The nurse’s professional identity on the Primary Health Care users perceptionABSTRACT
Objectives: to understanding the perception of Primary Health Care users about the professional identity of nurse.
Methods: this is an exploratory, descriptive, cross-sectional and quantitative study, using the STROBE instrument. The sample included 94 users grouped according to the Family Health Strategy coverage.
Results: the idealized identity of nurses dates back to the past of the profession. The subjects, in 81.9%, associate the female gender to the profession. 63.8% of them believed that the nurse is a subordinate, and from these, 90% believed they were subordinate to physicians. The analysis of the perception of the activities under responsibility of the nurse showed the predominance of assistance activities that are not exclusive to them. Conclusions: the findings indicate partial awareness about the identity and the role of nurses in Primary Health Care. The main deficits are related to the competences of this professional. The understanding of the role of the nurse was higher in the population under the coverage of the Family Health Strategy.
Descriptors: Nurses; Nurse’s Role; Professional Practice; Primary Health Care; History of Nursing
RESUMEN
Objetivos: comprender la percepción de usuarios de la Atención Primaria sobre la identidad profesional de la enfermera.
Métodos: estudio exploratorio, descriptivo, transversal y abordaje cuantitativo norteado por la STROBE. Muestreo consistió en 94 usuarios agrupados de acuerdo con la cobertura de Estrategia de Salud Familiar.
Resultados: identidad de la enfermera idealizada por los participantes remonta al pasado de la profesión. En 81,9%, vincularon el género femenino a profesión. Del total, 63,8% acreditaban haber subordinación de la enfermera, de los cuales 90% entendían subordinación a médicos. Análisis de la percepción sobre actividades de responsabilidad de la enfermera reveló el predominio de actividades no privativas y de cuño asistencial.
Conclusiones: hallados indican consciencia parcial sobre la identidad y papel de la enfermera en Atención Primaria. Principales déficits relacionaron a atribuciones de esa profesional. Apropiación del papel de la enfermera fue mayor en la población con cobertura por la Estrategia de Salud Familiar.
Descriptores: Enfermeras y Enfermeros; Rol de la Enfermera; Práctica Profesional; Atención Primaria de Salud; Historia de la Enfermería
RESUMO
Objetivos: compreender a percepção de usuários da Atenção Básica sobre a identidade profissional da enfermeira.
Métodos: trata-se de um estudo exploratório, descritivo, transversal e de abordagem quantitativa norteado pela ferramenta STROBE. A amostra consistiu em 94 usuários agrupados de acordo com a cobertura de Estratégia Saúde da Família.
Resultados: a identidade da enfermeira idealizada pelos participantes remonta ao passado da profissão. Os sujeitos, em 81,9%, vincularam o gênero feminino à profissão. Do total, 63,8% acreditavam haver subordinação da enfermeira, dos quais 90% entendiam subordinação aos médicos. A análise da percepção sobre atividades de responsabilidade da enfermeira revelou o predomínio de atividades assistenciais e não privativas.
Conclusões: os achados indicam consciência parcial sobre a identidade e papel da enfermeira na Atenção Básica. Os principais déficits relacionaram às atribuições dessa profissional. A apropriação do papel da enfermeira foi maior na população com cobertura pela Estratégia Saúde da Família.
Descritores: Enfermeiras e Enfermeiros; Papel do Profissional de Enfermagem; Prática Profissional; Atenção Primária à Saúde; História da Enfermagem
INTRODUCTION
The year 2020 was named by the World Health Organization (WHO) and by the International Nursing Council as the International Year of the Nurse, to celebrate the 200th year of the birth of Florence Nightingale and due to the conclusion of the international campaign Nursing Now, which aimed to increase the valorization and empowering of nursing professionals(1).
Although nurses are the largest workforce in the field of health(2-3), the need to value and strengthen nursing has always been a main goal of the category. The social invisibility has haunted nursing professionals throughout their centuries of existence and is one of the causes of their low recognition and social status(4).
The identity of a professional is a relational phenomenon with multiple conditions, and it is the product of social constructs(5-6). The exercise of a profession (the work), its historical journey, and the social memory about its workers are elements that strongly influence the structure of the thought about the profession.
The identity of nursing, especially that of the nurse, is influenced by many stereotypes that involve the history of the profession, which include the gender perspective, the exercise of the profession by categories with different educational levels (nurses, nursing technicians, nursing auxiliaries, and midwives(2,7), not to mention that health work was structured, throughout the centuries, around the figure of the physician, which led other professions to be seen as secondary(4-6,8).
In Brazil, the history of modern nursing is enmeshed with the trajectory and the institution of the Single Health System (SUS), and they share the same successes and obstacles(2). The dawn of Primary Health Care (PHC) as the support column of the SUS and as the setting where the health care model should be rerouted also had implications in the professional role and in the (re)construction of the identity of the nurse. This involves the reorganization of closer relations between user and nurse, and the increased number of competences(1-3,9-12).
The PHC, preferably, happens through the Family Health Strategy (ESF), which is opposed to the historically hegemonic and established outpatient model. The ESF teams produce care and have, as their main directives, the longitudinal and territorial work, and the care focused on subject, family, and community(10-13). Nurses are essential figures within the ESF. They are part of the minimal composition of the teams, together with nursing technicians, community health agents, and physicians(3,7,11-14).
Among the many responsibilities of the ESF nurse related to care, administration-management, and education(3,5), stand out the nursing consultations (NC) and the house visits. These activities reinforce their autonomy(6,13) and affect their relations with subjects, families, and community, thus influencing in the way the image of this professional is perceived(14-17).
However, the PHC has different organizations, with different conditions to access and different levels of ability to deal with the problems. As a result, the users have different experiences and ways to consume the services offered. The way in which the PHC works may affect the relations and the bond that exist between users and professionals(12-13), thus modulating the image that is subjectively constructed about the latter.
As a result, considering the central role of the nurse in the PHC and the potential of the ESF to (re)define the identity of this worker(6,13), which is still undervalued and socially invisible(2,4-5,15-17), this study aims to explore the social ideas connected to the image, the identity, and the professional role of the nurse, according to the perspective of Primary Health Care users, using the ESF coverage to delimit population. Few studies have elaborated on the way in which the population who uses primary health care sees and perceives nurses.
OBJECTIVES
To understand the perception of Primary Health Care users about the professional identity of nurses.
METHODS
Ethical aspects
This research was analyzed and approved by the Research Ethics Committee from the Universidade do Grande Rio Professor José de Souza Herdy - Unigranrio, according to Resolution 466/12, from the National Council of Health. The objectives of the research were explained to all participants, who signed the Free and Informed Consent Form voluntarily, before the research started. The results of this study are an original selection from the research “The identity and the social representation of nurses from the perspective of the user population of a public health service”, which was carried out during a nursing graduation course in the Universidade do Grande Rio Professor José de Souza Herdy.
Type of study
This is a quantitative, exploratory, cross-sectional, and descriptive study. According to the perspective of Prodanov and Freitas(18), the use of a quantitative approach to explore and describe the object being analyzed allows to transform the perceptions into numerical, objective, direct, and easily reproducible data. The instrument Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) was used to design the study.
Theoretical-methodological framework
The theoretical base for this study was the sociology of professions, as proposed by Eliot Freidson. His theories have been the framework for many current studies about the autonomy and the identity of health professionals, especially in nursing(19-21). The perspective of the author involves autonomy, social status, personal expertise/knowledge, and self-regulation(20). Arecognized profession has its own theoretical-scientific scope, defined place/object of work, ideal service, and an organized category. These postulates guided the creation of a data collection script (questionnaire) and made it possible to discuss the results more deeply.
Setting and period
The setting of the study was a Municipal Health Center (CMS) from the Primary Health Care network from the city of Duque de Caxias, in the state of Rio de Janeiro (RJ). The unit in question attended residents from two districts in Caxias (Imbariê and Xerém), providing assistance in medical clinics, women health, childcare, and mental care, in addition to programs to deal in hypertension, diabetes, tuberculosis, and Hansen’s disease. The service did not have Family Health Strategy (ESF) teams. It functioned as a health care unit that integrated the actions of the ESF for the users under its coverage, promoting access in primary health care to users that were not covered by the ESF. This study was carried out from February to July 2016.
Population or sample; criteria of inclusion and exclusion
The population of the study was formed by users of the CMS, the setting of the research, who went through nursing consultations during the data collection period. The sample was non-probabilistic and by convenience. Users who were available during the period when the researches were present were invited, based on the following inclusion criteria: being voluntarily interested in participating in the research, being from 18 to 86 years old, being under the coverage of a Primary Health Care service, having been through at least one nursing consultation in Primary Health Care. The exclusion criteria were: inability to answer the research instrument and refusing to sign the Free and Informed Consent Form (FICF).
From the 95 users invited, all accepted participating. There was one loss due to an illegible questionnaire. Therefore, the final sample included 94 subjects, which is equivalent to 98.9% of answers. The subjects were separated into groups, one including those “under Family Health Strategy coverage” (47 subjects) and another those “not under Family Health Strategy coverage”. This was to confirm or not the hypothesis according to which the nurse has a unique role within the PHC, which would affect the perception of users about the identity of this professional. The data collection setting, a CMS, was adequate for this task, since it was a privileged place to find subjects from both groups under study.
Study protocol: collection and analysis of data
Data collection was carried out using a self-applied structured questionnaire, elaborated by the authors. The questionnaire was formed by closed questions, including demographic data such as sex, age group, and educational level, in addition to 12 questions about the perception of the user with regard to nursing. The questions were defined based on a narrative literature review about the object of the research and the postulates of the sociology of professions. They were multiple choice questions and were grouped in the following themes: idealization regarding the identity and profile of the nurse; perceptions about the insertion and the role of nurses in the nursing team and in the health team; feelings and views about nursing consultations and the actions carried out by the nurse within health services.
The questionnaire was tested (pre-test) beforehand with ten users in the health unit where the research took place, to evaluate the clarity of the terms used, as well as the number and order of questions. The result of the pre-test was not used in any publication.
The analysis of data was carried out using the Statistical Package for the Social Sciences 20 (SPSS® Statistics), which helped establishing absolute and relative (percent) frequencies, means and standard deviations of the main variables of the groups. For the discussion, inferences were made taking into consideration the sociology of professions, allowing for an understanding of the identity, the autonomy, and the professional exercise of the nurse. The numbers, which did not represent empty values, allowed for a “panoramic” analysis of the current reality of nursing, and for broader discussions to be had.
RESULTS
There were 84% (n=94) woman participants. Women were the majority in both groups: in those under ESF coverage, they were 85.1%, while in the group of people not under that coverage, they were 83%.
In the group that was not covered by ESF, 61.7% of users had only elementary education, while in the other, that number was 42.6%. In the group covered by the ESF, 57.4% of subjects had, at least, finished high school. The most common age group in the service was from 46 to 55 years old. In the group under the coverage of ESF, young adults, from 18 to 35 years old, represented 42.5%.
About the image of the nurse, according to Table 1, both groups associated the female gender to the profession. In the group that was not covered by the ESF, this association was more pronounced. In the same group, there were more users who did not know that different professionals in the nursing team had different activities and more users who denied this fact. Still, the majority of both groups knew that nurses are professionals with university formation.
There were 63.8% of participants who believed that the nurse was submitted to the orders of another professional; the same was true for 70.2% of those in the group that was not covered by the ESF. Another aspect shown in Table 1 was that users believed that the work process of the nurse is hierarchically below that of physicians, accompanied by the perception that nurses must obey physicians more than they do nursing superiors.
The participants also listed some traits connected to the identity and the profile of the nurse (Figure 1), according to their frequency in the groups.
Figure 2 shows which characteristics the participants associate with the professional profile of the nurse, standing out their competence, technical and scientific knowledge, and availability.
Regarding the activities for which the nurse is responsible, the participants mentioned more those related with caring for wounds, bathing bedridden patients, administering medication, and attending to medical orders. Figure 3 shows these and other activities mentioned by the research participants, according to their absolute frequency.
The nursing consultation was one of the domains explored in this study. According to Table 2, the percentage of users who felt comfortable or very comfortable with the idea of being consulted by nurses was 34.1%, while 41.5% stated to feel uncomfortable or very uncomfortable. In the group under the coverage of the ESF, there were more users who felt comfortable with nursing consultations (NC).
Idealizations of the population being studied about the image and profile of the nurse, according to the Family Health Strategy, Duque de Caxias, Rio de Janeiro, Brazil, 2016
Attributes associated with the identity of the nurse by the participant population, Duque de Caxias, Rio de Janeiro, Brazil, 2016
Characteristics associated with the profile of the nurse by the participant population, Duque de Caxias, Rio de Janeiro, Brazil, 2016
There were 54.2% subjects who stated to feel safe during NCs, including those who felt safe and very safe. Once again, the group under ESF coverage was found to feel safer in nursing consultations. The feeling of satisfaction was present in 56.4%. Concerning this aspect, most subjects in both groups stated to be satisfied, but the group who was not under the coverage of the ESF showed a lower degree of satisfaction with NCs.
DISCUSSION
Historically, the idealized image of the nurse is influenced by a gender element, and it is not possible to think about the figure of a nurse, considering the category as a whole, without association with the female gender. In this study it was no different, considering that 81.9% of the population associated the female gender to the higher education nursing professional. Nursing is, in fact, a feminine profession, formed by women and, mostly, carried out by women(2-3,5).
Perception of participants about the activities and the responsibility of the nurse, Duque de Caxias, Rio de Janeiro, Brazil, 2016
Perceptions about the nursing consultations associated with the Family Health Strategy coverage, Duque de Caxias, Rio de Janeiro, Brazil, 2016
In Brazil, data from the Nursing Profile Research(22) show that 86.2% of higher education nursing professionals are women. It stands out that, although, since 1990, men have increasingly entered in this field, performing this activity which, up to 1980, was predominantly feminine(23), nursing has only been established as a profession due to the pioneer and revolutionary work of women. Worldwide, Florence Nightingale(8,24) and, in Brazil, Anna Nery, stand out as notable and influential historic personalities. This is still true today, considering the social understanding of nurses.
However, since the society we live in is structurally sexist and patriarchal, the work carried out by women was, for a long time, not seen as an occupation, in addition to being socially and financially undervalued(5,23). The work of the nurse has also been influenced by this, especially because the object of their work, care, is represented as a feminine activity, since it has long been thought that only women had adequate characteristics to provide this service — not to mention that, in its historic journey, nursing has lacked a scientific and professional character(15,23-28).
The percentage of subjects who denied that there are differences in the activities carried out in the nursing team or did not know such differences exist is another topic that stands out, considering that this was true for 44.6% of the sample. Although any nursing professional is usually called a nurse by the population(15), there are differences in nursing activities. These are based on the level of complexity and on the technical and legal competences of each professional(4-5).
Other works in literature also show a lack of knowledge on the part of health service users with regard to the differences among nursing professionals(14-17,23,28-30). Some studies state that this lack of knowledge is also present in the nursing team itself and in other health team professionals(2,28-29). In addition to this lack of knowledge about nursing professionals, the social perception about their attributions and competences is also obscured. The International Council of Nurses postulates that the title of nurse must be protected and reserved for those who are legally qualified to practice higher-level nursing as a profession(31).
The lack of knowledge about the attributions and competences of the nurse may be related to the lack of information about the exercise of the profession(5,26,28-29). This also leaves the door open for a lack of credibility, leading the user to feel unsafe and dissatisfied. Although the profession evolved from an empirical to a technical-scientific stage, the users do not see the nurse as a leader of the nursing team, capable of making evaluations and important decisions.
Despite this social lack of knowledge, the analysis about the perception of the educational level of the nurse showed contrast, since the participants recognized that this professional has a university formation, while, simultaneously, believe them to be subordinate to physicians. From the perspective of these subjects, the nurse is more subordinate to the physicians than to nursing superiors.
In the PHC, more specifically, in the ESF, although nurses carry out their main activities with more professional autonomy(6,28-29), they are also responsible for field activities, which are not exclusive responsibilities of any professional(3,14). Furthermore, the nursing consultation in the PHC is used as a mechanism to “unburden” the physicians(29), a factor that gives precedent to construct an identity that is not well defined(6,14,26), especially from the perspective of the user. This is perceived when the population covered by the ESF and studied here, from whom one would expect more understanding about the profile of the nurse, associated to them traits such as subservience and submission more often than leadership.
In the current social and sanitary crisis associated with the COVID-19 pandemic, some Brazilian cities devalued and decreased the value of the work of the nurse, saving more protective masks for physicians(32), asking nurses to work voluntarily in situations where physicians would get paid, and even increasing the wage gap between these professionals — for example, certain cities offered wages 400% higher per hour of work to physicians than they did to other higher education professionals, including nurses(33). As a result, there is a pervasive perception that the work of the nurse is inferior, subordinated to that of physicians, and would be carried out due to charity or goodness, as perceived by the population who participated.
In both groups studied here, goodness and charity were attributes associated to the profile of the nurse. Some of these attributes date back to the past of the professional, its empirical stage, when it was yet to be a profession with scientific knowledge. However, they are still alive in current social consciousness. It can also be said that the media has an important role in maintaining the truth of this social consciousness(15-17,34).
The attributes mentioned to delimit the image of the nurse showed the valuing of certain traits, associated with goodness, to the care for others, as part of the profile of a docile and submissive caregiver(16-17). According to the characteristics that the population estimates the most while analyzing the professional profile of the nurse, it can also be observed that the users are discerning and worry about the quality of the actions of this professional, as they estimate traits such as the competence and the technical and scientific knowledge.
Wound care was the most frequently mentioned activity under the responsibility of the nurse, by the studied groups. This finding is in line with studies in the literature in other realities that describe care for people with skin lesions and the knowledge about special dressings as fields of professional expertise of nurses with remarkable national and international recognition(35).
Regarding the actions carried out by nurses, the most complex ones were the least mentioned ones, showing that the interviewees do not believe in the technical ability of the professional to do them. Once again, the history of the professional was found to bear on the perception of the subjects who participated, and who evaluated the actions of these professionals based on backwards conceptions about the competences of the nurses. Relevant actions, supported by the law of professional exercise(7), by resolutions from the National Council of Nursing(10,12), by national policies(11), and by programs from the Ministry of Health, were the options selected the least. They were, therefore, the less known and perceived by the users.
An interesting contradiction emerges from a joint analysis of the characteristics associated to the profile of the nurse and the actions that the nurse can execute: the population believes that the nurse, in spite of being competent and having technical and scientific knowledge, is not capable of directing health services, carrying out consultations, or prescribing drugs. The social stigma of auxiliary/submissive contributes to this perception(15-17,23).
The study of the activities under the competence of the nurse also made it possible to find that the groups of participants do not understand well the role of the nurse within the nursing team and in the health care services, considering that essential assistance needs, which are not private and can be delegated, were mentioned the most. Although all nursing activities are part of the competence of nurses(7), in regard to the social division of labor, these professionals are the leaders of the nursing team(36). They are responsible for higher complexity assistance activities(7,10,36), not to mention their managerial, administrative, educational and research-related competences(12,37).
People covered by the ESF more dominance about nurse’s activities, especially regarding administrative activities. The population not covered by the ESF tended to confuse the common activities for the nursing staff to the private nurse, revealing potential ignorance of the activities performed by this professional within the health services. Figueiredo and Peres(24) describe that it is mainly through the attributions performed by the nurse that the image and identity of this professional are constructed.
The nursing consultation (NC) is one of the main attributions of assistance the nurse performs in the PHC(10). This activity can reconfigure their identity and shine a light on their professional role, through the interaction with the subjects and the community. The NC is an exclusive competence of the nurse. It has been prescribed by the Law of the Professional Exercise of Nursing since 1986(7), but, after nearly 35 years, it has not been naturalized in social consciousness(28).
In this study, the NC was one of the activities of the nurse mentioned the least by participants, although it is considered to be the most relevant care activity in the primary health care services(10). All subjects who participated had been through a nursing consultation before being invited to participate. However, most of them believe that this is not a responsibility of the nurse. Health education, another important role of the nurse in the PHC when it comes to health promotion(10-11), was not described. This shows that this practice is uncommon in the health services attended by the participants of this study.
The analysis of the perception of the groups about the NCs showed feelings of discomfort with the idea, feelings of safety during the consultation and satisfaction as it ended. Although the perception of the groups is similar, the group under the coverage of ESF had a clearer perception of reality, which may be associated with their habit to undergo NCs due to longitudinal health attention. However, the need for the users to understand better the role of nursing consultations and of the nurse in the primary care services should be pointed out.
The satisfaction with the NCs was mentioned by 56.4% of participants. Even in the group under the coverage of ESF, the degree of satisfaction was not high (57.4%). On the other hand, another study(38) carried out with pregnant women under prenatal monitoring showed that 84.3% of them were satisfied with their NCs, although they stated that they had limited capacity to solve their problems.
The NC is more than a simple method to systemize the working process. It is, above all, a tool to broaden the clinic, enabling encounters between subjects that “are not restricted to diseases, health programs, or mechanized and prescriptive practices”(6). As Peruzzo(4) mentions, it is also not a “sub-consultation” or a mechanism to replace medical consultations. It is a resource based on scientific evidence, focused on results, which makes it possible, in the context of the PHC, to provide broader access, to embrace, to produce bonds and monitor longitudinally the life cycles(4,6,38-40).
The actions of the nurse in the PHC, together with the community, increases the visibility of the actions of this professional(12,15-17,40), and, therefore, makes it possible to value their actions. More than the lack of knowledge about the nurse and their activities, the population also does not know how valuable are these professionals and their actions in the health services(6,16-17). Implementing advanced practices can be a strategy to increase the visibility and the valorization of the work of the nurse(1).
Study limitations
One of the limitations of this study was its sample. Since the research took place in a single health service, the results can indicate a trend, but not an absolute truth about the theme. The time of data collection was another limitation: since this work was carried out during a graduation course, it was necessary to establish this time frame. This shows that it is necessary to replicate this study with a larger sample and a longer time frame, in different health care units, with and without the Family Health Strategy, to show, more extensively, the image of the nurse.
Contributions to the Field of Nursing
A contribution of this study is related to the low visibility of nurses and their functions in the PHC, even for those under the coverage of ESF. Therefore, it enables interventions by the category itself and by the organs that represent it professionally, in order to elaborate strategies to disseminate, in the population, knowledge about the work of nurses.
During the COVID-19 pandemic, the image of the “superhero” nurse has been reinforced. In their daily work, they fight with all might, but with no magical powers; they fight with technical and scientific knowledge, resilience and competence. The social consciousness about the nurse must be changed. The Nursing Now campaign for the valorization and recognition of nursing, from the WHO, is only one of the paths that can be followed.
CONCLUSIONS
It has been shown that the population is partially aware of the identity and the role of nurses in the PHC. The main deficits are related to the competences of this professional. And the identity perceived by the users is culturally supported by historic and social markers that originate in the past of the profession.
Despite the huge progress of the nurse in their knowledge, with technical, theoretic, and scientific advancement, not to mention increments in autonomy and leadership, the identity of this professional is still hindered by imprecise judgements of their ability and competence. The data also showed that users understand that the nurse is responsible for the role of caring, but believe they are not autonomous, being subordinated to the roles of physicians, thus underestimating and undervaluing the relevance of this professional in the health service settings.
The results found here suggest that new studies should be made about how the population of primary health care service users understands the identity and the professional role of nurses in different organizational arrangements in PHC. Considering that since 2016 there has been a dismantling of the ESF, reaffirmed by the revision of the National Primary Care Policy in 2017, the advancements reached in the reorientation of the health assistance model and in the reorganization of services are at risk. The increasingly poor conditions of nursing work in the PHC have become an imminent outcome which will push the image and the identity of this professional even farther back.
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Edited by
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EDITOR IN CHIEF: Dulce BarbosaASSOCIATE EDITOR: Maria Itayra Padilha
Publication Dates
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Publication in this collection
25 Oct 2021 -
Date of issue
2022
History
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Received
14 Sept 2020 -
Accepted
27 June 2021
