ABSTRACT

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.

KEYWORDS
Nursing assistance; Workflow; Primary Health Care; Unified Health System

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”¹1 Marx K. O Capital: Crítica da Economia Política - o processo de produção do capital. Livro 1. 2. ed. São Paulo: Boitempo; 2017.^(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 place¹1 Marx K. O Capital: Crítica da Economia Política - o processo de produção do capital. Livro 1. 2. ed. São Paulo: Boitempo; 2017..

The health work process is better understood from the thinking of Mendes-Gonçalves²2 Mendes-Gonçalves RB. Tecnologia e organização social das práticas de saúde. Características tecnológicas do processo de trabalho em saúde na rede estadual de centros de saúde de São Paulo. São Paulo: Hucitec; 1994.,³3 Mendes-Gonçalves RB. Práticas de saúde: processos de trabalho e necessidades. Cad. CEFOR – Textos 1. São Paulo: CEFOR; 1992.. 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 process²2 Mendes-Gonçalves RB. Tecnologia e organização social das práticas de saúde. Características tecnológicas do processo de trabalho em saúde na rede estadual de centros de saúde de São Paulo. São Paulo: Hucitec; 1994.,³3 Mendes-Gonçalves RB. Práticas de saúde: processos de trabalho e necessidades. Cad. CEFOR – Textos 1. São Paulo: CEFOR; 1992.,⁴4 Peduzzi M, Schraiber LB. Processo de Trabalho em Saúde. Dicionário da Educação Profissional em Saúde. Fundação Oswaldo Cruz. Escola Politécnica de Saúde Joaquim Venâncio. 2009. [acesso em 2022 mar 25]. Disponível em: http://www.sites.epsjv.fiocruz.br/dicionario/verbetes/protrasau.html.
http://www.sites.epsjv.fiocruz.br/dicion... .

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 general⁵5 Ayres JRCM, Bruno R. História, processos sociais e práticas de saúde. Ciênc. Saúde Colet. 2015 [acesso em 2022 mar 25]; 20(3):905-912. Disponível em: https://www.scielo.br/scielo.php?script=sci_arttext&pid=S141381232015000300905&lng=pt&nrm=iso&tlng=pt.
https://www.scielo.br/scielo.php?script=... .

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 model⁶6 Merhy EE, Franco TB. Trabalho em Saúde. In: Pereira IB, Lima JCF, organizadores. Dicionário da Educação, Profissional em Saúde. 2. ed. rev. ampl. Rio de Janeiro: EPSJV; 2008. 478 p. [acesso em 2022 mar 25]. Disponível em: http://www.sites.epsjv.fiocruz.br/dicionario/Dicionario2.pdf.
http://www.sites.epsjv.fiocruz.br/dicion... .

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 society⁴4 Peduzzi M, Schraiber LB. Processo de Trabalho em Saúde. Dicionário da Educação Profissional em Saúde. Fundação Oswaldo Cruz. Escola Politécnica de Saúde Joaquim Venâncio. 2009. [acesso em 2022 mar 25]. Disponível em: http://www.sites.epsjv.fiocruz.br/dicionario/verbetes/protrasau.html.
http://www.sites.epsjv.fiocruz.br/dicion... ,⁷7 Scochi MJ, Mishima SM, Peduzzi M. Maria Cecília Puntel de Almeida: construtora de pontes entre Enfermagem e a Saúde Coletiva brasileira. Ciênc. Saúde Colet. 2015 [acesso em 2022 mar 25]; 20(12):3891-3896. Disponível em: https://www.scielo.br/pdf/csc/v20n12/1413-8123-csc-20-12-3891.pdf.
https://www.scielo.br/pdf/csc/v20n12/141... .

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 political-social context of the health sector⁸8 Ferreira SRS, Périco LAD, Dias VRGF. A complexidade do trabalho do enfermeiro na Atenção Primária à Saúde. Rev Bras Enferm. 2018 [acesso em 2022 mar 25]; 71(supl1):704-9. Disponível em: https://www.scielo.br/j/reben/a/qTVY5r3JLdL8xcTHNf9ZhxF/?lang=pt&format=pdf.
https://www.scielo.br/j/reben/a/qTVY5r3J... .

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 interdependent⁹9 Paula M, Peres AM, Bernardino E, et al. Características do Processo de Trabalho do Enfermeiro da Estratégia de Saúde da Família. Rev. Min. Enferm. 2014 [acesso em 2022 mar 25]; 18(2):454-462. Disponível em: https://cdn.publisher.gn1.link/reme.org.br/pdf/v18n2a15.pdf.
https://cdn.publisher.gn1.link/reme.org....

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)¹⁰10 Ferreira SRS, Mai S, Périco LAD, et al. O processo de trabalho da enfermeira na atenção primária, frente à pandemia da Covid-19. In: Teodósio SSCS, Leandro SS. Enfermagem na Atenção Básica no contexto da COVID-19. Brasília, DF: ABEEN. DEAB; 2020. (Série Enfermagem e Pandemias, v. 3). [acesso em 2022 mar 25]. Disponível em: https://publicacoes.abennacional.org.br/ebooks/atencaobasica.
https://publicacoes.abennacional.org.br/... .

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 profession¹¹11 Brasil. Gabinete da Presidência da República. Lei do Exercício Profissional de Enfermagem. Lei 7.498/86. DOU de 26.06.86. Seção I – fls. 9.273 a 9.275. Brasília, 1986. [acesso em 2022 mar 20]. Disponível em: http://www.cofen.gov.br/lei-n-749886-de-25-dejunho-de-1986_4161.html.
http://www.cofen.gov.br/lei-n-749886-de-... ,¹²12 Brasil. Ministério da Saúde. Portaria nº2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). 2017. [acesso em 2022 mar 25]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html.
https://bvsms.saude.gov.br/bvs/saudelegi... .

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 health⁸8 Ferreira SRS, Périco LAD, Dias VRGF. A complexidade do trabalho do enfermeiro na Atenção Primária à Saúde. Rev Bras Enferm. 2018 [acesso em 2022 mar 25]; 71(supl1):704-9. Disponível em: https://www.scielo.br/j/reben/a/qTVY5r3JLdL8xcTHNf9ZhxF/?lang=pt&format=pdf.
https://www.scielo.br/j/reben/a/qTVY5r3J... ,¹³13 Nauderer TM, Lima MADS. Práticas de enfermeiros em unidades básicas de saúde em município do sul do Brasil. Rev Latino-Am Enferm. 2008 [acesso em 2022 mar 25]; 16(5). Disponível em: https://www.lume.ufrgs.br/bitstream/handle/10183/94779/000667677.pdf?sequence=1&locale-attribute=en.
https://www.lume.ufrgs.br/bitstream/hand... .

Recognizing the importance of nursing care work and practices in PHC, this study aimed to analyze the PHC nursing work process in the state of Paraíba, Brazil, considering the professional profile and individual daily practices developed by nurses in the care dimension.

Material and methods

This article is an extract from the thesis study entitled: ‘Nursing Practice in Primary Health Care in the state of Paraíba: Theory, criticism, approaches and correlations with Advanced Nurse Practice (ANP)’. This thesis originates from the national research ‘Nursing Practices in the Context of PHC’, developed by the Center for Studies in Public Health of the Center for Advanced Multidisciplinary Studies at the University of Brasília (Nesp/ Ceam/UnB), in partnership with the Cofen; which was carried out with the collaboration of a national network of nursing researchers from public universities in all states of the federation and the Federal District. Its anchors, among other aspects, are the ontological, axiological, epistemological and methodological horizons of the social and human sciences applied to health¹⁴14 Conselho Federal de Enfermagem. Relatório. Práticas de Enfermagem no Contexto da Atenção Primária à Saúde (APS): Estudo Nacional de Métodos Mistos. Brasília, DF: CEAM; UnB; COFEN; 2022..

The research was carried out in different municipalities in the state of Paraíba from November 2019 to August 2021, turning to PHC, considering the services of the traditional UBS model and those of the ESF model.

Paraíba’s capital is the city of João Pessoa and is located in the Northeast Region of Brazil. It has, according to 2021 data, a territorial area of 56,467,242 km², 223 municipalities and 3,766,528 inhabitants; population density of 66.70 inhab./km² in 2010¹⁵15 Instituto Brasileiro de Geografia e Estatística. Censo Demográfico 2010: características da população e dos domicílios – Resultados do Universo. Rio de Janeiro: IBGE; 2011. [acesso em 2022 mar 25]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/periodicos/93/cd_2010_caracteristicas_populacao_domicilios.pdf.
https://biblioteca.ibge.gov.br/visualiza... and estimated population of 4,059,905 people in 2021¹⁶16 Instituto Brasileiro de Geografia e Estatística. Área territorial - Brasil, Grandes Regiões, Unidades da Federação e Municípios. 2021. [acesso em 2022 mar 25]. Disponível em: https://www.ibge.gov.br/geociencias/organizacao-do-territorio/estrutura-territorial/15761-areas-dos-municipios.html?=&t=acesso-ao-produto.
https://www.ibge.gov.br/geociencias/orga... .

It has 16 health regions distributed in 3 health macro-regions (CIB Resolution No. 43/2018). The first health macro-region, comprising four health regions, is headquartered in João Pessoa; the second, comprising five health regions, is headquartered in Campina Grande; and the third, comprising seven health regions, has two headquarters: one in Patos (Sertão) and another in Sousa (Alto Sertão)17. PHC coverage in Paraíba is 97.34%18. Among the 16 health regions in the state, 9 have 100% PHC coverage¹⁷17 Paraíba. Governo do Estado da Paraíba, Secretaria de Estado da Saúde. Plano Estadual de Saúde: Paraíba 2020/2023. [acesso em 2022 mar 25]. Disponível em: https://www.conass.org.br/wp-content/uploads/2021/04/PLANOS-ESTADUAL-DE-SAUDE-PB-2020-2023.pdf.
https://www.conass.org.br/wp-content/upl... .

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)¹⁴14 Conselho Federal de Enfermagem. Relatório. Práticas de Enfermagem no Contexto da Atenção Primária à Saúde (APS): Estudo Nacional de Métodos Mistos. Brasília, DF: CEAM; UnB; COFEN; 2022..

In the state of Paraíba, 1,635 nurses are registered in the PHC/ESF¹⁹19 Brasil. Ministério da Saúde. Cadastro Nacional de Estabelecimentos de Saúde. CNES. Base de Dados. DA-TASUS, 2021. [acesso em 2022 mar 25]. Disponível em: http://cnes.datasus.gov.br/pages/downloads/arquivosBaseDados.jsp.
http://cnes.datasus.gov.br/pages/downloa... ; among these, 462 responded to the data collection instrument in the quantitative study stage.

As an inclusion criterion, the participation of all nurses who developed care or management practices in the PHC/ESF were admitted. Exclusion criteria were: preceptor nurses, consultants, among others who did not have a formal working relationship with the health service, and nurses absent due to vacation or leave of any kind¹⁴14 Conselho Federal de Enfermagem. Relatório. Práticas de Enfermagem no Contexto da Atenção Primária à Saúde (APS): Estudo Nacional de Métodos Mistos. Brasília, DF: CEAM; UnB; COFEN; 2022..

Data analysis was performed using SPSS® software (Statistical Package for the Social Sciences), version 21.0 for Windows®, using descriptive and inferential statistical analysis.

The project was submitted to the Research Ethics Committee of the Faculty of Health Sciences of the University of Brasília, approved under Opinion No. 3,619,308 and CAAE: 20814619.2.0000.0030, in accordance with Resolution No. of Health (CNS)²⁰20 Brasil. Ministério da Saúde. Resolução nº 466, de 12 de dezembro de 2012. Conselho Nacional de Saúde. [acesso em 2022 mar 25]. Disponível em: http://conselho.saude.gov.br/resolucoes/2012/Reso466.pdf.
http://conselho.saude.gov.br/resolucoes/... . 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.

Results and discussion

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 model²¹21 Lima EFA, Sousa AI, Primo CC, et al. Perfil socio-profissional de trabalhadores de equipes saúde da família. Rev. Enferm UERJ. 2016 [acesso em 2022 mar 25]; 24(1):e9405. Disponível em: https://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/9405.
https://www.e-publicacoes.uerj.br/index.... .

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’²²22 Organização Pan-Americana da Saúde. Infográfico - Situação da enfermagem na Região das Américas. Organização Pan-Americana da Saúde Organização Mundial da Saúde. Escritório Regional para as Américas. 2021. [acesso em 2022 mar 25]. Disponível em: https://iris.paho.org/handle/10665.2/54504.
https://iris.paho.org/handle/10665.2/545... . 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 women²³23 Oliveira APC, Ventura CAA, Silva FV, et al. The State of Nursing in Brazil. Rev. Latino-Am. Enfermagem. 2020 [acesso em 2022 mar 25]; (28):e3404. Disponível em: https://www.scielo.br/j/rlae/a/nwPZbvkYp6GNLsZhFK7mGwd/?lang=pt.
https://www.scielo.br/j/rlae/a/nwPZbvkYp... .

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 women²⁴24 Organização Pan-Americana da Saúde. Fotografia da enfermagem no Brasil. [acesso em 2022 mar 25]. Disponível em: https://apsredes.org/fotografia-daenfermagem-no-brasil/.
https://apsredes.org/fotografia-daenferm... .

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,²⁵25 Biff D, Pires DEP, Forte ECN, et al. Cargas de trabalho de enfermeiros: luzes e sombras na Estratégia Saúde da Família. Ciênc. Saúde Colet. 2020 [acesso em 2022 mar 25]; 25(1):147-158. Disponível em: https://www.scielo.br/j/csc/a/GRyVBGTqC6GfcpnHTVf9RVr/?format=pdf&lang=pt.
https://www.scielo.br/j/csc/a/GRyVBGTqC6... the Cofen study on the ‘Profile of Nursing in Brazil’²⁶26 Machado MH, Aguiar Filho W, Lacerda WF, et al. Características gerais da enfermagem: o perfil sociodemográfico. Enferm. Foco. 2016 [acesso em 2022 mar 25]; 6(1/4):11-17. Disponível em: http://biblioteca.cofen.gov.br/wp-content/uploads/2016/07/Caracter%C3%ADsticas-gerais-da-enfermagem-o-perfil-s%C3%B3cio-demogr%C3%A1fico.pdf.
http://biblioteca.cofen.gov.br/wp-conten... ,²⁷27 Conselho Federal de Enfermagem. Relatório final da pesquisa Perfil da Enfermagem no Brasil. Rio de Janeiro: Fiocruz; Cofen; 2017. v. 1. [acesso em 2022 mar 25]. Disponível em: http://www.cofen.gov.br/perfilenfermagem/index.html.
http://www.cofen.gov.br/perfilenfermagem... 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 territory¹⁴14 Conselho Federal de Enfermagem. Relatório. Práticas de Enfermagem no Contexto da Atenção Primária à Saúde (APS): Estudo Nacional de Métodos Mistos. Brasília, DF: CEAM; UnB; COFEN; 2022..

It should be noted that, in the national survey on ‘Nursing Practices in the Context of PHC’¹⁴14 Conselho Federal de Enfermagem. Relatório. Práticas de Enfermagem no Contexto da Atenção Primária à Saúde (APS): Estudo Nacional de Métodos Mistos. Brasília, DF: CEAM; UnB; COFEN; 2022., 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%²⁸28 World Health Organization. State of the world’s nursing 2020: investing in education, jobs and leadership. Geneva: World Health Organization; 2019. [acesso em 2022 mar 25]. Disponível em: https://www.who.int/publications/i/item/9789240003279.
https://www.who.int/publications/i/item/... .

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 participation²⁹29 Santos AL, Rigotto RM. Território e territorialização: incorporando as relações produção, trabalho, ambiente e saúde na Atenção Básica à Saúde. Trab. Educ. Saúde. 2010/2011 [acesso em 2022 mar 25]; 8(3):387-406 Disponível em: https://www.scielo.br/j/tes/a/H5BtBJTGvQZgSXKvNrTKphp/?format=pdf&lang=pt.
https://www.scielo.br/j/tes/a/H5BtBJTGvQ... .

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 institutions²⁷27 Conselho Federal de Enfermagem. Relatório final da pesquisa Perfil da Enfermagem no Brasil. Rio de Janeiro: Fiocruz; Cofen; 2017. v. 1. [acesso em 2022 mar 25]. Disponível em: http://www.cofen.gov.br/perfilenfermagem/index.html.
http://www.cofen.gov.br/perfilenfermagem... .

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 care²⁵25 Biff D, Pires DEP, Forte ECN, et al. Cargas de trabalho de enfermeiros: luzes e sombras na Estratégia Saúde da Família. Ciênc. Saúde Colet. 2020 [acesso em 2022 mar 25]; 25(1):147-158. Disponível em: https://www.scielo.br/j/csc/a/GRyVBGTqC6GfcpnHTVf9RVr/?format=pdf&lang=pt.
https://www.scielo.br/j/csc/a/GRyVBGTqC6... .

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 nurses³¹31 Corrêa ACP, Araújo EF, Ribeiro AC, et al. Perfil sociodemográfico e profissional dos enfermeiros da atenção básica à saúde de Cuiabá - Mato Grosso. Rev. Eletr. Enf. 2012 [acesso em 2022 mar 25]; 14(1):171-80. Disponível em: https://revistas.ufg.br/fen/index.
https://revistas.ufg.br/fen/index... .

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 socio-sanitary responsibility with a view to inverting the health care model, reproducing the high turnover, precariousness and dissatisfaction of health workers³²32 Sousa MF, Santos BM, Paz EP, et al. Complexidade das Práticas da Enfermagem na Atenção Primária à Saúde. Enferm Foco. 2021 [acesso em 2022 mar 25]; 12(supl1):55-60. Disponível em: http://biblioteca.cofen.gov.br/wp-content/uploads/2021/09/complexidade-praticas-enfermagem-atencao-primariasaude.pdf.
http://biblioteca.cofen.gov.br/wp-conten... .

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 health³²32 Sousa MF, Santos BM, Paz EP, et al. Complexidade das Práticas da Enfermagem na Atenção Primária à Saúde. Enferm Foco. 2021 [acesso em 2022 mar 25]; 12(supl1):55-60. Disponível em: http://biblioteca.cofen.gov.br/wp-content/uploads/2021/09/complexidade-praticas-enfermagem-atencao-primariasaude.pdf.
http://biblioteca.cofen.gov.br/wp-conten... .

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 knowledge³³33 Barros ALBL, Batista NA, Barbosa DA, et al. Livredocência: o reconhecimento de uma trajetória comprometida com o ensino, pesquisa e extensão. Rev Bras Enferm. 2021 [acesso em 2022 mar 25]; 74(supl5):1-4. Disponível em: https://www.scielo.br/j/reben/a/rMFh5VvDmMj7wwgKWr8bY5r/?format=pdf&lang=pt.
https://www.scielo.br/j/reben/a/rMFh5VvD... .

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 life⁸8 Ferreira SRS, Périco LAD, Dias VRGF. A complexidade do trabalho do enfermeiro na Atenção Primária à Saúde. Rev Bras Enferm. 2018 [acesso em 2022 mar 25]; 71(supl1):704-9. Disponível em: https://www.scielo.br/j/reben/a/qTVY5r3JLdL8xcTHNf9ZhxF/?lang=pt&format=pdf.
https://www.scielo.br/j/reben/a/qTVY5r3J... .

Ordinance No. 2,436/2017, of the PNAB¹²12 Brasil. Ministério da Saúde. Portaria nº2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). 2017. [acesso em 2022 mar 25]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html.
https://bvsms.saude.gov.br/bvs/saudelegi... , lists the specific duties of nurses, presenting a set of actions, among which are those that make up the care practice in PHC. In this scope, nursing consultations, aimed at groups of users in different life cycles; vaccine room supervision; performing dressings; the request for exams; and medication prescription are, among others, individual daily practices present in the nursing work process.

The practices mentioned above are distributed in table 2, which shows how often and in what percentage PHC/ESF nurses in the state of Paraíba develop them.

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 Law¹¹11 Brasil. Gabinete da Presidência da República. Lei do Exercício Profissional de Enfermagem. Lei 7.498/86. DOU de 26.06.86. Seção I – fls. 9.273 a 9.275. Brasília, 1986. [acesso em 2022 mar 20]. Disponível em: http://www.cofen.gov.br/lei-n-749886-de-25-dejunho-de-1986_4161.html.
http://www.cofen.gov.br/lei-n-749886-de-... 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 flows³⁴34 Bonatto SR, Steffani P, Lima LA, et al. Protocolos de enfermagem no município de Jaraguá do Sul/SC: estratégia transformadora para atenção primária. Enferm. Foco. 2021 [acesso em 2022 mar 25]; 12(supl1):147-52. Disponível em: http://revista.cofen.gov.br/index.php/enfermagem/article/view/5173/1175.
http://revista.cofen.gov.br/index.php/en... .

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 authors³⁴34 Bonatto SR, Steffani P, Lima LA, et al. Protocolos de enfermagem no município de Jaraguá do Sul/SC: estratégia transformadora para atenção primária. Enferm. Foco. 2021 [acesso em 2022 mar 25]; 12(supl1):147-52. Disponível em: http://revista.cofen.gov.br/index.php/enfermagem/article/view/5173/1175.
http://revista.cofen.gov.br/index.php/en... 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 valorization³⁵35 Cavalheiro AP, Silva CL, Veríssimo ML. Consulta de enfermagem à criança: atuação do enfermeiro na atenção primária à saúde. Enferm Foco. 2021 [acesso em 2022 mar 25]; 12(3):540-5. Disponível em: http://revista.cofen.gov.br/index.php/enfermagem/article/view/4305/1200.
http://revista.cofen.gov.br/index.php/en... .

It is known that, among the consultations in the daily work of PHC, nurses perform low-risk 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.

Alicerçando-se na Lei nº 7.498/8611, o Cofen, através da Resolução nº 195/9737 e da Resolução nº 317/200738, define que, para a prescrição de medicamentos, a(o) enfermeira(o) necessita solicitar exames de rotina e complementares, estabelecidos em programas de saúde pública e em rotina aprovada pela instituição de saúde, para uma efetiva assistência ao paciente, sem risco para ele.

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’³⁹39 Conselho Regional de Enfermagem da Paraíba. Protocolo do Enfermeiro na Estratégia de Saúde da Família do estado da Paraíba. 2. ed. João Pessoa: COREN-PB; 2015. [acesso em 2021 mar 25]. Disponível em: http://www.corenpb.gov.br/wp-content/uploads/2015/12/Coren-Pb-Protocolo-do-Enfermeiro-pb-20102015.pdf.
http://www.corenpb.gov.br/wp-content/upl... .

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 Health³⁶36 Lima MVP. Estratégias da gestão local para prescrição de medicamentos por enfermeiros da atenção primária à saúde. [dissertação]. Campina Grande: Universidade Estadual da Paraíba; 2019. [acesso em 2022 mar 25]. Disponível em: http://tede.bc.uepb.edu.br/jspui/handle/tede/4059.
http://tede.bc.uepb.edu.br/jspui/handle/... .

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’¹⁴14 Conselho Federal de Enfermagem. Relatório. Práticas de Enfermagem no Contexto da Atenção Primária à Saúde (APS): Estudo Nacional de Métodos Mistos. Brasília, DF: CEAM; UnB; COFEN; 2022..

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 resolution⁴⁰40 Conselho Federal de Enfermagem. Código de Ética dos Profissionais de Enfermagem. Rio de Janeiro: Conselho Federal de Enfermagem; 2007. Disponível em: http://www.cofen.gov.br/wp-content/uploads/2012/03/resolucao_311_anexo.pdf.
http://www.cofen.gov.br/wp-content/uploa... .

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.

References

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