve the entire nursing care process¹⁵.

There is a wide range of sources of information on the evidence for clinical nursing practice. The protocols can be considered as one of these tools, because they gather evidence and can facilitate the work of nurses in the search for ways to change their practice¹⁶.

It was possible to show that this process represents a potent strategy of permanent education for nurses who were involved in searching for new knowledge and strengthening their proposals to face the challenges of the care process.

A very important aspect in the process of doing together, in the construction of the contents, was related to the adequacy of the protocols to the local reality, which revealed the questions to establish the flows and the practices and, at the same time, the extent to which the protocol, regional or municipal, could contribute to the security of professionals.

According to the documents examined, the participants identified the use of a participative methodology and collective construction as a differential of the process, the object of this study, and other training previously experienced. The strength of the principle of regionalization, which contributed to a look turned to regional specificities, is linked to this.

The interaction among nurses and between nurses and the construction of the contents of the care lines was recorded in the documented testimonies. The participants themselves agreed to the decisions, in a living process, in an environment of autonomy, dialogue and experience. This dialogical essence is necessary, with action and reflection; it is in the encounter between the people that dialogue happens, as an act of creation and of joint form ¹⁷.

Positive changes in professional performance can be caused by problematizing the attention offered to users in the different services of the system, associated with the institutional structure of health, local or regional, valuing the interaction of all the actors involved¹².

In relation to the construction processes, some participants reported previous experiences, elaborating protocols based on the experience of managers and coordinators, and including the content of routines in protocols already developed in the municipalities. Protocols elaborated in the organizational dimension, to be executed by professionals in the professional dimension¹⁸.

The records highlight the participation of nurses in the process and point to a differential in the experience lived during the process under study, such as collective construction and the inclusion of team nurses and managers in the process of construction of the protocol.

In the experience, the construction process integrated these two dimensions, organizational and professional, and described them as dimensions that are interlined and correlated. These dimensions are structured from the problematization of the professionals' real practices, generating knowledge about this work, identifying potentials and gaps that mobilized nurses in the search for further knowledge, for the transformation of their practices, with reference to the health needs experienced in their territories and the assistance model of the FHS ¹⁹.

CONCLUSION

The construction of this experience was motivated by the need, identified by the nurses, for ethical-professional support for the development of nursing care in basic attention. Nurses understood that the best way was to establish a nursing care protocol that could legitimize their actions. Although this was the major motivation for participation, it was evident that the methodological characteristics of the shared construction process was what kept the group cohesive and integrated to the proposal for such a long period.

In the category Motivation as a facilitator of the process, collective construction, adaptation of protocols to regional realities and exchange of experiences were pointed out in the documents analyzed as motivational factors for the study, reflection and incorporation of changes in care practices.

The results showed that the regionalization of the protocols made it possible to adapt them to the health needs of the territories where they worked, taking into account their experiences, and stimulating the joint search for more appropriate solutions to their realities, favoring the security and legitimation of nursing care in PHC.

For the category of the methodological strategies of the process, the process was set up in a collective construction of intense exchange of experiences, strategies, and generated interaction, study, research, reflection and learning, within the lines of care, in which the process of construction has become more important and has qualified not only the product of experience but also its own participants.

In addition, it should be noted that the limitations of the study are linked to limited generalization of the results as well as the need to expand the study to other regions with different realities related to the professional practices experienced.

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