Being a nurse in the daily routine of Primary Health Care: the doing, learning and living with
Lívia Silveira Silva1, Selma Maria da Fonseca Viegas1, Cássia Menezes1
1 Federal University of São João del-Rei
ABSTRACT
Objective: understand the daily life of the Primary Health Care (PHC) nurse and their experiences as being it, doing it, and learning to live together. Method: a holistic-qualitative multiple case study, based on Comprehensive Sociology of Daily Life, with 54 nurses. Results: The being a nurse in PHC experiences protagonism, autonomy, the applicability of knowledge and professional skills by performing the doing with humanization, empathy, responsibility, and ethics. The nurses live, learn and live with daily challenges, such as a high number of registered people, lack of human resources, high spontaneous and repressed demand, attention focused on illness and the need for continuing education. Final considerations: the being, doing, learning, and living with of the nurses is guided by great responsibilities and charges around what is ideal and what is real in the daily life of the PHC. The infrastructure and functionality of PHC units are far from the idealized and desired reality.
Descriptors: Primary Care Nursing; Role of the Nursing Professional; Professional Competence; Male and Female Nurses; Advanced Nursing Practice.
INTRODUCTION
The “nurse is the pillar of Primary Health Care (PHC)”(1:157). In their daily life, they associate their professional identity, sometimes harmonious, sometimes conflicting, with their perceptions of the self, of their neighbor, of the environment and their daily practices closely linked to the social, historical and cultural context of the enrolled population. The nurse relates their being, doing, learning and living with to the sense that is wrapped in the word all, attributing to it positive and negative senses marked by the perception of their actions and their professional space that may or may not distance them from their identity referential(1).
At the international level, being a nurse means to redesign and re-signify at all times your knowledge, techniques, and practices to the rapid demographic, sociological and cultural changes of the population. International evidence indicates that nurses have gained increasing prominence and autonomy by providing individualized and holistic health care, permeated with a respectful and flexible approach. This approach has been structured based on therapeutic relationships, which increasingly emphasize the awareness of users, despite the undeniable technical-healing practices of the traditional biomedical model(2).
At the national level, the nurse in the daily routine of PHC assumes attributions that cover assistance actions of promotion, protection, rehabilitation and maintenance of health, prevention of risks and illnesses, diagnosis and treatment, in the assistance and management dimensions, for individual and collective benefit(3), attributions that give them “the sociological notion of essentiality in the scope of the professions”(4:08).
In PHC day-to-day work, the nurse has proven to be fundamental for the performance of activities inherent to the organization, coordination, planning, management, and promotion of care(5). Through the complexity of the demands, they develop the activities guided by their knowledge, skills, and attitudes capable of contributing to the effectiveness and quality of the attention(6).
Furthermore, a study conducted in Norway identified that the importance of the nurse in PHC is beyond the activities inherent to care. By performing them, they become the ones who empower and work from a perspective of relational and resolutive care(7).
However, regarding the daily life of the nurse in PHC, the being, doing, learning, and living with can be marked by possibilities and challenges. A study conducted with 23 Norwegian nurses, aiming to identify knowledge and identity of the professional, shows that the work in public health gives the nurse possibilities of autonomy, protagonism, and acknowledgment, in addition to the challenges of walking with users/families under the ethical responsibility, work overload and subject to physical/emotional exhaustion(8).
The several responsibilities assumed by nurses in PHC can bring them closer to a new way of health assisting and caring, as well as harming and distancing them from their specific knowledge and responsibilities. This situation often favors the loss of workspace and autonomy and, consequently, the devaluation, overload, suffering, and even the invisibility of the profession(1-6).
In view of the above, therefore, we wonder: What is it like to be a nurse in PHC day-to-day? What are their experiences in doing, learning and living with? This study aimed to understand the daily life of the PHC nurse, in two capitals of Brazil, and their experiences in being, doing, learning and living with.
METHOD
The study is of qualitative approach, outlined by the methodological framework of Multiple Holistic Case Studies (9), based on the theoretical framework of Comprehensive Sociology of Daily Life(10), originated from a Master's Dissertation.
The case study is based on the investigation and global understanding of a phenomenon of the individual or collective interest; organizational or social; political or related inserted in some real-life context(9).
In order to understand certain phenomena of being, living and live with, inherent to daily life and work, it is opportune to look at the object of this study from the eyes of the Comprehensive Sociology of Daily Life(9), considering being a nurse. By proposing an open and sensitive reason, the Comprehensive Sociology of Daily Life values everyday knowledge, common sense and the constitutive aspects to the daily life of subjects and their interactions(10).
The research had a proposal to carry out an individual case study in two Brazilian capitals: Florianópolis (421,240 inhabitants), capital of the state of Santa Catarina (SC), with 89.53% population coverage by FHS; and Belo Horizonte (2,375,151 inhabitants), capital of the state of Minas Gerais (MG), with 78.67% population coverage by FHS. The two cases were defined by the study scenarios, setting up a holistic multiple case study(9).
The participants were 54 nurses working in 30 PHC units in the two Brazilian capitals, 23 of them from the city of Florianópolis and 31 from the city of Belo Horizonte, whose participation was voluntary. The inclusion criterion was the performance of at least six months in the function or position. The exclusionary was a nurse on vacation or away from work during the data collection period, totaling five. There was a refusal to participate in the survey and eleven nurses were unable to participate due to the high work demand on the days previously scheduled for data collection.
Regarding gender, 93% of the participants were female; the average age among them was 41 years; the average time of exercising the nursing profession was 16 years; 63% of the participants graduated from public institutions; 33% of the sample work in Traditional PHC, with an working average of 6 years; 67% work in FHS, with an average performance of 7 years; 89% of the nurses had some kind of specialization: 56% in Family Health, 31% in Public Health, 10% in Health Management, 8% in Obstetric Nursing; 8% have Master's Degree, among others.
The sources of evidence were the intensive open individual interview with a semi-structured script; the field notes (FN); the Ordinance No. 2436, 21 September 2017, for the purpose of analyzing daily experiences according to the duties of the nurse and the common duties of team members; the Nursing Code of Ethics. The interview addressed the characteristics of the research participants, the safety of the professional nurse, and the ethical and bioethical problems in PHC. The FNs had operational purposes of research development, describing peculiar characteristics of the study scenarios, teams, PHC/FHS units, and data collection, being them analyzed and incorporated into the text of this article. First of all, a pre-test of the interview script was conducted under the guidance of the researcher in charge.
Data collection took place in August 2018 and May/June 2019. The interviews were conducted by the researcher; they lasted an average of twelve minutes with the participants of the research in Florianópolis, and seventeen minutes with those of Belo Horizonte. They were performed according to the availability of the nurse, in private space in the health unit where they were present, with only the researcher and the participant.
The interview was recorded in a digital file and validated, when it was finished, by the participant's hearing, awareness, and freedom of authorization of the data in full or with the option of correction. It is worth noting that all participants have authorized the use of their interview data in its entirety. The interviews were transcribed in full, preserving the reliability of the information.
The collection was concluded in the 54th The collection was concluded in the 54th interview when the data saturation in each of the cases of this study was verified, that is, when a sufficient number of replicated information was obtained, configuring the literal replication of the data(9:64-65).
The analysis of the research data was based on the Thematic Content Analysis technique(11), defined by the semantic criterion, that is, the analysis of “meanings” according to the phases: pre-analysis, exploration of the material, treatment of the results, inference, and interpretation. The analysis was in line with the Holistic Qualitative Multiple Case study methodological framework (9), based on the theoretical framework of Comprehensive Sociology of Daily Life(10). They originated three thematic categories: Safety of professional nurses and ethical and bioethical problems experienced in Primary Health Care; Being (bio)ethical in the daily routine of Primary Health Care: notions of the nurse; Being a nurse in the daily routine of Primary Health Care: the doing, learning and living with . This article will address the third thematic category.
For the interpretation and discussion of the results, it became necessary to appropriate, also, the ethical vision applied as Critical Hermeneutics, based on the Kantian philosophy and Giovanni Berlinguer's vision of Daily Bioethics to meet the precepts of ethics and bioethics in PHC.
It is worth noting that the research was developed in accordance with the National Health Council Resolution No.466, of December 12, 2012, obeying the guidelines and regulatory standards for research involving human beings. The Free and Informed Consent form was prepared in two copies, signed down by the research participant and the responsible researcher. The data collection started after the project approvals, under Opinion No. 3,137,192 of the Research Ethics Committee of the Federal University of São João del-Rei, Midwest Campus; and of the Opinion No. 3,260,376 of the Research Ethics Committee of the Municipal Health Secretariat of Belo Horizonte. The entry into the research field for data collection was after authorization from the municipal health departments. The anonymity of the participants was guaranteed by means of the alphanumeric identification, in which the letter “E” represents the interviewee, and the consecutive numbering was given by the sequence of the interviews (E1, E2, E3...).
RESULTS
The presentation of the theme “Being a nurse in the daily routine of Primary Health Care: the doing, learning and living with” is configured in two subcategories: The acting of the professional nurse in the daily life of PHC and Being a nurse in the daily life of PHC.
The subcategory The acting of the professional nurse in the daily life of PHC promotes reflection on behavior, characteristics or skills needed to perform activities or function of the nurse in the face of daily practices in the Unified Health System (Sistema Único de Saúde, SUS).
In this study, the protagonism of nurses in PHC was declared in the organization, planning, and operation of PHC units, performing activities of an administrative, welfare, and educational nature, contributing significantly to the implementation of individual and collective actions in relation to the health needs of user-families and the community.
According to 33 of the 54 participants in the research, the nurse's acting transitions into resoluteness and co-responsibility, into knowing and making a difference, into empathy and walking with the user, being an open door:
I am a very active person, I try to solve as many problems as possible of the patients who come to me. So I don't have to stay in that back and forth, sending them from one corner to the other, but always within my limit. Trying to make the patient understand that they need to do their part, because we can't do everything for them [...] for 16 years I have fought for and thought on the nurse's need for them to have their space! Use our knowledge to help the patient, exercise our profession as it is there, thoroughly, with all the rights to perform consultations and procedures [...] with quality. (E14)
I really like what I do, so I always try to do it for the user the way I would like to be served. I understand Primary Care as the gateway to all Health Services. There must be a well-expanded view [...] and I try to achieve the goals that the patient came for. (E15)
I realize that I am making a difference in the life of some patient, I see that I could really help, clarify the doubt, give an orientation that they can understand [..] and leave satisfied with that resolved. (E31)
In my day-to-day, it is important to assist the community, the nurse, they have a link between community and care, so the practice of the nurse is important to guide the user in what they need. It is important to have mastery over the issue of flows, and we have a very important role to play in this, in guiding the patient throughout their lives and the needs that they have at each age, at each time of life. (E53)
The autonomy in the nursing consultation, the work overload, the emotional and physical exhaustion and making a difference in people's lives are part of the nurse's daily life:
I think we nurses have autonomy both on a scheduled appointment and spontaneous demand. We always find ourselves a little overwhelmed; a little not, a lot! [...] but I can act and make a difference in people's lives. It's just that it requires too much emotionally and physically. (E8)
The daily work of the nurse is guided by great responsibilities that do not match the working conditions they are offered. Thus, situations are observed between what one should do for what one can do, a constant fight between the ideal versus real:
I see that, by the day, the activities that are the responsibility of the nurse have been increasing, I feel overloaded, without no options [...] then, I have to act in all the actions of the surroundings, I have to give assistance and also have to accompany the technician and guide the technician, so, this overload of the nurse, it is smashing. (E44)
The demand has been increasing a lot due to the country's situation, and there are no longer health rules, that's so outrageous! Here, there is an assigned area, but this area is not respected, the working conditions are very precarious, there is no a cool bathroom, no pantry, and no fan, and this is 2019, this place is a reference. Even so, we offer a good service, a good response, people really come from health plans and say “oh, how well attended I am here, I'm attended faster”. But, we workers are overloaded and the conditions for work are very difficult. (E45)
We face many challenges, so, between the ideal and the real, there is a distance, as in any place or any category, and in the health area we experience it a lot, we arrive full of ideas and plans and cannot make it effective. At all times it is work overload, the dynamics interfere with it, I would like to implement it, then, something else comes taking the front and it ends up just in the desire. (E46)
The subcategory Being a nurse in the daily routine of PHC reveals the living and living with the daily challenges in PHC, represented by the high number of registered people, lack of human resources, high spontaneous and repressed demand, attention focused on illness and the need for training, which implies the need for Continuing Education:
Quite overloaded because we work with overcapacity of people for the territory [...] the experience is outside our governance as a professional and servant of a Public Institution, because there is a lack of human resources [...] and this generates a repressed demand of people who seek service and end up not getting it. We work with the human limit, so whenever possible we do what we can, but we know that a lot of people go away without attendance and that it is not possible sometimes to attend everybody [...] also from the model that we have experienced now, in my opinion, it unsets a little of what I have come from, of my education and what I have learned to practice in those 11 years of FHS that were more centered on the person, the individual, the promotion and prevention, we worked with health. I usually wonder what will be the day I will work in a Municipal Health Secretariat again and not in the Municipal Secretariat of Illness? It is too much disease-guided because we have been working on a system to increase user access to the service, so we have reduced our schedules with scheduled attendance to increase access to spontaneous demand. The care of a consultation, where you demand more time for self-care guidance, the practice of physical activity, feeding, to be able to teach how to manage your own health [...] are getting a little run over and swallowed up by spontaneous demand. (E8)
There has been a very large disfigurement of the FHS. We are meeting a lot of urgency demand, and the educational and preventive part too. The care with our chronic patients was kind of lost on this path [...] this FHS proposal here is very out of context, in fact, we are beginning to live a matter of putting out fires, we have no more training, no more investment in the professional. [...] we are not trained, we don't get new instruments and it is time to do, to do, to do! (E27)
Humanization, welcoming with sensitive listening and walking with the user are present in the daily life of the nurse's being, living with, and doing. However, the culture of the user seeking care attention and care in the illness predominates:
We try to make a sensitive listening, make a welcome and, if possible, direct this user to some path that they can have their demand heard. (E8)
I try, within my knowledge sense of humanization and perception, to treat the patient biologically, sociologically, and economically, then I put it all together and try to put on the balance that care of mine of the patient's urgency and what urgency I should treat here. Then I get very tired, overloaded and sometimes drying ice because the patient does not want to do the health promotion, he just wants the cure. (E43)
Being a nurse in the daily life of PHC is to be a protagonist in the organization, administration, and planning of actions, the assistance and education necessary for the implementation of individual and collective health actions. The doing is about resoluteness and co-responsibility, autonomy, humanization and welcoming with sensitive listening, empathy and making a difference when walking together with the user in their needs. In this daily routine doing, the nurse experiences precarious working conditions. However, nurses live, learn, and live with the daily challenges represented by the high number of registered people, lack of human resources, high spontaneous and repressed demand, attention focused on illness and the need for “training”, which denotes the need for continuing education. Thus, we observe situations that range from what should be done to what can be done, a constant struggle between the ideal and the real (NC).
DISCUSSION
As a right, the nurse should exercise their activities with freedom, autonomy and should be treated according to legal, ethical and human rights assumptions and principles. As a duty, the nurse must exercise the profession with justice, commitment, equity, resolution, dignity, competence, responsibility, honesty and loyalty(12). Between the lines, the research participants allude to the rights and duties of the profession.
The presence of the nurse has been fundamental to the functionality and consolidation of the SUS in Brazil, by possessing knowledge, techniques, and characteristics that make him/her a care manager, capable of impacting the health of users through control, monitoring, prevention of risks and illnesses, and health promotion(1).
International studies have shown that the care and attention provided by nurses provide better health outcomes compared to other health professionals. The PHC nurse can achieve and provide high levels of satisfaction to users and their families because they offer superior duration and quality in their consultations than other professionals. Nurse guidance and interventions can provide significant changes in users' lifestyles. Also, users who have received some form of care, guidance or intervention from the nurse have a greater understanding of the health problem, in addition to better dealing with the diagnosis and new life changes(13-14).
So the nurse “needs to see some kind of instinctive wisdom there. Wisdom that should not be considered from a moral point of view [...] that does not necessarily refer to reason, but that knows how to integrate that part of passion which, it is known, is an essential component of social life”(15: 267).
The results brought the daily work of nurses “in such a way as to ensure broad access, the link between people and professionals, and care's continuity, coordination, and longitudinality”(3:14). These attributes are experienced implying the relationship's appreciation of the bond and indicate the walk with the user and not forwarding it.
The attributes that relate the synergic, relational and interpersonal dimensions developed by professionals in their daily work promote a balance between the expressive and the technical, the individual and the collective, dialogue and listening, meanings and individual or collective values(16). Thus, it is in this daily routine that the nurse provides opportunities, amplifies and optimizes the perspectives of their performance towards the being to be cared for (1-6).
The relationships and interrelationships, expressed by the activities of caring, must be based on the moral, ethical and bioethical legitimizations and responsibilities of knowledge, values, and actions, permeated by a competent and reflexive critical posture, pondered from the view of the individual in all its totality - emotional, physical, environmental, relational and labor(17).
Therefore, in order to take care of the whole being, it should be considered that “in knowledge, a priori, nothing can be assigned to objects except what the thinking subject takes from themselves; [...]and no principle can be found safely in a relationship without examining it at the same time in your total relationship” (18:23).
However, the reality researched has shown that the nurses' doing is centered more on illness and spontaneous demand than on risk prevention and health promotion. Prioritizing curative activities of spontaneous demand disfigures the objectives of PHC and the professional identity of nurses(8). In this way, there is an increasing gap between the specific duties of the nurse in the PHC(3), at the expense of the flow/resolution needs of activities or more urgent demands.
This study presents the need for training, which denotes the need for continuing education as a tool capable of strengthening, reflecting and building integral and more resolute practices in PHC. Incorporating it would bring to the daily lives of the nurses an attitudinal and cultural orientation and remodeling in the face of the experienced challenges(19).
In addition, the protagonism, importance and essence of the nurse within PHC are capable of exposing them to suffering, attributed to work overload, emotional and physical exhaustion, biological risks and mistakes. The desire for risk-free praxis is utopian but striving to improve it is not only professional responsibility but a moral duty(18).
On this premise, being a nurse in the daily life of PHC means, in its broadest form, learn, live and live with the daily challenges represented in this study by the high number of registered people, lack of human resources, high spontaneous and repressed demand and attention focused on illness. Such factors can permeate the emotional, physical, psychic and ethical dimensions of the nurse in their work. A study conducted in the five Brazilian regions on PHC showed that the attributions and responsibilities of nurses linked to the challenges, characteristics, and contexts of the SUS may trigger or not moral distress to these professionals, becoming a limiting factor for the ethical performance, continuity and quality of care, the effectiveness and provision of PHC services(20).
Furthermore, a multi-centered study conducted with FHS nurses revealed that faced with this challenging daily routine, nurses are motivated by the magnificence of the quality of care, expressed by teamwork, the enjoyment of what they do, the support of the teams of the Expanded Core of Family Health and Basic Care (Núcleo Ampliado de Saúde da Família e Atenção Básica,NASF-AB) , and in good relationships with users and co-workers(21).
In Maffesolian theory, there is the being, sometimes person (persona), sometimes individual, unique and single unique and singular endowed with varied characteristics, dimensions, and individual or collective, rational or sensory experiences (22). In this study, the nurse, in assuming the being of caregiver, their preferences and their place in the world, the interest is not only for the phenomena described but for the casual, banal and subjective representations and presentations of this being in their imaginary, sensory and sensitive daily life(15-22). “This forces a conversion of gaze: to appreciate each thing from its own logic, from its underground coherence, and not from an external judgment that dictates what it should be”(23:143-144). Thus, being and to have been become elements of a plural being.
Finally, we note that the being, the doing, the learning and the living with of nurses is guided by great responsibilities and charges around what is ideal and what is real in the PHC daily routine. In several scenarios, the infrastructure and functionality of Brazilian PHC are far from the idealized and desired reality. Therefore, knowledge and reflection on the determinants and difficulties inherent to professional practice, as well as the provision of favorable and efficient environments for productivity and the promotion of excellence in patient care and safety(7) and also the safety of the professional, become timely.
FINAL CONSIDERATIONS
The PHC nurse being experiences protagonism, autonomy, the applicability of knowledge and professional skills while performing the doing with humanization, empathy, responsibility, and ethics the activities of administrative, managerial, welfare and educational nature, significant to the health needs of the population.
The doing of the nurse goes through the resoluteness and co-responsibility, in a daily life marked by work overload, emotional and physical exhaustion, the culture, still predominant, of the user seeking attention and care in the illness, the high number of registered people, lack of human resources, high spontaneous and repressed demand and the need for continuing education. These factors do not match with the working conditions they are offered, besides causing a growing disfigurement between the identity of this professional and the recommended attributions they wish to experience.
We observe, therefore, that the nurses live with everyday situations and challenges that resignify their actions, identity and processes of doing and learning.
* The authors declare that there are no conflicts of interests.
*Authors’ contributions: Lívia Silveira Silva worked on the conception, design, collection, analysis, data interpretation, article writing. Selma Maria da Fonseca Viegas worked on the conception, design, collection, analysis, data interpretation, article writing, critical review and approval of the version to be published. Cássia Menezes worked on the collection, analysis, data interpretation, and article writing.
*Funding: This study was funded by a scholarship from the Stricto Sensu Post-Graduation Incentive Program (PIPG) of UFSJ, as well as by a scientific initiation scholarship from Edital 009/2017 PIBIC/FAPEMIG (Fundação de Amparo à Pesquisa do Estado de Minas Gerais).
REFERENCES
1. Fernandes MC, Silva LMS, Silva MRF, Torres RAM, Dias MSA, Moreira TMM. Identity of primary health care nurses: perception of “doing everything”. Rev Bras Enferm [Internet]. 2018 [Cited 2019 Set 5]; 71(1). Available from: http://www.scielo.br/pdf/reben/v71n1/0034-7167-reben-71-01-0142.pdf.
Doi: http://dx.doi.org/10.1590/0034-7167-2016-0382
2. Eriksson I, Lindblad M, Moller U, Gillsjo C. Holistic health care: Patients' experiences of health care provided by an Advanced Practice Nurse. Int J Nurs Pract [Internet]. 2017 [Cited 2019 Aug 22]; 24(1): e12603. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5813192/. Doi: 10.1111/ijn.12603
3. Brasil. Ministério da Saúde. Portaria 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelencendo a revisão de diretrizes para organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União [Internet]. Brasília, DF; 21 set 2017 [cited 2019 ago 15].Available from: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt2436_22_09_2017.html
4. Silva MCN, Machado MH. Health and Work System: challenges for the Nursing in Brazil. Cienc saude Colet [Internet]. 2020 [Cited 2020 Jan 31]; 25(1). Available from: http://www.scielo.br/pdf/csc/v25n1/en_1413-8123-csc-25-01-0007.pdf. Doi: 10.1590/1413-81232020251.27572019
5. Sonya L, Kowalski MSN, Maureen A. Nursing’s Evolving Role in Patient Safety. AJN [Internet]. 2017 [Cited 2019 Aug 22]; 117(2). Available from: https://insights.ovid.com/crossref?an=00000446-201702000-00025. Doi: 10.1097/01.NAJ.0000512274.79629.3c
6. Barbiani R, Nora CRD, Schaefer R. Nursing practices in the primary health care context: a scoping review. Rev Latino-Am Enferm [Internet]. 2016 [Cited 2020 Jan 31]; 24(e2721). Available from: http://www.scielo.br/pdf/rlae/v24/0104-1169-rlae-24-02721.pdf doi: http://dx.doi.org/10.1590/1518-8345.0880.2721
7. Dahl BM, Clancy A. Meanings of knowledge and identity in public health nursing in a time of transition: interpretations of public health nurses' narratives. Scand J Caring [Internet]. 2015 [Cited 2019 Aug 29]; 29(4). Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/scs.12196. Doi: https://doi.org/10.1111/scs.12196
8. Ferreira SRS, Périco LAD, Dias VRGF. The complexity of the work of nurses in Primary Health Care. Rev Bras Enferm [Internet]. 2018 [Cited 2019 Set 12]; 71(supl1). Available from: http://www.scielo.br/pdf/reben/v71s1/pt_0034-7167-reben-71-s1-0704.pdf. Doi: http://dx.doi.org/10.1590/0034-7167-2017-0471.
9. Yin R K. Estudo de Caso: Planejamento e Métodos. Porto Alegre:Bookman editora; 2015.
10. Maffesoli M. O conhecimento comum: introdução à sociologia compreensiva. Porto Alegre: Sulina; 2010.
11. Bardin L. Análise de Conteúdo. São Paulo: Edições 70; 2011.
12. Conselho Federal de Enfermagem. Resolução COFEN nº 564/2017. Aprova o novo Código de Ética dos Profissionais de Enfermagem[Internet]. Brasília, DF; 2017 [cited 2019 Set 19]. Available from: http://www.cofen.gov.br/resolucao-cofen-no-5642017_59145.html
13. Laurent M, Biezen ML, Wilers M, Watananirun K, Kontopantelis E, Vught AJAH. Nurses as substitutes for doctors in primary care. Cochrane Database of Systematic Reviews [Internet]. 2018 [Cited 2019 Set 19]; 7(1). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001271.pub3/full. doi:10.1002/14651858.CD001271.pub3.
14. Taranta E, Marcinowicz L. Collaboration between the family nurse and family doctor from the perspective of patients: a qualitative study. Family Practice [Internet]. 2019 [Cited 2019 Set 26]; 20(20). Available from: https://www.ncbi.nlm.nih.gov/pubmed/31281923.
doi: 10.1093/fampra/cmz035.
15. Maffesoli M. Elogio da razão sensível. Petrópolis: Vozes; 1998.
16. Kessler M, Lima SB, Weiller TH, Lopes LP, Ferraz L, Eberhardt TD, et al. Longitudinality of Primary Health Care: an evaluation from the perspective of users. Acta Paul Enferm [Internet]. 2019 [Cited 2019 Ago 29]; 32(1). Available from: http://www.scielo.br/pdf/ape/v32n2/en_1982-0194-ape-32-02-0186.pdf.
Doi: http://dx.doi.org/10.1590/1982-0194201900026
17. Berlinguer G. Bioética Cotidiana. Brasília: Editora UnB; 2015.
18. Kant I. Crítica da razão pura. Lisboa: Acrópolis; 1987.
19. Martins JRT, Viegas SMF, Oliveira VC, Rennó HMS. Vaccination in everyday life: experiences indicate Permanent Education. Esc Anna Nery [Internet]. 2019 [Cited 2019 Set 12]; 23(4). Available from: http://www.scielo.br/pdf/ean/v23n4/1414-8145-ean-23-04-e20180365.pdf. doi:10.1590/2177-9465-EAN-2018-0365
20. Barth PO, Ramos FRS, Barlem ELD, Rennó HMS, Brehmer LCF, Rocha JM. Generating situations of Moral Distress in Primary Care Nurses. Rev Bras Enferm [Internet]. 2019 [Cited 2019 Set 5]; 72(1). Available from: http://www.scielo.br/pdf/reben/v72n1/0034-7167-reben-72-01-0035.pdf. doi: http://dx.doi.org/10.1590/0034-7167-2018-0378 .
21. Biff D, Pires DEP, Forte ECN, Trindade LL, Machado RR, Amadigi FR et al. Nurses’ workload: lights and shadows in the Family Health Strategy. Cienc saude Colet [Internet]. 2020 [Cited 2020 Jan 31]; 25(1). Available from: http://www.scielo.br/pdf/csc/v25n1/en_1413-8123-csc-25-01-0147.pdf. Doi: 10.1590/1413-81232020251.28622019
22. Maffesoli M. O ritmo da vida. Variações sobre o imaginário pós-moderno. Rio de Janeiro: Record; 2007.
23. Maffesoli M. No fundo das aparências. Petrópolis: Vozes; 1996.
Received:01/14/2020
Revised:02/23/2020
Approved:02/23/2020