The identification of nursing interventions in primary health care: a parameter for personnel staffing

Abstracts

In Primary Health Care (PHC) there is empirical planning regarding the nursing staff, which causes a distortion between personnel distribution and the real needs of the health units. The objective was to identify the nursing interventions at the PHC that support personnel staffing. The following sources were: literature review of databases from 1999-2009; field observation at a Family Health Unit; survey of family forms; mapping of nursing activities and interventions according to the Nursing Interventions Classification; and validation of these interventions. A total of 169 activities were identified: 11 associated activities; five personnel activities and 153 direct and indirect care giving activities validated in seven domains, 15 classes and 46 NIC interventions. The study allowed for recognition of the nursing practices at the PHC by means of a standardized language, providing support for its application in the creation of instruments to identify the nursing workload.

Primary Care Nursing; Workload; Classification; Nursing staff; Primary Health Care

Na Atenção Primária à Saúde (APS) o quadro de trabalhadores de enfermagem é planejado de forma empírica, gerando distorção entre a alocação e a real necessidade das unidades de saúde. O objetivo deste trabalho foi identificar as intervenções de enfermagem na APS para subsidiar o dimensionamento dos trabalhadores. Foram utilizadas as seguintes fontes: revisão bibliográfica em bases de dados no período de 1999-2009; observação em campo em Unidade de Saúde da Família; levantamento em prontuários de famílias; mapeamento das atividades em intervenções de enfermagem segundo a taxonomia Nursing Interventions Classification e validação dessas intervenções. Identificaram-se 169 atividades: 11 atividades associadas; 5 pessoais; e 153 de cuidados diretos e indiretos que foram mapeadas e validadas em 7 domínios, 15 classes e 46 intervenções da NIC. O estudo possibilitou o reconhecimento das práticas de enfermagem na APS por meio de uma linguagem padronizada, subsidiando a sua aplicação na construção de instrumentos para a identificação da carga de trabalho.

Enfermagem de Atenção Primária; Carga de trabalho; Classificação; Recursos humanos de enfermagem; Atenção Primária à Saúde

ORIGINAL ARTICLE

The identification of nursing interventions in Primary Health Care: a parameter for personnel staffing

Daiana Bonfim^I; Raquel Rapone Gaidzinski^II; Flávia Monique Santos^III; Camila de Souza Gonçales^IV; Fernanda Maria Togeiro Fugulin^V

^IRN, Collective Health Specialist. Master. Doctoral Student of the Nursing Management Program at School of Nursing, University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^IIFull Professor, Department of Professional Guidance, School of Nursing, University of São Paulo. [e-mail]

^IIINursing graduate by the School of Nursing, University of São Paulo. PIBIC/CNPq fellow. São Paulo, SP, Brazil. [e-mail]

^IVNursing graduate by the School of Nursing, University of São Paulo. PIBIC/CNPq fellow. São Paulo, SP, Brazil. [e-mail]

^VAssociate Professor, Department of Professional Guidance, School of Nursing, University of São Paulo. [e-mail]

Correspondence

ABSTRACT

In Primary Health Care (PHC) there is empirical planning regarding the nursing staff, which causes a disagreement between personnel distribution and the real needs of the health units. The objective was to identify the nursing interventions at the PHC that support personnel staffing. The following were used: literature review of databases from 1999-2009; field observation at a Family Health Unit; survey of family forms; mapping of nursing activities and interventions according to the Nursing Interventions Classification; and validation of these interventions. A total of 169 activities were identified: 11 associated activities; five personnel activities and 153 direct and indirect care giving activities validated in seven domains, 15 classes and 46 NIC interventions. The study allowed for recognition of the nursing practices at the PHC by means of a standardized language, providing support for its application in the creation of instruments to identify the nursing workload.

Descriptors: Primary Care Nursing; Workload; Classification; Nursing staff; Primary Health Care

RESUMEN

En Atención Primaria de Salud (APS) el grupo de trabajadores de enfermería se planifica empíricamente, generándose desequilibrio entre asignaciones y necesidades reales de las unidades de salud. Se objetivó identificar las intervenciones de enfermería en APS para determinar la distribución laboral. Se utilizaron: revisión bibliográfica en bases de datos entre 1999 y 2009, observación en campo en Unidad de Salud de la Familia, datos de historias clínicas de familias, mapeo de actividades en intervenciones de enfermería según taxonomía Nursing Intervention Classification y validación de las intervenciones. Se identificaron 169 actividades: 11 asociadas, cinco personales y 153 de cuidados directos e indirectos, mapeadas y validadas en siete dominios, 15 clases y 46 intervenciones de la NIC. El estudio posibilitó reconocer las prácticas de enfermería en APS mediante un lenguaje estandarizado, ayudando su aplicación en la construcción de instrumentos para identificación de la carga de trabajo.

Descriptores: Enfermería de Atención Primaria; Carga de trabajo; Clasificación; Personal de enfermería; Atención Primaria de Salud

INTRODUCTION

To look at the managerial aspects of collective health care means to apprehend management

from the historically structured and socially articulated health care standpoint, seeking to respond to the contradictions and tensions observed in the everyday provision of services⁽¹⁾.

(...) management, as an instrument of the working process in the organization of health care services, implies making decisions that affect the structure, the production process and the produce of a given system, with the purpose of creating actions that make possible striking interventions in the health care working process, thus making way to the implementation of efficient, efficacious and effective care services that are capable of supplying health care needs (...)⁽²⁾.

The nursing managerial work process is based on particular technical instruments, such as planning, staffing, recruitment and selection of nursing personnel, continuing and/or permanent education, supervision, performance assessment, among others⁽¹⁾.

Among the health care managerial issues, the work staff is a highly relevant aspect in current discussions. Such issue originates in the institutionalization of the Brazilian Unified Health System (SUS) and together with other issues, such as decentralization, financing and social control, plays a fundamental role in the operation of the health care system⁽³⁾.

Thus, in addition to the qualification of workers and the guarantee of quality of the care services rendered in the Primary Health Care, the definition of the staff size (...), which takes into account the number of workers and the unit's specificities regarding health care risks ⁽³⁾ is a major challenge. It is important to highlight that an insufficient staff and their lack of professional qualification were considered as one of the greatest obstacles toward the Family Health Strategy (FHS)⁽⁴⁾.

In this way, whenever the planning of the nursing staffing is discussed, it should not only be seen as a technical process, but also as an ethical-political proceeding correlated to several other factors. Bearing such definition in mind, the nursing staffing is defined as:

(...) a systematic process that grounds the planning and the quantitative/qualitative assessment of nursing personnel in order to provide care in accordance with the singularity of the health care service, thus ensuring the safety of both patients/clients and workers⁽⁵⁾.

The human resource staffing has been a relevant issue for related research in several nursing fields: Intensive Care Unit (ICU), Admission Units, Surgical Clinic, Psychiatry, Emergency Room, Surgical Center, Pediatrics, Rooming-ins, and Home Care⁽⁵⁾. This area shows the highest amount of publications on nursing human resources between 1986 and 2003⁽⁶⁾.

However, few studies address the instruments used in the quantitative and qualitative planning of the nursing staff in the Primary Health Care area.

A review study on the methods applied to measure community nursing workloads showed that Primary Health Care managers still lack close acquaintanceship with the methods or data that can enable them to reach the width and the depth of staff planning and development⁽⁷⁾.

Among other issues, this fact highlights the relevance of the scientific foundations towards the construction of more quantitatively and qualitatively adequate working teams that can safely and humanely meet the health needs of populations in a given territory.

As nursing team coordinators, nurses should be essentially empowered by instruments that can make them capable of planning according to the needs of the community. Some authors describe the need they have of

(...) seeking effective mechanisms to articulate methods aimed to foster the development of a methodology that integrates mathematical calculations and political, economic and social contexts⁽⁸⁾.

In this way, given the scarcity of studies addressing the instrumentalization of the Primary Health Care (PHC) nursing staffing, the identification and validation of nursing interventions/activities stand out as the first step toward the construction of an instrument that is able to determine the time spent in these interventions, thus allowing for a clear acknowledgement of the nursing workload and consequently contributing to a more efficient human resource planning in this field.

METHOD

This is a descriptive, exploratory, quantitative-based study.

The research was performed in three methodological phases, in addition to the data collection process.

The first phase identified the activities carried out by the nursing team in Basic Health Units (BHU) and/or in Family Health Units (FHU) by means of a bibliographic review, field observation and survey of medical forms.

The second phase mapped out the nursing interventions and activities, in a standardized language. Finally, in the third phase, a group of specialists gathered in workshops in order to validate the identified and mapped activities and interventions.

The bibliographic review took into account scientific articles, theses, dissertations and books published from 1999 to 2009. The researched databases were the Latin-American and Caribbean Health Sciences Literature Database (LILACS) and the Brazilian Nursing Database (BDENF) by means of the following descriptors: primary health care, nursing care, family healthcare program, children's health, women's health, adult health, and health of the elderly. The descriptors were crossed with the following words: actions, activities and practices.

The survey and analysis of the articles generated the creation of an instrument, in the format of an activity list, in order to help field observations.

The field observation process was performed in a FHU within the Central-West Healthcare Region, in the city of São Paulo. The FHU was built in 1996 based on the request and participation of the community.

The FHU is currently managed by a Social Health Organization (SO) through a comprehensive management contract. The unit holds the Family Healthcare Strategy (FHS) as its founding principle. The FHU encompasses a territory comprised of 5,426 families, the equivalent to 18,702 people. Some of the existing risks in the covered area are: mostly low income-based life and work conditions; predominance of mid-class settlements in some regions, as well as two urbanized slums settled on illegalized areas; drug traffic; home violence; unemployment; collapsing risks; and a polluted stream. The most frequent health incidents in the area are: arterial hypertension, diabetes mellitus, and respiratory diseases. The strengths of the territory are the union and the engagement of population.

This unit was chosen based on the referral of the professors of the School of Nursing, University of São Paulo, as it is considered a unit with good collective health nursing practices. The unit is composed of six FHS Teams (six physicians, six nurses, 12 nurses' aides, and 36 community health agents), one nurse and one technician for epidemiologic surveillance and material sterilization, one teaching and surveillance physician, one nurse manager, three administrative professionals, four dentists, one dentistry assistant, one psychologist, one social worker, one occupational therapist, one oral hygiene technician, one pharmacist, three pharmacy technicians, three janitors (outsourced) and one security guard (outsourced). The unit is open to the community Monday through Friday, from 7 a.m. to 6 p.m.

The non-participant, direct and structured observation process lasted for a week considered as a typical care period in the unit, from 3-7 August of 2009, from 8 a.m to 5 p.m. Participants in the study were all nursing staff members (6 nurses and 9 nurse's aides) who were present at the unit during the data collection process.

The analysis of the nursing forms was carried out in a random sample of 32 family forms, aiming to identify activities that were not covered by the literature analysis and field observation.

After being identified and listed, the activities carried out by the nursing team were grouped according to nursing interventions and in compliance with the Nursing Interventions Classification⁽⁹⁾ (NIC), as such taxonomy expresses a standardized, clear, comprehensive, research-based language and owns an easy-to-use organizational structure, in addition to the fact that other studies have successfully used its methodology^(10-15).

The NIC⁽⁹⁾ is a three-level classification represented by domains, classes and interventions. Level 1 is comprised of seven domains (Physiological: Basic, Physiological: Complex, Behavioral, Safety, Family, Health System, and Community). Level 2 is composed of 30 classes distributed into the domains. Level 3 is composed of the 514 nursing interventions⁽⁹⁾.

The grouping process of intervention activities was carried out by means of the cross-mapping technique that can

(...) carry out studies showing that existing nursing data, collected in different places, can be mapped out in the Nursing Classifications and hence adapted to a standardized language⁽¹⁶⁾.

Care activities were mapped out in direct and indirect care nursing interventions, according to the NIC⁽⁹⁾, which conceptualizes nursing interventions as

(...) any type of treatment grounded on the judgment and clinical knowledge of a nurse toward improving patient/client results (...), including direct (treatment carried out by means of the nurse's interaction with the patient), indirect (remote treatment, but still favoring the patient or a group of patients), community or public health care (aimed to promote and preserve the health of populations)⁽⁹⁾ interventions.

In addition to the care activities, the activities associated with the nursing work, that is, those that could be performed by other professionals, but are actually carried out by the nursing team, as well as the personnel activities related to necessary work breaks aimed to supply physiologic needs and get together with other nursing professionals, were also listed.

The last phase involved the face validity - a subtype of content validation – of the listed nursing interventions and activities. For that purpose, workshops counting on the participation of three nurses, three nursing assistants who worked at the FHU in which the field observation was carried out, two professor doctor nurses who worked with the NIC⁽⁹⁾ methodology, one observer and one coordinator, were held.

The workshops took place in two thee-hour meetings. First, the NIC⁽⁹⁾ conceptualization was presented, together with the goals of the work. The discussion was structured by means of an instrument composed of all interventions and activities, and their respective definitions.

Each intervention was sequentially presented. After the presentation, the participants were requested to report their opinions/judgments on the activity. At the end of each round, discussions were carried out. The appreciation of a further item was made only after the presented item was consensually agreed to or accordingly altered.

Each intervention assessed the following aspects: the clarity, pertinence and objectivity of the conceptualization, the description and classification of listed activities, whether or not the listed activities represented the nursing work in the PHC, and whether or not any activity/intervention should be included or excluded.

The project was approved by the Research Ethics Committee of the São Paulo City Hall under number 242/09-CEP/SMS. Participants were fully informed on the study and received the Free and Informed Consent Form to be signed following their agreement to take part in the study.

RESULTS

Literature data, observed in the field and found in the forms allowed for the identification of the number of nursing activities, as shown in Table 1.

Data collection methods allowed for the identification of 235 activities. After being reviewed by researchers, activities were reduced to 169, as those representing a similar action – for instance, child nursing appointment and woman nursing appointment – were grouped into a single activity – in this case, nursing appointment.

From all 169 identified activities, 153 (90.5%) corresponded to care activities, being 70 (46%) direct and 83 (54%) indirect care; 11 (6.5%) activities were associated to the work and 5 (3%) activities were correlated with personal activities.

The NIC⁽⁹⁾ was applied to map out the intervention-based care activities. The instrument identified 152 activities, distributed into seven domains, 16 classes and 59 interventions. The only activity that did not correspond to the interventions proposed by the NIC was Embracement⁽⁹⁾.

The mapping process was validated in the workshops, where participants proposed alterations, such as: the insertion of activities composing the intervention; grouping of several interventions into one single intervention; change from an activity to another intervention; and the creation of a new intervention – Embracement.

At the end of the workshops, participants affirmed that the mapped out, proposed and discussed interventions represented the work carried out by the nursing practice in a PHC, thus validating the list of interventions by means of individual judgment and consensus.

Following the validation process, the NIC⁽⁹⁾-based classification of nursing activities in the Primary Health Care showed seven domains, 15 classes, 46 interventions and 169 activities, which can be seen in Chart 1-3.

   

DISCUSSION

Among the applied methodologies, this study observed the abundance and the variability of activities identified in the bibliographic review, as well as the importance of the field observation toward filtering the obtained data and the validation workshops carried out along with the professionals who daily share the nursing practices, thus drawing the instrument closer to the daily reality of the nursing practice.

Among the articles listed in the bibliographic review, only a small portion of studies applied the methodology that combines literature review and mapping-out procedure (6.2%). Other compositions, such as the interview (63.4%) and the observation (14.4%) are less frequently used.

The cross-mapping technique, therefore, is still poorly explored toward the translation of daily nursing practices, as shown by a bibliographic study on the knowledge produced concerning the NIC⁽⁹⁾ between 1980 and 2004, where only 3% of performed interviews correlated interventions and current practices⁽¹⁷⁾.

However, it is worth highlighting the relevance of the standardized language cross-mapping procedure in the daily nursing practice aimed to produce and develop nursing technologies that make possible an open dialogue between several specialties and countries.

The identified activities corroborate the diversified daily nursing practices carried out in the Primary Health Care and are displayed in all domains proposed by the NIC⁽⁹⁾, thus diverging from the realities of the nursing practices carried out in hospital units, such as the Emergency Unit⁽¹²⁾, in which practices were identified in five domains, and also in Rooming-in⁽¹¹⁾ and Medical-Surgical⁽¹³⁾ Units, described in six domains. Domains such as Community and Family do not characterize these hospital units.

Such diversity of interventions in the Primary Health Care can be correlated to the nurse's transitional work process, (...) at times experiencing the limits of the biomedical model, at other times going beyond it (...)⁽¹⁸⁾. It can also be associated with the condition of being the entrance door to the FHU/PHC, represented by a diversified demand and showing plenty of needs, which on their turn are cared for in the healthcare unit itself or forwarded to a health care network (specialized outpatient service, secondary and tertiary hospital services, urgency and emergency services and mental health services).

Among the mapped out interventions, the study points out the predominance of the Healthcare System and Community domains, both representing 54% of the nursing practice carried out in the Primary Health Care. On the other hand, domains such as Family (2%) and Behavioral (7%), which encompass healthcare education and support to families, are present in only 9% of the practices. This percentage is lower than the Physiological: Complex (13%) and Physiological: Basic (11%) domains, which leads us to rethink the integration of domains proposed by the NIC⁽⁹⁾ toward the nursing practice in the Primary Health Care, as the actions related to and involving families are comprised of interventions that entangle several domains.

Another highlight is the expressive implementation of work-related activities (9%). This result could also be found in studies carried out in Primary Health Care Units in the city of Porto Alegre, where they are correlated with the lack of professionals in all the network, causing nurses to leave their own work responsibilities in favor of covering the nursing basic work and providing support to all other health teams, thus restricting actions such as the home visit, considered as a central action of the Family Healthcare Strategy⁽¹⁹⁾.

The International Classification of Nursing Practices in Collective Health (- CIPESC)⁽²⁰⁾ listed 105 nursing activities carried out by the primary health care in Brazil. In compliance with the NIC⁽⁹⁾, these activities were identified in the Health System (52%), Safety (16%), Physiological: Complex (10%), Community (10%) and Family (10%)⁽²¹⁾ domains. The relevant percentage observed in the Health System domain corroborates the findings of this present research and other studies in the health care area^(11-13). Therefore, it can be seen that regardless the level (primary, secondary or tertiary) of the delivered nursing care, these are the most predominant cares that support the efficient use of the health care system.

Some activities still present mapping difficulties toward the description of the nursing practice in the Primary Health Care, such as the Home Visit, a mapped out activity that may represent both the CASE Management/Home Visit and the Embracement interventions.

As for the Home Visit, it can be highlighted that the term used to describe the CASE Management/Home Visit intervention is not adequate toward accurately naming such activity carried out within the context of the Primary Health Care; this fact suggests deeper reflection and clearer review. The definition of an intervention grants the Home Visit activity a more managerial profile; this feature is hardly observed in the Brazilian reality.

The Embracement activity was not mapped out, as no intervention that could correspond to such activity took place in the NIC⁽⁹⁾, except for interventions 6362-TRIAGE: catastrophe⁽⁹⁾, 6364-TRIAGE: emergency unit⁽⁹⁾ and 6366-TRIAGE: telephone⁽⁹⁾, which do not represent an Embracement activity, since

(...) a triage stands out as a technique used to filter patient care processes and drain the demands of a healthcare unit, still grounded only on technical criteria. As clinical protocols and diagrams are employed, bringing together the subjectivity and the context of patients apprehended by a qualified hearing process, only then we will be talking about Embracement⁽²²⁾.

Hence, the Embracement activity demands a specific discussion about the creation of a new type of intervention.

CONCLUSION

Community care and the implementation of a series of practices that can supply the needs of patients in each territory is the primary object of the nursing in the Primary Health Care. The activities listed in this present research are the most prevalent among several others, as the diversity of practices carried out in each health care unit, aimed to cope with the demands and characteristics of each community, were fully respected.

In any case, this study enables the recognition of nursing activities by means of a set of standardized interventions capable of describing the nursing practice carried out in the Primary Health Care. The results of this research will allow future studies to correlate the interventions carried out in several different territories.

Additionally, this research will also encourage the creation of instrument models toward the identification of the nursing team's workloads in the Primary Health Care aiming at measuring the time spent by workers in each nursing intervention and therefore subsidizing the necessary nursing personnel staffing toward meeting the demands in the territory.

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Identificación de las intervenciones de enfermería en la Atención Primaria de Salud: parámetro para el dimensionamiento de trabajadores

Publication Dates

• Publication in this collection
  30 Jan 2013
• Date of issue
  Dec 2012

History

• Received
  23 Feb 2012
• Accepted
  27 Apr 2012