New Coronavirus: (Re)thinking the care process in Primary Health and Nursing

Nuevo Coronavírus: (Re)pensando el proceso de cuidar en Atención Primaria y Enfermería

ABSTRACT

Objective:  to reflect on the challenges and power of the nursing care process in Primary Health Care in the face of the New Coronavirus, COVID-19, in the Brazilian scenario.

Method:  reflective study, based on the discursive formulation in the context of COVID-19 in Primary Health Care, based on theoretical foundations and practical effects of neoliberal policy, the care process, and Nursing.

Results:  in Brazil, COVID-19, has caused the need for challenges for strengthening primary care in the face of neoliberal policy, but it presents the potential of dialogue with communities and the (re)creation of the nursing care process through solidary collaborative networks.

Final considerations:  reflecting on the nursing care process in primary care restores the strength present in the cooperation between health teams and community solidarity networks to change social and health circumstances, despite the challenge imposed by underfunding aggravated by neoliberalism.

Descriptors: Coronavirus; Primary Health Care; Nursing Care; Nursing; Pandemics

RESUMEN

Objetivo:  Hacer una reflexión sobre los desafíos y potencias del proceso de cuidado de Enfermería en la Atención Primaria de Salud frente al nuevo Coronavirus, COVID-19, en el escenario brasileño.

Método:  Estudio reflexivo, fundamentado en la formulación discursiva de la COVID-19 en la Atención Primaria de Salud, con base en fundamentos teóricos y efectos prácticos de la política neoliberal sobre el proceso de cuidado de Enfermería.

Resultados:  La COVID-19 en Brasil ha impuesto desafíos para la Atención Primaria en razón de la política neoliberal, pero trae como potencia un mayor diálogo con las comunidades y la (re)creación del proceso de cuidado de Enfermería, a través de redes colaborativas solidarias.

Consideraciones Finales:  Esta reflexión fortalece la cooperación entre equipos de salud y redes solidarias comunitarias, en la búsqueda de mejorías en lo social y en la salud, ante los desafíos impuestos por la política neoliberal.

Descriptores: Coronavirus; Atención Primaria de Salud; Cuidados de Enfermería; Enfermería; Pandemias

RESUMO

Objetivo:  refletir sobre desafios e potências do processo de cuidado de enfermagem na Atenção Primária à Saúde diante do Novo Coronavírus, COVID-19, no contexto brasileiro.

Método:  estudo reflexivo, fundamentado na formulação discursiva no contexto da COVID-19 na Atenção Primária à Saúde, com base em fundamentos teóricos e efeitos práticos da política neoliberal, do processo de cuidado e da Enfermagem.

Resultados e Discussão:  a COVID-19, no Brasil, tem imposto os desafios do fortalecimento da atenção primária em face à política neoliberal, mas apresenta como potência o diálogo com as comunidades e a (re)criação do processo de cuidado de enfermagem por meio das redes colaborativas solidárias.

Considerações finais:  refletir sobre o processo de cuidado de enfermagem na atenção primária restabelece a força presente na cooperação entre equipes de saúde e redes solidárias comunitárias para mudar situações sociais e de saúde, a despeito do desafio imposto pelo subfinanciamento agravado pelo neoliberalismo.

Descritores: Coronavírus; Atenção Primária à Saúde; Cuidados de Enfermagem; Enfermagem; Pandemias

INTRODUCTION

“I am that ship, in a sea without direction and an owner; I have the mirage of the harbor, to comfort my sleep; And drift on the forgetfulness tides...” Miragem do Porto, Lenine.

The close links between globalization and health are increasingly drawing attention in the global context and have been accompanied by new terms, new concepts and new health problems that demand political relevance, international cooperation, and global and local governance. For Fidder cited by Almeida⁽¹⁾, however,

[…] for most of the 20^th century, health was an irrelevant issue and neglected by decision-makers in the area of external policy. In the last decade of the century, however, the theme returns to the international schedules and strategies of developed countries. At the discourse level, the objectives are excellent, but in practice, the effort is complex, full of ambiguities and uncertainties.

In this context, the onset of the COVID-19 pandemic places civilization facing a mirror where the weaknesses of the global world are reflected, which until then seemed immune to these situations due to its technological achievements, speed to react to any circumstance and quick resoluteness due to funding and market volatility in almost all territories.

Nowadays, much more than in former decades, the weaknesses of global life are evident. Events have a loco-global dimension, which means that situations once experienced at a given space-time, now, with the connections established by transport and technological communication, create real and/or symbolic effects in almost all places and times. In this sense, COVID-19 takes health systems to experience a new and unexpected time in the daily care process, with the requirement to create a new routine that meets the needs of the moment, but without losing sight of the barriers dictated by capitalism, which lessens the concept of health and prioritizes the economy instead of the individuals.

Thus, new learning is in progress. However, the contagion power of the virus seems to be greater to our own ability to face it, and it is understood, then, that it will not be the market, nor the neoliberal ideology, that will be able to overcome this situation, but the possibility of reflection and acting in solidarity on the (re)structuring of a new, more sustainable and fair model of society. In this new model, health, in its greatest sense, needs to be the main factor of the accumulation of social capital.

In Brazil, the neoliberal economic policy has led to the aggravation of the historical underfunding of Social Security, whose budget never materialized and, consequently, of public health policy, expressed concretely in the Unified Health System (SUS)⁽²⁾. Today, care for people with symptoms of COVID-19 is mixed with actions intended at longitudinal care for individuals with chronic non-communicable and transmissible conditions; acute conditions; and strategies for health promotion and disease and grievance prevention⁽³⁾. The Family Health Teams (FHS) and the teams that work in Primary Care are the protagonists in such care, capable of acting in several territories, contexts, and vulnerabilities.

Combining the history of serious disregard with the arrival of the pandemic in Brazil, there is an increase in the different obstacles faced by the FHS in providing care. However, because they establish fundamental attributes such as teamwork, interdisciplinarity, comprehensiveness, family and community guidance and cultural competence, it enables the daily remaking in health care and in the ways of creating and recreating ties with collectives, which allows the practical implementation of the care process in a particular way⁽⁴⁾.

It is based on this scenario of uncertainties of the Brazilian health reality that the challenges and the power of the nursing care process must be thought and legitimated concerning their involvement in a complex health system. It is a glance at Primary Health Care (PHC), which is understood as the main access to the Health Care Network in Brazil, the users’ first interaction with the SUS and the care coordinator also for coping for COVID-19.

This reflection started with the following questions: how can PHC face the challenges arising from the New Coronavirus? How will this battle impact the nursing care process in PHC?

OBJECTIVE

To reflect on the challenges and the power of the nursing care process in Primary Health Care in the face of the New Coronavirus, COVID-19, in the Brazilian scenario.

METHODS

This is a reflective study, based on the discursive formulation in the context of COVID-19 in PHC, based on theoretical foundations and practical effects of neoliberal policy, the care process and Nursing.

The text is organized into the following sections: Primary Care and the challenges imposed by Neoliberal Policy in the COVID-19 scenario: theoretical and practical perspectives; and (Re) creating the health care process by Nursing in PHC: the community collaborative networks and solidarity. Thus, based on the New Coronavirus pandemic and the importance of PHC in the Brazilian Health Care Network, the theme was addressed in the perspective of the neoliberal policy and the challenges and potentialities of the nursing care process in the face of coping with COVID-19 associated with the other health actions outlined for this field of care.

The construction of this reflection started from the practical experience and dialogue between PHC nurses and teachers from a federal university, followed by a bibliographic survey, selection of publications related to the theme and association of scientific evidence with COVID-19.

The care process must mean, in this reflection, to the action of experiencing social contexts and producing care aimed at the individual, family and community, a process that is dynamic and political, with activities arranged in an interprofessional way and in living care networks. Given this pandemic context, we sought to associate the theoretical foundations with the practices that have been carried out in PHC, based on the emphasis on rescuing life through the creation and recreation of bonds and caring with the individuals, and not for the individuals.

PRIMARY CARE AND THE CHALLENGES IMPOSED BY NEOLIBERAL POLICY IN THE COVID-19 SCENARIO: THEORETICAL AND PRACTICAL PERSPECTIVES

Although Brazil has the SUS, universal and financed by taxes and social contributions, is facing a challenging moment⁽²⁾. The agents that produce knowledge and practices in Collective Health are immersed in a neoliberal policy, with an intense dispute in the public-private relationship, in which there is an uneven distribution of the hard technology and, also, a decrease of the virtuous effects of PHC and, consequently, of the Family Health Strategy in longitudinal monitoring and population access.

When arriving in a territory of continental dimensions and with striking social inequalities that are expressed in epidemiological and socioeconomic characteristics that perpetuate high incidences and prevalence of diseases typical of precarious living conditions, COVID-19 comes across local and regional epidemics in Brazil. In our country, in addition to endemic tuberculosis, there are diseases such as Dengue, infection by the Zika Virus and Chikungunya Virus and Measles, which characterizes a very worrying scenario.

Considering the family health as the main strategy for PHC reorganization in Brazil, expressed in the National Policy of Primary Care (PNAB) of 2006, the practices of planning and implementing actions in the territories in health care stand out in the perspective of ensuring comprehensive care, access to the population and an understanding of the real needs of the territory. They are essential actions, as they contribute to the transformation of social determinants of health⁽⁴⁾.

In this context, Epidemiology must be understood as an important tool to approach the reality of study, although with limitations to ensure that the care process, responds to the single needs of individuals in the territory. These limitations take place, above all, from political aspects and economic interests, typical of neoliberal rationality, which permeate everyday life.

According to Breilh⁽⁵⁾,

[…] critical epidemiology breaks with the linear model of empirical epidemiology and with the biomedical and functionalist model that imprisons the thinking of the old public health. Therefore, it needs to re-establish the close relationship between the health effects of different human collectivities and the processes created due to a social reproduction subordinated to the accumulation of capital [...] that operates destructively on nature, impair peoples’ sovereignty, ruins the solidary relationship and causes frantic consumerism.

Consequently, this pandemic, although devastating, makes us reflect not only concerning epidemiological aspects, but also allows us to see the invisible routine of collectives that live far down in the vulnerability in which the State itself places them, the product of the huge inequality and social injustice arranged in Brazilian society. And this makes us run away from standardization in coping with COVID-19, as the effectiveness of the measures to be taken is directly proportional to the singularization of the characteristics and priorities that come from the territories.

Thus, based on the different local realities and health settings, there are different ways of care organization in primary care units, thus, different ways of articulating care practices in this pandemic are expected. The innovations in the care process of the teams establish the power of the Family Health Strategy, because they already work based on light technologies, understood as technologies of relationships, such as user embracement, bonding and the individual’s autonomy, as well as on light-hard technologies, understood as structured knowledge, such as the Amplified Clinic, critical epidemiology and comprehensive care⁽⁶⁾.

Such technologies can be a tool in health surveillance and longitudinal follow-up, necessary for the care of individuals with chronic conditions and, also, of people affected by COVID-19 during and after the phase of greatest infection of the disease in our country⁽³⁾. However, the Neoliberal Policy limits investment in light and light-hard technologies, as it prioritizes technical equipment for diagnostics, present primarily in the hospital environment, imposing additional challenges to the PHC care process⁽²⁾.

In recent decades, neoliberal policies have intensified and dramatic changes for PHC, validated by the 2017 PNAB have been implemented^(2,4). Insufficient public budget in addition to the crisis set up by the new coronavirus, shows the weakness of PHC, which, due to its role as SUS ordering authority and resoluteness care processes in the territories, consequently affects the whole Health Care Network.

Also, the challenges imposed by the neoliberal policy are manifested in the priority given to meeting acute demands, instead of longitudinal care with a community and family approach. Specifically, for Nursing, overact care is aggravated by the precarious structural, material and dimensioning of professionals shorter than the ideal^(4,7). Thus, in a practical perspective, the fragile and critical situation that PHC is going through, especially due to neoliberalism, imposes a massive challenge for the effectiveness of the processes related to the continuity of care and resoluteness of the teams⁽²⁾ and, today, to face the pandemic in community and family level.

Precisely in the year 2020, defined by the WHO as the ‘International Year of the Nurse’, this professional category stands out for the quantity and magnitude of staff it represents, especially in SUS. Nursing, allocated in just about all health units, in different locations of care (permanent) and organized in a network (flows), is responsible for actions based on scientific evidence present in the various dimensions of health⁽⁸⁾.

Situating the “International Year of the Nurse” requires thinking like Davis⁽⁹⁾ in the recent and accurate analysis in the chapter entitled “The coronavirus crisis is a monster fueled by capitalism”, in which capitalist globalization now seems biologically unsustainable in the absence of a real international public health infrastructure. However, such an infrastructure will never exist if popular movements do not break the power of the for-profit health care industry or as long as there is an obligation of choice brought about by neoliberalism between health and the economy, as if they were dichotomous aspects.

In this perspective, Nursing engender power in acting in the population’s life territories, recreating care processes aimed at social changes and health realities, in the context of critical epidemiology and the perspective of interprofessionality and intersectoriality. They are powers that consider solidarity relations intending to break neoliberalism, strengthening PHC and community collaborative networks and overcoming the pandemic experienced today.

(RE) CREATING THE HEALTH CARE PROCESS BY NURSING IN PRIMARY HEALTH CARE: THE COMMUNITY COLLABORATIVE NETWORKS AND SOLIDARITY

When reflecting on the current neoliberal scenario in which Nursing is inserted, in the Brazilian context of PHC, and outlining the demands to face the pandemic, there are important difficulties to be overcome. The most evident ones refer to the physical structure of health establishments and the exhausting workday that the pandemic has demanded since the increase in the number of cases and the search for user embracement and information.

In the hypothesis that most people affected by COVID-19 will present themselves as mild or asymptomatic cases⁽³⁾ and that these people live in territories with different epidemiological and social characteristics, it is predictable that, at this moment, despite the high number of patients who need specialized hospital beds, the epidemic is centered on PHC, as it is in the life territory that people will seek care.

Prediction on cases and deaths, ways to mitigate transmission and assess the impact of the actions implemented have become the focus of fighting the pandemic in the Brazilian context. However, in the scenario of COVID-19, little has been discussed about the consolidation of PHC and its ethical competence, for the inclusion of individuals in the care processes.

The PHC specific actions in the fight against COVID-19 refer to combating its transmission, the dissemination and implementation of control actions and quality health information, the reorganization of the internal flows of primary and external care units related to the referral to other network locations and to follow up the isolation of users affected by the disease and their close contacts. They also include new technological strategies for health surveillance, such as the use of applications and telephone monitoring⁽³⁾.

Thus, it is imperative to dialogue with communities in the territories of life, regarding the challenges imposed by neoliberalism and the need to (re)create care processes to face the pandemic. Such processes are associated with the longitudinal monitoring of the population not affected by the disease, but exposed, in urban and rural communities. Lives continue to need care, some, such as children, continuous care, pregnant women, puerperal women, and people with chronic conditions that require specific actions within the PHC. It is at this level of care that these demands will be accepted and resolved, supporting self-care and access to continuous use medication, with vaccination as a transversal axis.

If this overact of activities is seen, on the one hand, as a challenge for the nursing care process in PHC, on the other, the study by Biff et al⁽⁷⁾ reveals that teamwork, the bond with health system users, good interpersonal relationships, management support and resoluteness of actions are positive aspects of this level of care⁽⁷⁾. Such characteristics favor the care processes and can even contribute to coping with COVID-19.

Simultaneously, it is considered critical to implement actions aimed at facing situations of high social vulnerability and people living in agglomerations, which were there regardless of the pandemic, but aggravated in the current scenario. Access to least resources, such as drinkable water with permanent availability, housing, food, work, income, and education, has not been guaranteed by the State.

Reflection on people’s life situations and social and health conditions proved the creation of community solidarity networks⁽¹⁰⁾, which constitute a new power to change these realities of life and, consequently, the health of collectives. Such networks have made communities, previously forgotten, visible, and have historically been engines that have driven and made possible the Health Reform. In the context of the pandemic, groups of peripheries are the ones working to guarantee food, hygiene, and health guidelines to the communities, thereby reducing the epidemic curve.

This way, the FHS constitute the support of scientific and technical knowledge in the care of people affected by the pandemic, which join the knowledge of individuals, families and communities in the favelas and peripheries, who know the routine of these lives and enhance the possibilities of coping with illnesses and deaths. This combination of knowledge and practices, collaborative and solidary, makes communication as a dialogical, negotiated, and creative practice and has been an important tool in confronting COVID-19 in these territories.

It is emphasized that the guarantee of suitable financing for PHC can foster and strengthen community solidarity networks⁽¹⁰⁾. It is therefore urgent, to re-establish links between family health teams and the community, to support and associate health with solidarity projects and to rebuild intersectoral actions to support territories, face several vulnerabilities and overcome neoliberalism.

It is through the central role of community, family approach and solidarity networks that the processes of nursing care and FHS will be (re)created, expanding the possibility of overcoming the pandemic, reducing social inequities and ensuring access to health as a right . For that, it is essential to recognize and value PHC, with adequate physical setups and the dimensioning of multidisciplinary teams, maintenance of the Family Health Support Center and sufficient financing. It is also essential to strengthen the whole Health Care Network where PHC is inserted and, in this sense, COVID-19 explains the importance of choosing health and life, breaking with the reasoning of neoliberal policy.

The predicted arrival of the New Coronavirus in Brazil made society aware of the social reality marked by inequality. On the one hand, we see communities facing the absence of the State to guarantee rights and, on the other hand, health teams in PHC experiencing the overacting of activities in the care processes and the precarious structural and material conditions combined with the lack of health funds aggravated by neoliberalism. Despite this, care processes can be (re)created through the important role of community and health care with the individuals, and not for the individuals.

Limitations of the Study

The objective of this article is not to exhaust the reflection on the power and challenges of PHC in the face of COVID-19 in the Brazilian neoliberal scenario, but to provoke reflections on the innovations necessary for the (re)creation of nursing care processes to strengthen community action and public policies aimed at guaranteeing the right to health and the (re)construction of the Primary Care field in Brazil. It is an essential reflection since such policies have the consequence of valuing all the lives of the Brazilian Society.

Contributions to the field

This reflection, whose theme is emerging and necessary, aims to support the debate among workers, society, managers and researchers about the legacy of COVID-19 in Brazil, the PHC situation and its role in the current pandemic scenario, in which the nursing care processes are understood as the front line in the fighting. It is also expected that this reflection encourages discussion about the consequences of neoliberal policy in the field of Public Health and the urgent need for investments in public health policy, which means expansion and appreciation of PHC and the right to health endorsement to all SUS users.

FINAL CONSIDERATIONS

Reflecting on the nursing care process facing the New Coronavirus in PHC re-establishes the strength present in the cooperation between health teams and community solidarity networks to change social and health situations, despite the challenge imposed by the consequences of underfunding aggravated by neoliberalism.

It is necessary to acknowledge the value of the Health Care Network and, therefore, of investment in other levels of care as well, but always considering PHC as the main access to this system and capable of being highly effective in different health situations. However, for this to happen, its essential characteristics (access, first contact, longitudinality and integrality) and secondary characteristics (family and community guidance, cultural competence) must be guaranteed and implemented in practice, considering the particularities of the territories.

Thus, it is essential that PHC is recognized and receives adequate funding to (re)create care processes both for people affected by COVID-19 and for longitudinal health monitoring in the territories. In this way, it will be possible to (re)create Brazilian public health by strengthening the SUS.

ACKNOWLEDGMENT

We would like to thank the Nursing workers, our partners, without them, we would not have thought and raised questions that have gained expression in our text. We would also like to thank all the professors in the Department of Public Health Nursing (DESP / UNIRIO) who contributed to the discussions and to the inspiration for this reflection article elaboration.

REFERENCES

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Edited by

• EDITOR IN CHIEF: Dulce Barbosa

• ASSOCIATE EDITOR: Hugo Fernandes

Publication Dates

• Publication in this collection
  18 Sept 2020
• Date of issue
  2020

History

• Received
  09 Apr 2020
• Accepted
  26 June 2020