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Nurses' perceptions of their educational role in the family health strategy


Michelly Evangelista de AndradeI, Jorge Wilker Bezerra ClaresII, Edigleide Maria Figueiroa BarrettoIII, Eliane Maria Ribeiro de VasconcelosIV

INurse. Master student in Nursing, Federal University of Pernambuco. Recife, Brazil. Email:
IINurse. Master in Nursing Clinical Care, State University of Ceará. Fortaleza, Brazil. E-mail:
IIINutritionist. PhD in Nutrition, Federal University of Pernambuco. Recife, Brazil. Email:
IVNurse. PhD in Nursing. Federal University of Pernambuco Recife, Brazil. Email:





Objective: to analyze nurses' perceptions of their role as educators in the family health strategy (FHS). Method: in this qualitative, descriptive study of 15 nurses working at 12 family health clinics in Recife, data was collected in 2012 through recorded semi-structured interviews with a script consisting of two questions. The data were analyzed using Collective Subject Discourse. The study was approved by the research ethics committee (CAAE 02185412.5.0000.5208). Results: nurses' day-to-day work features overlapping educational activities connected with the traditional model and with the new model of health care embodied in the FHS. Conclusion: there is a need to rethink nurses' educational work in the FHS, to address the need to acknowledge its limitations and develop strategies to surmount them.

Keywords: Health education; family health; public health nursing; role of nursing professionals.




Health Education is the field of theory and practice that deals with the relationship between knowledge and health/disease process in individual and collective level, resulting in generation of specific and shared knowledge aiming to promote the autonomy of subjects from their own choices1.

In the contexto of Family Health Strategy (FHS), one of the main consolidation strategies of the National Health System, Health Education appears as a practice planned and assigned to all professionals who make up the family health team and is considered an important tool for health promotion. Its practice allows the quality of life of individuals, families and communities through joint technical and popular knowledge, institutional and community resources, public and private initiatives, surpassing the biomedical view of health care and covering multiple determinants of the health/disease process, with a view to improving the population's self-care2,3.

Thus, health education can be considered a possibility of transforming the current health care practice, contributing to the concept of the implementation of promotion of human health and reorientation of primary health care.

Nurses stand out in this context as members of the multidisciplinary health team and as an educator by nature. Educational practices in health performed by nurses make up the social practice of nursing and are characterized as fundamental instruments in the health work process4.

Health education is a key tool for good quality of care, through which the nurse carries out guidance for self-care, both individually and collectively, making subjects, families and communities multipliers of knowledge in healthcare5. Furthermore, by systematizing and individualizing care, these professionals can assist people in adopting a healthier lifestyle, through a dialogic-reflexive relationship established with users, making them subjects of their own decisions. Therefore, the nurse's educational work is geared to not only the disease, but also health promotion and empowerment of the population6.

Given the above, to study the knowledge and educational practices developed by nurses in the context of the FHS becomes necessary and can show the potential and limitations in the everyday practice, subsidizing planning strategies and alternatives in order to develop their actions and promote improvements in clinical and educational care to the population. Thus, this study aimed to analyze the perception of nurses about their educational performance in the FHS.



The Family Health Program was created in 1994 and was later called FHS, in order to offer its users greater access to health services, greater quality in health care, rational use of other levels of health care and better results in health indicators where the program is deployed7.

It is, therefore, a program that comes with a proposal with substitutive character compared to conventional care practices by engaging a new work process, with the principles of universal and equal access to the population, full and continued assistance in each stage of the life cycle to all family members of the population in a context of decentralization and targeting popular participation8.

It can be inferred, however, that the great challenge of the FHS is to change the health care centered on the procedure in a health care focused on the user. For that, the FHS performance in relation to individuals should not be restricted to biologically present health problems, but should involve actions to individuals for the promotion of their health9.

To achieve all the assumptions previously described, the professionals working in the FHS must be able to plan, organize, develop and evaluate actions that meet community needs, in conjunction with the various sectors involved in health promotion10.

Therefore, these professionals need to have abilities, skills and attitudes to overcome the possible difficulties that may be detected in the performance of their duties, and the implementation of actions and strategies impacting the community. For this, there must be commitment, with priority in development of activities aimed at promoting health, as well as, and not least important, the development of disease prevention activities, health recovery, rehabilitation, and act in the maintenance of community health11.

In this sense, the nurse's role involves making individuals to become autonomous, creating opportunities, strengthening beliefs and skills, respecting the decisions and the learning pace of each user, making them part of a process of growth and development, highlighted by understanding that teaching means to create possibilities for the production or construction of knowledge12.



This is a descriptive study with qualitative approach developed in the year and 2012 in 12 family health units (USF) of the V Health District in the city of Recife/PE, a region where health courses at the University Federal de Pernambuco develop teaching, research and outreach activities.

The participants were 15 nurses intentionally selected, following the inclusion criteria: being a nurse and acting in the FHS for at least one year. Professionals who were off, on vacation and on sick leave in the period of data collection were excluded.

Data collection was performed using a semi-structured interview consisting in two questions that focused on concepts and health education practices developed by nurses in the FHS. The interviews were recorded and transcribed verbatim. For data analysis, we used the method of the Discourse of the Collective Subject (DCS), a methodological approach indicated for empirical social research with qualitative focus using a discursive strategy, aiming to clarify a social representation in the speech, which is the way people think13.

The construction of the DCS involved the following steps: selection of key phrases (KPh), which are excerpts from the verbal material of each statement in its entirety; identifying the main idea (MI) of each KPh; and the grouping of KPh relating to similar or complementary MI, in a speech synthesis in the first singular person, which is the DCS13.

The study met the Resolution n° 466/12 of the National Health Council, and it was approved by the Research Ethics Committee of the Federal University of Pernambuco (CAAE 02185412.5.0000.5208).



Characterization of subjects

All respondents were female. The age ranged between 28 and 51 years, and the majrority were in the age group of 30 to 39 years (86.7%). All participants have post-graduate degree, predominantly in areas of public health and family health. The time of professional activity ranged was from 4 to 14 years. Only one (6.7%) participant had attended a training course to work in the FHS.

Health Education Conceptions

The analysis of the theme about the health education conception identified the following MI:Disease prevention, exchange of information/knowledge and Empowerment.

The MI Prevention of diseases resulted in the speech:

Health education is a set of actions that are developed in order to prevent both physiological and psychological diseases and to promote health. In case of hypertensive patients, for example, there is the talk, then I talk about diet, here comes the question of the measures that the patient should take. (DCS1)

From the MI Exchange of information/ knowledge emerged the following account:

Health Education is an information channel that professionals create with the user and/or community in an attempt to expand knowledge. It is to strengthen the link with the user, because I will listen and guide. In this process, an approximation to the patient happens. (DCS2)

The MI Empowerment of the population gave rise to the testimony:

Health education seeks dissemination of health concepts in order that the community may be responsible and be aware that the health situation in which they live does not depend exclusively on public policies, as well as the knowledge that each one has on his own health. I hope with health education activities that the population be also an active subject in the determination of their health. (DCS3)

Health education in practice

The speech of participants allowed the identification of the following MI in relation to educational practices developed by nurses in the FHS:Punctual actions, Continuous actions and Difficulties for educational activities.

Regarding MI Punctual actions, there is the following speech:

I develop health education actions in groups of this unit. Especially with the group of teenagers, it is one that I have much affinity, for various reasons. Mainly because this audience only comes to the post when they are going to the dentist, and I know they need accessing information in the lectures. There are also cases of campaigns on tuberculosis, leprosy, uterus and breast cervical cancer, man health, conversation circles, activities in schools, continuing education with the FHS team. (DCS4)

With respect to the MI Continuous actions, there is:

Health education activities are present in our day to day, in consultations we do, in home visits. I think it's better to develop conversations during consultations, although this may take a lot on the time and may make the consultation to delay a lot time (DCS5)

From the MI Difficulties in development of health education practices emerged the speech:

I encounter many difficulties in developing health education in our daily lives because we are not able to work in health education. Educational materials such as brochures, posters, they may come, but they are few for the amount of people that come here. And there is still the fact that when I stop to carry out health education during consultations, many people complain because I'm not giving assistance. We are very much demanded as professionals, for filling forms, productivity and this ends up interfering a lot in health education activities that are in the second plan. (DCS6)

Discussing concepts and practices

Health education, as the act of providing information and imparting knowledge to the population in order to prevent disease and promote health, reflects a discourse fundamented in the traditional biomedical model, in which educational work is centered on the simple transmission of information. According to this model, users are a passive repository of knowledge and must modify their behavior according to what is recommended, being also considered guilty of falling ill14-16.

Even today, many health professionals are guided by the reductionist and positivist view of health education, whose guidelines are based on the adoption of behaviors deemed appropriate, related to the proper use of medication, control of health problems, knowledge on pathologies or activities developed in health units. However, this model has long shown to be ineffective in responding to the real needs of the population.

The reality shows that, despite the fact that the reorientation of the care model, part of the FHS, is a concrete proposal, in practice this is still under construction, and elements of the two models of health care coexist. At the same time, society in general persists in the idea that health services are associated with situations of illness and not with health17.

In this context, the major challenge for the FHS is rethinking its practice on new paradigms. It is essential to reorient the work processes and explore new methodologies, tools and knowledge in order to promote the desired changes18.

The paradigm change makes possible to understand science in a much more critical and creative level, where health education is considered na area of human knowledge that reaffirms the exercise of citizenship 19. Therefore, the educational work of nurses in the FHS should not be based on the guidelines related to prevention of diseases and disorders, and should be grounded in the quest for public awareness of the importance of self-care and full understanding of the health/disease process20.

In this sense, it is emphasized that the health education speech, as a way to enable awareness and active participation of people in determining their health, meets the real purpose of the FHS. The educational practice, from this perspective, enables the community ability for self-care and coping with the health/disease process, contributing to the reconstruction of meanings and attitudes that result in healthier choices in their lives and consequently in improving health.

For this to happen, there needs to be a process of interaction between the theoretical content and the life experience of each individual and it is necessary to establish relationships of trust and bond between users, professionals and health services, allowing the acceptance of the educational proposal, even though this does not imply an immediate solution to the population's health problems21. Thus, the bond favors negotiation between professionals and users to reach a consensus about needs and responsibilities, establishing co-responsibility pacts in search for the best conduct of care.

Furthermore, for the educational proposal reach the expected results, a dialogical relationship between nurses and users is needed. This will be possible through the approximation and creation of emotional ties, trust and respect between the individuals involved, supporting the achievement of a resolutive and humanized care.

Despite of being an innovative speech in line with the objectives of the FHS, educational practices developed by nurses are still strongly linked to the approach to vertical programs of the Ministry of Health, through the simple transference of information, which can be considered a limiting factor for the effectiveness of comprehensive care.

We reiterate that the educational process is beyond the information and communication processes, constituting a social practice that gives meaning to information, making critical space of the causes of population problems as well as the actions necessary for its resolution22. Thus, the educational process should permeate all nursing activities, including care assistance, glimpsing possibilities of transformation.

It is necessary that nurses and other health professionals overcome the obstacles that arise during the educational practice, enabling the improvement of care assistance. It is, therefore, extremely important to identify the needs of the population and the exploitation of potential users for the transformation of habits and adoption of self-care, by a process of production, accumulation and exchange of knowledge in order to ensure comprehensive health care 23. Nurses need to develop strategies and pedagogical methodologies that approach the families to know their way of life and allow greater participation of users in the construction of knowledge on health.

Given the above, the nursing consultation is revealed as a tool capable of enabling the creation of links between professionals and users, through proximity, dialogue and trust that is established in the act of direct and individualized care and thus, appears to be fertile ground for the realization of educational activities in more effective health.

In this study, nursing consultations appear as an important promoting strategy of links, favoring the realization of health education. At the moment of consultation, the nurse is attentive to user's demands through an active and qualified listening, establishing a close and trusting relationship that allows identifying problems for which care actions are directed.

The educational character of the nursing consultation is a proof of its effectiveness in clinical practice, because in order to identify and find solutions to a problem, an exchange of knowledge between nurses and individual, family and/or community must take place, resulting in health promotion through stimulating and empowering users to actively participate in building their knowledge and awakening them for self-care14.

Thus, it is necessary that nurses in their work dynamics, be trained and attentive to the development of educational activities to promote the health of the population and help them to develop a social consciousness.

According to the speech of the participants, health education in the FHS is still fraught with difficulties, corroborating the results of another study, which showed that the educational work of nurses faces several obstacles, namely: lack of physical, materials and financial resources; lack of acceptance and adherence to educational activities; great spontaneous demand; work overload; training and professional qualifications; lack of continuing education; and limited vision of the managers of the FHS policy24.

Given the above, there is a need to establish changes in the care practice and in the management grounded in the purposes of the FHS, in order to enhance the educational work in this level of attention. It is necessary to develop continuous training programs for professionals, qualifying them for the full development of educational practices and promotion of health of the population20.



The results showed that the daily work of nurses participating in this study is marked by overlapping educational activities linked to the traditional model and the new health care model, which incorporates the FHS. This may be related to various difficulties for the development of health education at this level of attention, relating to users, healthcare professionals and management.

Before this reality, it is important that nurses and other members of the multidisciplinary health team awake to the need to recognize the limitations and develop strategies to overcome them. It is necessary to strengthen social participation and autonomy of users, contributing to the formation of social individuals responsible for changes facing the reality where they live.

The study has limitations inherent to the method, which restricts the scope of the findings to the study population, making it impossible to make comparisons and generalizations. On the other hand, although the results portray a specific reality, it is of fundamental importance to establish changes in the educational work of nurses in the FHS and thus achieve the improvement in the health of the population.



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