Claudia Santos Martiniano

Medication prescription by nurses and the case of the Brazil: what can we learn from international research?

The role of the nurse in the process of medication scription and ordering diagnostic tests and clinical minations has intensified worldwide. For the Internaal Council of Nursing (ICN), these actions are innovaelements that contribute to advanced nursing practice , 2011). The term prescription by nurses encompasses versity of practices within which we can highlight three dels: the independent or substitute prescriber, the i-autonomous or complementary prescriber, and the up protocol (Patient Group Directions) (Consejo Genl de Enfermerı́a, 2006; Kroezen et al., 2011). Among the ntries where prescription and the requisition of clinical minations by nurses is already consolidated, the United gdom (UK), Sweden, United States, Canada, Australia, Zealand, South Africa and Ireland stand out (Van Ruth l., 2008; Krozen et al., 2012; Latter et al., 2010). The UK particular, has both an extensive form of nurse scribing, embracing all three models above, and a well eloped evidence base from research into its acceptlity and effectiveness. But not all countries have progressed so far. In this torial we consider the implications of this evidence base countries where the practice is still developing. We us on our country, Brazil, as an example and use the rnational evidence and reviews to illuminate the rent situation of nurses in Brazil and offer recommenions for progress. The prescription of medication through group protocols nurses is a legally permissible practice in Brazil within ary health care, following authorization from the istry of Health. Prescribing protocols are designed to be d in strategic areas (child health, women’s health, onic and acute diseases), where nurses are normally cticing. Examples of protocols that are inclusive of scribing for diseases or injuries include: tuberculosis; rosy; hypertension and diabetes mellitus; prenatal e; child nutrition; and HIV and other Sexually nsmitted Diseases (STD). Medicines that can be ivered by nurses include antibiotics, analgesics, antiammatory agents and bronchodilators. The evolution of the use of Patient Group Directions by nurses in Brazil coincides with the growth of the availability of health care services and the public’s lack of access to medical professionals in many areas in primary health care, in a context of reduction of expenditure on health care (Oguisso and Freitas, 2007). Whilst improvement in care for patients and better use of nurses’ skills has ostensibly driven the expansion of prescribing in countries such as the UK, in Brazil, like other countries such as Canada and Australia, forces external to the nursing profession have motivated the introduction of prescription by nurses. These include reduction of health care expenditure, efficient use of time and resources (Van Ruth et al., 2008; Consejo General de Enfermerı́a, 2006), reduction of doctors’ workload, resolution of the problem of lack of doctors and to assist with coverage of patients in remote areas (Kroezen et al., 2011). The fact that these are externally driven forces may have contributed to the situation that, despite the legislation enabling nurses to prescribe using Patient Group Directions in Brazil, the current context is problematic and in practice the extent to which nurses are prescribing remains very limited. A study on prenatal care performed by nurses in São Paulo found that only 40 of a total of 131 nurses used therapeutic protocols to treat infections of pregnant women and their partners (Narchi, 2010). Other studies show that nurses demonstrate fear and insecurity in prescriptive actions (Ximenes Neto et al., 2007) or that they do not prescribe for fear of complaints (Moura et al., 2007). There may be several possible reasons for this lack of prescribing. Firstly, there is no requirement for nurse training prior to the initiation of prescriptive practice. In contrast, the ICN recommends specialized knowledge, clinical experience and registration as a prescriber, as pre-requisites for prescribing. This acquisition of specialized knowledge through educational preparation varies internationally with respect to the duration and the level of training. In the UK, qualified nurses with at least three years’ experience undertake a degree level training programme of 26 days, with 12 days supervision

RISCOS OCUPACIONAIS: PERCEPÇÃO DE PROFISSIONAIS DE ENFERMAGEM DA ESTRATÉGIA SAÚDE DA FAMÍLIA EM JOÃO PESSOA – PB

Objective: To investigate the understanding of nursing staff of the family health units regarding occupational risks to which they are exposed, and to identify their suggestions in order to minimize such exposure. Material and Methods: This is a descriptive study with qualitative approach. We conducted interviews with 12 nurses from four units in Joao Pessoa, PB. Data were processed through the content analysis. Results: There were physical, chemical, biological and ergonomic risks along with accidents in the units. According to subjects’ reports, the risks occur due to the contact between professional and user, difficult for working in group, work routine, lack of protective equipment and resistant conduct of the workers themselves. Professionals pointed out to the need for education in health, improvement of working conditions, expansion of the number of professionals and use of personal protective equipment as a strategy to minimize exposure to occupational hazards. Conclusion: It was evident that nursing professionals have knowledge about risks to which they are exposed and suggest changes that can reduce these risks; such knowledge should be valued in the adoption of measures to promote care and maintenance of workers´ health. DESCRIPTORS: Occupational Risk. Nursing. Family Health.

ANÁLISE DA ORGANIZAÇÃO DA REDE DE SAÚDE DA PARAÍBA A PARTIR DO MODELO DE REGIONALIZAÇÃO

Objective: This article analyses the organization of the Paraiba state public health network from the regionalization model proposed by the Paraiba state government. Material and Methods: This is a documentary study that was primarily based on the Master Regionalization Plan (MRP) and on official documents of the Ministry of Health that guide the construction of these sorts of plans by the states. Results: Data analysis revealed some limitations in the process of implementation of the MRP/Paraiba, such as: (i) absence of social, economic and cultural analyses when selecting venues to represent health regions and (ii) lack of description regarding organization of health care in the state territory. Conclusion: The process of regionalization and the development of MRP in Paraiba did not follow the instruction of the Ministry of Health in some aspects, ignoring the specificities of each health region, which might lead to problems in access and coordination of network services in view of legitimating these health regions in the state. DESCRIPTORES: Health System. Decentralization. Regionalization.

LEGALIZATION OF NURSE PRESCRIBING OF MEDICATION IN BRAZIL: HISTORY, TRENDS AND CHALLENGES

Objetivou-se identificar os contornos legais e normativos da prescricao de medicamentos por enfermeiros no Brasil apontando sua historia, tendencias e desafios. Estudo exploratorio, realizado por meio de pesquisa documental da legislacao da enfermagem, normatizacoes do Ministerio da Saude e do setor saude que abordam a questao. Seguiram-se as etapas do estudo documental e a analise de conteudo dos dados. A categoria da enfermagem contribuiu para a legalizacao da prescricao, porem nao para a sua legitimacao; na Atencao Basica, essa atribuicao esta consolidada por meio de protocolos e legislacao, embora sem estrategia clara de acompanhamento pelo Ministerio da Saude; observa-se resistencia em algumas normatizacoes dentro do setor saude. Conclui-se que ha tendencia da prescricao de medicamento, por enfermeiros, permanecer apenas na legalidade e o principal desafio e alcancar a legitimidade.Se objetivo identificar contornos legales y normativos de la prescripcion de medicinas por enfermeros en Brasil apuntando su historia, tendencias y desafios. Es un estudio exploratorio, realizado por medio de investigacion documental de la legislacion de la enfermeria, las normas del Ministerio de la Salud y del sector salud que abordan esta cuestion. Se siguieron etapas del estudio documental y el analisis de contenido de los datos. La categoria de enfermeria contribuyo para legalizacion de la prescripcion, pero no para su legitimacion; en Atencion Basica, esa atribucion esta consolidada por medio de protocolos y legislacion, mismo sin estrategia clara de acompanamiento por el Ministerio de Salud; se observa resistencia en algunas normas dentro del sector salud. Se concluye que hay tendencia de la prescripcion de medicinas, por enfermeros, permanecer solo en la legalidad y el principal desafio es alcanzar la legitimidad.

NÚCLEO DE APOIO À SAÚDE DA FAMÍLIA: REFLETINDO SOBRE AS ACEPÇÕES EMERGENTES DA PRÁTICA

Objetivo: Analisar as praticas profissionais das equipes dos Nucleos de Apoio a Saude da Familia (NASF) dos municipios de Campina Grande e Joao Pessoa, em consonância com os modelos de apoio matricial identificados. Metodologia: Realizou-se observacao nao-participante junto aos profissionais do NASF de Campina Grande e Joao Pessoa, em um total de 480 horas, em que puderam ser observadas capacitacoes promovidas pela Secretaria Estadual de Saude e Ministerio da Saude para as equipes NASF, reunioes entre equipe e gestores, alem de atividades cotidianas das equipes. Foram realizadas tambem entrevistas semi-estruturadas com 36 profissionais, coordenacao geral do NASF e dois gerentes distritais. Resultados: Identificaram-se cinco acepcoes de apoio: o gerencial-administrativo, que busca solucionar problemas burocraticos das unidades de saude e exercer funcoes burocraticas; o politico-institucional que opera os direcionamentos politicos defendidos pela gestao na conducao das acoes de saude; o tecnico-pedagogico, que promove processos de educacao permanente junto as equipes, com intuito de conferir maior resolubilidade aos problemas de saude pertinentes; o tecnico-assistencial que oferta atendimentos diretos aos usuarios; e o politico-comunitario que fortalece a organizacao politica da comunidade. Conclusao: A assuncao de uma ou mais concepcoes de apoio matricial por uma gestao nao ocorre apenas por opcao tecnica, mas e influenciada por uma variedade de fatores politicos e economicos que influenciam a adocao de um determinado modelo tecnico-assistencial em saude. DESCRITORES: Atencao Basica. Programa Saude da Familia. Gestao de Servicos de Saude.

Análises das diretrizes para o apoio institucional das gestões da Atenção Básica das capitais brasileiras

Objetivou-se investigar os limites e as potencialidades das diretrizes gerais das gestoes da Atencao Basica das capitais brasileiras para o apoio institucional. O estudo e descritivo, exploratorio, qualitativo, realizado de fevereiro a outubro de 2014, a partir do modulo IV do Programa Nacional de Melhoria do Acesso e da Qualidade da Atencao Basica. Incluiram-se 22 formularios de gestao de capitais brasileiras analisados com o software Atlas ti.7.1 e analise de conteudo. Nas capitais brasileiras, as condicoes de gerir os processos para a institucionalizacao do apoio nao e uma realidade predominante. Conclui-se que essas gestoes precisam ser apoiadas na conducao desses processos.

Acesso potencial à atenção primária em saúde: o que mostram os dados do programa de melhoria do acesso e da qualidade do Brasil?

Objective: to analyze the influence of contextual indicators on the performance of municipalities regarding potential access to primary health care in Brazil and to discuss the contribution from nurses working on this access. Method: a multicenter descriptive study based on secondary data from External Evaluation of the National Program for Access and Quality Improvement in Primary Care, with the participation of 17,202 primary care teams. The chi-square test of proportions was used to verify differences between the municipalities stratified based on size of the coverage area, supply, coordination, and integration; when necessary, the chi-square test with Yates correction or Fishers exact test were employed. For the population variable, the Kruskal-Wallis test was used. Results: the majority of participants were nurses (n=15.876; 92,3%). Statistically significant differences were observed between the municipalities in terms of territory (p=0.0000), availability (p=0.0000), coordination of care (p=0.0000), integration (p=0.0000) and supply (p=0.0000), verifying that the municipalities that make up area 6 tend to have better performance in these dimensions. Conclusion: areas 4,5 and 6 performed better in every analyzed dimension, and the nurse had a leading role in the potential to access primary health care in Brazil.Objetivo: analisar a influencia de indicadores contextuais no desempenho dos municipios, no que tange ao acesso potencial a Atencao Primaria a Saude no Brasil e, ainda, discutir a contribuicao do trabalho da enfermagem nesse acesso. Metodo: estudo descritivo multicentrico, a partir de dados secundarios da Avaliacao Externa do Programa de Melhoria do Acesso e da Qualidade da Atencao Basica no Brasil, com a participacao de 17.202 Equipes de Atencao Basica. Recorreu-se ao teste qui-quadrado de proporcoes para verificar diferencas entre os estratos de municipios, no que se refere as dimensoes territorializacao, oferta, coordenacao, integracao, e, quando necessario, foram considerados os testes qui-quadrado com correcao de Yates ou exato de Fisher. Para a variavel populacao, foi aplicado o teste Kruskal-Wallis. Resultados: a maioria dos participantes era de enfermeiro (n=15.876; 92,3%). Observaram-se diferencas estatisticamente significativas entre os municipios em termos de territorializacao (p=0,0000), disponibilidade (p=0,0000), coordenacao do cuidado (p=0,0000), integracao (p=0,0000) e oferta (p=0,0000), verificando-se que o municipios que compoem o estrato 6 tendem a ter melhor performance nessas dimensoes. Conclusao: verificou-se que os estratos 4, 5 e 6 apresentam melhor desempenho em todas as dimensoes analisadas e, tambem, o papel preponderante do enfermeiro no acesso potencial a Atencao Primaria a Saude no Brasil.

Potential access to primary health care: what does the National Program for Access and Quality Improvement data show?

Objective: to analyze the influence of contextual indicators on the performance of municipalities regarding potential access to primary health care in Brazil and to discuss the contribution from nurses working on this access. Method: a multicenter descriptive study based on secondary data from External Evaluation of the National Program for Access and Quality Improvement in Primary Care, with the participation of 17,202 primary care teams. The chi-square test of proportions was used to verify differences between the municipalities stratified based on size of the coverage area, supply, coordination, and integration; when necessary, the chi-square test with Yates correction or Fishers exact test were employed. For the population variable, the Kruskal-Wallis test was used. Results: the majority of participants were nurses (n=15.876; 92,3%). Statistically significant differences were observed between the municipalities in terms of territory (p=0.0000), availability (p=0.0000), coordination of care (p=0.0000), integration (p=0.0000) and supply (p=0.0000), verifying that the municipalities that make up area 6 tend to have better performance in these dimensions. Conclusion: areas 4,5 and 6 performed better in every analyzed dimension, and the nurse had a leading role in the potential to access primary health care in Brazil.Objetivo: analisar a influencia de indicadores contextuais no desempenho dos municipios, no que tange ao acesso potencial a Atencao Primaria a Saude no Brasil e, ainda, discutir a contribuicao do trabalho da enfermagem nesse acesso. Metodo: estudo descritivo multicentrico, a partir de dados secundarios da Avaliacao Externa do Programa de Melhoria do Acesso e da Qualidade da Atencao Basica no Brasil, com a participacao de 17.202 Equipes de Atencao Basica. Recorreu-se ao teste qui-quadrado de proporcoes para verificar diferencas entre os estratos de municipios, no que se refere as dimensoes territorializacao, oferta, coordenacao, integracao, e, quando necessario, foram considerados os testes qui-quadrado com correcao de Yates ou exato de Fisher. Para a variavel populacao, foi aplicado o teste Kruskal-Wallis. Resultados: a maioria dos participantes era de enfermeiro (n=15.876; 92,3%). Observaram-se diferencas estatisticamente significativas entre os municipios em termos de territorializacao (p=0,0000), disponibilidade (p=0,0000), coordenacao do cuidado (p=0,0000), integracao (p=0,0000) e oferta (p=0,0000), verificando-se que o municipios que compoem o estrato 6 tendem a ter melhor performance nessas dimensoes. Conclusao: verificou-se que os estratos 4, 5 e 6 apresentam melhor desempenho em todas as dimensoes analisadas e, tambem, o papel preponderante do enfermeiro no acesso potencial a Atencao Primaria a Saude no Brasil.

AVALIAÇÃO DE ESTRUTURA ORGANIZACIONAL DOS CENTROS DE ATENÇÃO PSICOSSOCIAL DO MUNICÍPIO DE CAMPINA GRANDE, PARAÍBA

Objetivo: avaliar a estrutura dos Centros de Atencao Psicossocial (CAPS) quanto as dimensoes fisicas, recursos humanos e organizacionais. Materiais e metodos: estudo analitico de abordagem quantitativa. Utilizou-se, como instrumento de coleta de dados, um questionario auto-aplicado com perguntas direcionadas ao objetivo da pesquisa, baseado em questionario validado. Os sujeitos da pesquisa foram cinco coordenadores dos Centros de Atencao Psicossocial de Campina Grande, PB. A coleta ocorreu entre os meses de agosto e setembro de 2014. Os dados foram analisados pelo programa Epiinfo 3.3.2. Resultados: do total de coordenadores 60% sao do sexo feminino, com idade entre 30 e 50 anos, e enfermeiros; 80,0% com pos-graduacao.No perfil dos coordenadores, destacou-se a pouca qualificacao especifica na area de saude mental, a fragilidade do vinculo funcional e a sobrecarga de trabalho. Observou-se CAPS com ambiencia precaria e sem predio proprio, com estruturacao adequada e equipamento para as oficinas terapeuticas em apenas um CAPS I; deficit de recursos humanos com concentracao de psicologos; desorganizacao da porta de entrada e pouca articulacao na rede de contrarreferencia. Conclusao: A ambiencia precaria, o deficit de profissionais e a falta de organizacao do fluxo de referencia e contrarreferencia afetam as acoes de atencao integral na saude mental a medida que a concretizacao desta pressupoe trabalho em equipe, intersetorialidade e visao ampliada do processo de reabilitacao psicossocial. DESCRITORES Saude mental. Centros de Atencao Psicossocial. Enfermagem.

Tuberculosis care: an evaluability study

tlng=es 23. Santos Filho ET, Gomes ZMS. Estrategias de controle da tuberculose no Brasil: articulacao e participacao da sociedade civil. Rev Saude Publica. [Internet]. 2007. [accessed on Jul 6, 2012]; 41 Supl 1:111-6. doi: 10.1590/S0034-89102007000800015.OBJECTIVE: to verify whether the tuberculosis control program (TCP) is evaluable and to examine the feasibility of building an evaluation model in apriority municipality for the control of tuberculosis. METHOD: this evaluability study was conducted in a municipality in northeastern Brazil. For data collection, documental analysis and interviews with key informants were performed. For indicator validation, the nominal group technique was adopted. RESULTS: the details of TCP were described, and both the logical model and the classification framework for indicators were developed and agreed up on, with the goal of characterizing the structural elements of the program, defining the structure and process indicators, and formulating the evaluation questions. CONCLUSION: TCP is evaluable. Based on logical operational analysis, it was possible to evaluate the adequacy of the program goals for the control of tuberculosis. Therefore, the performance of a summative evaluation is recommended, with a focus on the analysis of the effects of tuberculosis control interventions on decreasing morbidity and mortality.