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Authors summary
Why was this study done?
This study was initially carried out because it is a relevant topic for the nursing category, both from a social, human, scientific, care and management point of view. Thus, investigating about the perception of nurses regarding the systematization of nursing care, help to deepen the knowledge of nursing, expanding discussions and understanding regarding the perception of professionals in primary health care. It is possible to contribute to the improvement of direction for teaching and service institutions in view of the knowledge and difficulties of nurses in relation to the implementation of the systematization of nursing care and in the work process model, in order to rethink effective strategies to reorganize care and contribute to the strengthening of health policies that invest in promotion and prevention.
What did the researchers do and find?
First, selection of study participants, then a semi-structured interview was applied with nurses registered in the family health team of family health units, which work in the primary care network. After collecting the data, we proceeded to the organization and interpretation where we opted for the content analysis proposed by Bardin. After analyzing the data, it was possible to find three results, which originated the three categories of the study, the first: it was evidenced that the perception of professional nurses regarding the Systematization of Nursing Care, the second refers to the assistance provided by professionals does not happen mediated by the implementation of the nursing process and the third, there are still obstacles in training, highlighting points such as the need to broaden the discussion on the subject during training and professional practice.
What do these findings mean?
Considering the findings, it showed that there is a lack of knowledge about the systematization of nursing care, with this, nurses face difficulties in implementing care in their daily activities. In addition, with the lack of applicability of the Nursing Process method, they direct their care to the momentary complaints of individuals, with this, they fail to expand knowledge to the client in an integral and individualized way, causing a fragmented care practice, leaving to meet the real needs of the population.
Highlights
The study points to the need to generate knowledge for professionals who work in patient care, expanding their view even during graduation. Training and directing professionals is essential for better results in health services and care. In order to change the scenario, it is necessary to have paradigm shifts, starting in educational institutions, introducing disciplines that encourage practice and offer sufficient knowledge for professional performance with the objective of achieving quality results.
INTRODUCTION
The Systematization of Nursing Care (SNC) as a method allows nurses to plan care in a systematic way and with a focus on the needs of the individual.
The Federal Nursing Council, through its Resolution 358/2009, recognizes that organized nursing care requires to use of methodological instruments, which, based on the method, makes the nursing intervention more feasible; this assistance has as an instrument the nursing process (NP)1.
The SNC is a way of organizing the professional work of nursing on a theoretical and philosophical basis. Its use is crucial during the provision of safe care and with technical, scientific, and human resources to improve the quality of care and favor teamwork and communication, enabling greater appreciation of professionals2,3.
In Brazil, the method described for the first time in the 70s stands out, guided by the theory of basic human need (BHN) developed by Wanda Horta, which has the phases of the Nursing Process (NP)4,5.
Horta (1979) defines the NP stages as dynamic, interconnected, and interrelated and divides them into history, diagnosis, care plan, nursing care plan or prescription, nursing prognosis, and evaluation, and stages that make care integral and specific6,7.
In this way, it is necessary to implement the nursing care process to guarantee care assistance and more resources during the patient’s treatment. Therefore, developing the best technique using the nursing process as a methodology for organizing and scheduling services and providing a better quality of favorable team (11) with results continuously and individually8,9.
The Pan American Health Organization (PAHO) defines PHC as a strategy for organizing the health system, enabling comprehensive and universal assistance for everyone who needs to be met in a more holistic, continuous way through actions and health services. Thus, a model of care that meets these characteristics provided throughout the person’s life cycle and/or community comes into play10,11.
SNC helps nurses review their decision-making effectively and persistently, approach other professionals and patients, and share and apply information to guarantee the continuity of care provided by diverse care needs12.
Therefore, investigating nurses’ perceptions regarding SNC in primary care is highly relevant, expanding the discussions and understanding of professionals’ perceptions. It is still possible to contribute with directions for teaching and service institutions, given the knowledge and difficulties of nurses concerning the implementation of SNC and the work process model, and thus, rethink effective strategies to reorganize care and contribute to the strengthening of health policies that invest in promotion and prevention. Therefore, this study’s general objective is to analyze nursing care in primary health care in light of the theory of basic human needs.
METHODS
It is a descriptive study with a qualitative approach, developed in the city of Rio Branco, Acre, Brazil. The research, with the opinion of 1,975,410 of the Research Ethics Committee, had as its scenario the Basic Family Health Units (BFHU) distributed by 69 Family Health Teams (FHT), 13 of which work in the Support Unit format of Family Health.
Nurses connected to the FHT participated, with a minimum of six months of experience, totaling 48 interviewees. A semi-structured interview addressing questions about SNC’s knowledge and practices was used to collect the data.
Following Minayo13, non-participatory observation was done. In addition to bringing the action of speaking closer to the practical exercise of day-to-day related to thinking and acting in practice with the use of a checklist14.
For data analysis, as a method for organization and interpretation, we opted for the content analysis proposed by Bardin15, developed through three methodological steps allowing the construction of an analysis structure according to the needs and objectives presented by the research, figure 1.
Based on the previously defined rules, the applicability of the data exploration and processing phase began. For this, the enumeration/evaluation rules of the units are made based on the coding process. The choice of counting rules makes it possible to define the Registration Units (RU) and Context Units (CU) according to the objectives arising from the indicators of a semantic nature regarding the affirmation of the SNC theme. The RUs and UCs are organized according to their evidence and guided by the definition of the simple frequency rule, where it is only possible to count the number of appearances of the RUs. According to Bardin, Simple Frequency (SF) corresponds to the frequency of appearance of words or themes. It corresponds to the frequency of appearance of the theme words, which are repeated when considering the importance value. The more they are repeated, the more meaning is given to the expression or significance, giving more importance to the RU.
This rule made it possible to count only the words as a signifier, that is, the representativeness identified in the nurses’ statements of what they understand concerning SNC. Thus, RUs and CUs are based on the rules, as shown in table 1:
Table 1 : Record units and context of analytical categories. Rio Branco, Acre, Brazil, 2020
| Categories | Participants | Registration units | Context units |
|---|---|---|---|
| Nurses' perception of the Systematization of Nursing Care | Professionals | (1) Service organization (2) Priority-diagnosis/problem, (3) Planning, implementation, diagnosis, (4) Nursing process/history, physical examination, nursing prescription, (5) Facilitates the Service, (6) Care plan (7) Apply Protocols | Some point out the SNC as the form of the service organization, prioritization of diagnosis/problem, planning, implementation and diagnosis, nursing process or phases in the elaboration of the care plan/intervention method. And some consider it just a way to facilitate the service and/or apply protocols to meet the health needs of the person or the population. |
| How nurses systematize nursing care | Professionals | (1) Interview; anamnesis; physical examination (2) Medical diagnosis/complaint/problem (3) Problems/pathology. | The screening process guides the Systematization of Nursing Care with a focus on carrying out an anamnesis/interview, identifying the problem based on the primary complaint or diagnosed pathology, and then carrying out a possible care and intervention plan. |
| Challenges in the care implementation mediated by the Nursing Process | Professionals | (1) Structure/internet, (2) Time, (3) High demand, (4) Lack of connection with the community, (5) Academic education and training | The nursing process implementation becomes limited due to obstacles such as high demands, lack of human and material resources, and lack of time and an unestablished bond with the community. In addition, academic training and insecurity are also elements that contribute to limiting the execution of the NP. |
Source: Self-elaboration.
Thus, the criteria defined for the enumeration rules were used in the three analytical categories which emerged from this research; they are:
Category I: Nurses’ perception of the Systematization of Nursing Care, considering the value given more importance to those with more significant scientific evidence in order of words or ideas defined from the analysis of simple frequency were: (1) Organization of services (2) Priority-diagnosis/problem, (3) Planning, implementation, diagnosis, (4) Nursing process/history, physical examination, nursing prescription, (5) Facilitates Service, (6) Plan of care (7) Apply Protocols.
Category II: How nurses systematize nursing care, the fragments of communications that demonstrate how the organization of the work environment in the FHT units happens. Related to word order or defined ideas of higher value to those with more substantial scientific evidence used from simple frequency analysis were: (1) Interview; anamnesis; physical examination (2) medical diagnosis/complaint/problem (3) Problems/pathology.
Finally, category III: Challenges in implementing care mediated by the NP, deals with the difficulty or ease of implementing care mediated by the NP. Applying the simple frequency rule allowed the identification of RUs, making it possible to count only the words while significance presented in the statements, following the order and quantity of appearance. The order of words or ideas defined from the simple frequency analysis were: (1) Structure/internet, (2) Time, (3) High demand, (4) Lack of connection with the community, (5) Academic education and training.
The last phase corresponds to the treatment of the results categorized and organized by RUs and UCs, subsidizing the elaboration of evidence and the construction of the framework for each analytical pre-category.
For each analytical pre-category, the research evidence that guided the discussions was described, seeking to understand the meaning of social representations in the light of their evidence, whether you are favorable, unfavorable, or neutral with the ideas presented, as illustrated in board 2.
Table 2 : Registration units, context units, and the formation of the respective analytical pre-categories according to Bardin’s analysis technique (2011). Rio Branco, Acre, Brazil, 2020
| Analytical Categories | Registration units | Context units |
|---|---|---|
| Nurses' perception of Systematization of Nursing Care. | Priority diagnosis/problem; Planning, implementation, diagnosis; nursing process/history, physical examination, nursing prescription; Facilitating the Service; Care plan. | Some point out SNC as a service organization, prioritization of diagnosis/problem, planning, implementation and diagnosis, nursing process or phases in elaborating the care plan/intervention method. Others consider it only as a facilitator of the service and/or protocol application to meet the health needs of the person or the population. |
| How do nurses systematize nursing care? | Interview; anamnesis; physical exam. Medical diagnosis/complaint/problem. Problems/pathology. | A triage process guides the Systematization of Nursing Care with a focus on carrying out an anamnesis/interview and identifying the problem based on the primary complaint or diagnosed pathology and, after, carrying out possible care and intervention plan. |
| Challenges in the implementation of care mediated by the nursing process. | Time; Academic education Structure/internet. High demand. Lack of connection with the community. | The implementation of the nursing process becomes limited due to obstacles such as high demands, lack of human and material resources, and lack of time and an unestablished bond with the community. In addition, academic training and insecurity are also elements that contribute to limiting the execution of the NP. |
Table 3 : Description of the study evidence related to the categories. Rio Branco, Acre, Brazil, 2020
| Thematic categories | Identified evidence |
|---|---|
| Nurses’ perception of the Systematization of Nursing Care | Evidence: SNC with a focus on protocols; punctual and fragmented assistance. |
| How nurses systematize nursing care | Evidence: A curative view of care, focused on punctual and fragmented practices. |
| Challenges in the implementation of care mediated by the nursing process | Evidence: Obstacles in academic education and training; need to reorganize care; need to build a protocol for SNC. |
Source: Self-elaboration.
RESULTS
Category Analysis
The study results were identified based on significant evidence. In addition, the enumeration rules were considered, with the treatment of data distributed in RUs and CUs.
In category I, it was evident that the perception of nursing professionals regarding the SNC is directed to the steps already programmed; even recognizing the importance of systematization, they end up being linked to complying and implementing care that is guided and based on ministerial protocols.
In category II, the assistance provided by professionals is not mediated by the implementation of the nursing process (NP), being limited to anamnesis, giving priority to the diagnosis or problem of that individual, and failing to provide comprehensive and holistic care. Assistance is focused on specific issues and interventions, making it difficult to improve the quality of life of the patient, family, and community.
In category III, there are still obstacles in training, highlighting points such as the need to broaden the discussion on the subject during training and professional practice. Light and light complex technologies appeared, such as interpersonal relationships, bonding with the community, and training as challenging points, in parallel with issues of organization, structure, and workspaces, which can be referred to as complex technologies.
DISCUSSION
Nurses perceive the SNC as an instrument for organizing care, but in practice, they end up thinking that SNC is focused on assistance directed to the use of ministerial protocols. In this context, it was also evidenced that they focus on support for health problems and complaints, indicating the anamnesis as a phase of the implemented NP, with the other stages concentrating on the disease diagnosis and specific interventions.
Regarding challenges, professionals reveal that the most significant limitations are high demands, lack of personal and material resources, and a lack of bond between professionals and patients so that they can better understand the needs of individuals and groups. Thus, problems come from training these professionals and continue while they are still in the workplace.
The nursing professional has direct contact with patients and is imperative in ensuring qualified health care. This assistance demanded them to look different to provide care with individuality and integrality16,17.
Therefore, the SNC aims to improve the care process of professionals, organizing the best plan and work process so that the objectives are achieved, improving results, and ensuring more qualified care that meets the biopsychosocial needs of each individual18.
Nurses’ perception of the Systematization of Nursing Care
In this context, the first category describes the nurses’ perception of SNC, based on the assumption that nursing, when working with individuals who need care, needs to have knowledge and knowledge that enable the provision of qualified health care.
Thus, from the perspective of the speeches of nursing professionals, the findings show that nurses differ in their perception of SNC, revealing a knowledge focused on a care plan following the ministry’s protocols, as testimonials below:
Nur. 4: “It is the planning, identification, planning, and intervention of nursing actions for individuals as a result of situations”.
Nur. 15 “When talking about the systematization of nursing care, it reminds me a lot of the nursing process, the five stages, the history, the physical examination, the nursing prescription, the implementation, and the evaluation”.
Nur. 29 “I understand that it is a more organized assistance, right, in which you can follow, where we follow the protocols, [...]”.
Nur. 36 “These are protocols, norms that guide our daily service routine”.
There is a fixed view on the implementation of SNC, which leads to organized practices based on already available protocols. Although they point to a form of organization and planning of care, in most cases, they prioritize the diagnosis/problem of the individual.
A study carried out in 2018 also showed that although professionals present knowledge about SNC, this knowledge is still confusing, with several doubts and conflicts regarding the theme19.
Most professionals have inadequate knowledge about SNC and its work methodology and, therefore, end up during their care practice failing to perform some steps and prioritizing others20.
Corroborating the study’s findings, Araújo et al.21 show that through SNC, professionals see the opportunity to organize actions and perform services as a team. In addition, the methodology allows for more humanized care and autonomy, based on the foundations of technical-scientific knowledge, favoring individual and qualified care and assistance.
It is known that SNC implementation is characterized by the organization and standardization of services that guide care, contributing to the improvement and continuity of individualized care, in addition to generating benefits in the organization of health services22.
Thus, although professionals recognize the importance of systematization in the organization of care and its result when applied, many still do not perform the NP stages the way they should23.
Corroborating the study, Ribeiro and Padoveze (2018)19, show that nurses cited the use of protocols as a tool for implementing SNC. Therefore, it is possible to observe that professionals, when implementing the systematization, end up developing actions erroneously based on programs and manuals of the Ministry of Health (MH), which will imply the incorrect use of the methodology, reaching only specific points and individuals of these protocols24.
Thus, the evidence of this study is that the perception of Primary Health Care (PHC) nurses about SNC are focused on the process stages for building a care plan; however, linked to the ease of implementation of ministerial protocols.
In this way, it can be understood that professionals are not performing the systematization correctly, much less taking the necessary steps for the NP, developing only actions focused on the diagnosis/problem of the individual.
Santana et al.23 guarantee that is improving the quality of health services, regardless of the level of care, is not based on protocols, rules, and norms. To improve these services, it is essential to include systematized work plans that guide the health actions that will be developed by the nursing team.
Xavier et al.25 brought up the importance of professionals knowing and applying the SNC, as this methodology can direct care in an individualized way and decision-making to solve problems from the direction of your actions and your team.
Bureaucratic activities are what most hinder the performance of care correctly. SNC does not happen in primary care services due to the distance between nurses’ thinking and performing since many are there only to fulfill protocol demands25.
SNC is seen as a methodology created to improve the assistance provided. Still, they are limited to carrying out programs imposed by the MS with the implementation of pre-established protocols. Because of this, there is a gap in reformulating new care practices so that SNC is recognized and practiced as the essential tool it is so that it is possible to introduce it in the daily work process and, thus, provide individualized care.
Professionals using the NP develop more useful care skills and promote greater patient/professional behavior autonomy to facilitate the acquisition of fundamental data during care and individualized assistance6.
Given this, the importance of systematization for professionals is perceived, directing the realization of broader and more resolute care for individuals and health services.
How nurses systematize nursing care
The second category describes how nurses systematize nursing care, having the practice of care as primary evidence based on the problem and/or diagnosed complaint. In this way, they carry out a schedule and an intervention, visualizing the punctual solution, without understanding the patient in meeting their deepest care needs in an integral, holistic and integrated way with primary health care. As mentioned by the nurses’ statements below:
Nur. 1 “[...] I do the interview, the anamnesis, the physical exam and sometimes and many times I make a schedule or even a... I write down all the care that this patient needs [...]”.
Nur. 12 “It is from the moment that the patient comes in I identify the problem, that I plan an action, that I intervene, so, this is all the nursing process”.
Nur. 20 “[...] we interview, looking for the main problems we have in the community to put together our action plan”.
Nur. 43 “Organizing my assistance, how am I going to talk to her, if what she is saying there, she is feeling is another type of problem, I try to differentiate one thing from the other”.
Therefore, it is possible to perceive that the nurses direct their care to the current problem identified in the data collection. The focus is to solve the patient’s complaint and carry out a care plan and intervention, approaching only that problem.
Corroborating our findings, a study showed that nursing professionals do not complete all the NP stages, focusing only on some steps19.
A study carried out four years ago mentioned that nurses need to understand the importance of SNC. Thus, its implementation will take lightly and complements this methodology to add and conform to the planning of services, helping in the execution, control, and evaluation of health actions, whether directly or indirectly linked to individuals and their families26.
However, the study points out that although professionals believe in implementing SNC as a tool to improve care, unfortunately, most are not in the habit of using it. The centered, patient approach is not unknown to professionals, but for some reason, they do not put it into practice27.
The study also mentions that SAE implementation is more frequent in secondary and tertiary care10. Therefore, this reinforces the need to enhance its use daily. In this way, when the NP is not carried out thoroughly, the information and care end up fragmented.
Therefore, professionals must put aside biological practices and begin to analyze the individual as a whole, creating innovative and effective strategies. Consequently, it is essential to understand that each individual is unique and has to be treated holistically and not just as a disease28,29.
It was evidenced that professionals practice care without using the method with defined steps, focusing only on the individual’s problem at that moment and performing specific interventions with a curative look.
Therefore, these professionals must understand the need for the applicability of the NP integrally so that they can understand the individual more broadly, identifying needs beyond the disease.
Thus, nurses need to understand the importance of SNC, so its implementation will take place lightly. It adds to the planning of services, helping to execute, control, and evaluate health actions30.
The SNC guarantees professionals a mechanism of valorization, autonomy, and quality practices, enabling them to provide differentiated assistance and create alternatives to improve the quality of life of individuals.
In this way, the SNC subsidizes actions that will contribute to the promotion, prevention, recovery, and rehabilitation of the health of individuals, families, and the community. However, in practice, this process shows difficulties, especially in PHC. However, it must be implemented in work environments, especially since professionals know how and when to use it31.
However, even during so many difficulties observed, professionals end up not seeing the functionality of the SAE, which would help organize and plan their care based on scientific and well-founded principles32.
Several factors are associated with the difficulty of implementing the SNC; they are organizational, professional, and even personal, and to be overcome, these professionals must be qualified.
Challenges in the implementation of care mediated by the nursing process
In this context, the third category describes challenges in the performance of care driven by the NP, showing that there are factors such as lack of human and material resources, deficits in professional training, excessive demand, and difficulty in communication, in addition to insecurity in the applicability of SNC.
It was evidenced that nurses missed being prepared to implement SNC in PHC. In addition, they question the high demand for services.
Nur. 45 “In my opinion, my difficulty started at college, we didn’t work the SNC in primary care, to tell you the truth, I don’t even know how to create a diagnosis [...]”.
Nur. 8 “The time, the demand is very high, and the process should be more dynamic to facilitate patient data collection; we don’t have that”.
Nur. 32 “I think the difficulty is because the population has not yet understood that prevention is better than coming here when the problem is already installed”.
Nur. 38 “[...] we have a little difficulty, and I don’t have the SNC in the file, in the hospital we end up organizing care in primary care according to the protocols of the ministry of health [...]”.
Therefore, the difficulties in implementing the NP are diverse. Still, they punctuate the problems related to academic training and preparation, issues with high demand, time to carry out activities, and the lack of internet. Professionals also report that the lack of proximity to the population impairs the implementation of the SNC, as they cannot create a bond or have good communication.
A study identified factors hindering SNC implementation: lack of training, excessive work demands, interruptions during the nursing consultation, and professional devaluation19.
The study by Penedo and Spiri33 reveals findings similar to ours; they point out an overload of activities, many users, a lack of human resources, and appropriate records.
The difficulty in implementing the NP is justified by the lack of knowledge of professionals about its phases, low quality of training, deficiency in the quality of training in the work environment, few personal resources, and investments in services, in addition to the limitation of professional autonomy33,34.
Thus, our findings suggest that challenges encountered in implementing care mediated by the NP are related to interpersonal relationships, reception, and bonds. In addition, those factors focused on knowledge, highlighting training and equipment and materials, such as technologies, which in nursing practice are allied to the care practices that underlie the profession35.
Health technologies are material and non-material instruments to assist in care practice and are divided into light technologies related to acts of health, reception, and humanization. Soft and hard technologies are technological, clinical, and epidemiological knowledge; hard technologies are machines, equipment, and other material resources36,37.
Thus, considering the challenges pointed out, there are those focused on light technologies, which are related to and interact with the community, for soft technologies, the training process, and hard technologies, the physical space, and instruments of care.
It is noteworthy that these factors are interconnected. And the health work process involves relationships, knowledge, care instruments, and organizational and structural issues.
For this reason, there is a need to develop and unite these technologies to guarantee a better quality of care, implementing in daily life several instruments capable of providing an evolution in care and nursing care. Thus, it is crucial to know the technical-scientific aspects, materials, and tools that involve these technologies to enable a group of sets that can improve quality care and expand the possibilities of practices capable of promoting care38,39.
Therefore, services must reorganize the care model, creating new care organization processes that do not impair care. And build a material that guides them during the systematization of quality care.
Therefore, as Silva et al.40 revealed in their study, teaching the nursing process even in training nursing professionals is essential. Training must accompany all theoretical, scientific, and technological advances so that educators are continuously trained to ensure good results in the methodology development and transform the care model provided in health services.
Therefore, the gap between training and practice needs more attention to reviewing professionals’ teaching methodologies. The educational institution is accountable for training students for professional life, essential for articulating theory and practice19.
It is noted a demand for a change in training. Educational institutions must adequate their methods, bringing theoretical/practical knowledge concurrently, especially concerning SNC, considering the challenges in the work environments so that it is possible to reduce them to guarantee a better quality of health for the population and more autonomy in health spaces.
Regarding the scarce professional/user interaction, it should be considered that this is a way of establishing bonds. It should start from the reception at the service to the nursing consultation.
Thus, given the implementation of SNC in primary care, it is clear that the knowledge of professionals is fundamental to guaranteeing the expected outcomes. Hence, it is vital to guide them to value SNC to improve patients’ and families’ quality of life.
It is also known that there are many challenges to implementing SNC, especially in PHC. Therefore, it is up to health services and educational institutions to create opportunities and specific actions that can help professionals, from training to using the methodology as an ally in providing care.
The quality of care and the guarantee of the population’s quality of life depends on the actions that will be developed; therefore, the implementation of SNC is essential. At the same time, it can create more autonomy and recognition for health professionals, ensuring greater occupation satisfaction and better working conditions.
CONCLUSION
In this research, it was evidenced that nurses working in primary health care end up directing their care only to the momentary complaints of individuals, failing to broaden the view as a whole. It is noticeable the use of protocols as a method to systematize nursing care by providing punctual and fragmented care.
Thus, nursing care occurs in a fragmented mode, failing to meet the real needs of the population, turning curative actions/acting into a punctual and fragmented practice.
Therefore, there is necessary to prepare professionals for the applicability of systematized nursing care capable of achieving better outcomes.
