ORIGINAL ARTICLE

ILLEGALITIES AND IRREGULARITIES IN ETHICO-PROFESSIONAL OVERSIGHT IN PRIMARY HEALTH CARE: A DOCUMENTARY STUDY

Rodrigo Guimarães dos Santos Almeida1, Andrezza Gabrielly dos Santos Soldera2, Rosilene Rocha Palasson3, Sebastião Junior Henrique Duarte4

1 Doctor of Science. Universidade de São Paulo. Escola de Enfermagem de Ribeirão Preto. Ribeirão Preto, São Paulo, Brazil. Orcid: https://orcid.org/0000-0002-4984-3928. E-mail: rgclaretiano@gmail.com   

2 Master in Nursing. PhD student in the Programa de Pós Graduação em Enfermagem Fundamental. Universidade de São Paulo. Escola de Enfermagem de Ribeirão Preto. Ribeirão Preto, São Paulo, Brazil. Orcid: https://orcid.org/0000-0001-9000-5179. E-mail: andrezzasoldera@usp.br

3 Doctor of Nursing. Universidade Federal de Mato Grosso do Sul. Instituto Integrado de Saúde. Curso de Graduação em Enfermagem. Campo Grande, MS, Brazil. Orcid: https://orcid.org/0000-0003-1474-7503. E-mail: rrpalasson@gmail.com

4 Doctor of Science. Universidade Federal de Mato Grosso do Sul. Faculdade de Medicina. Campo Grande, MS, Brazil. Orcid: https://orcid.org/0000-0003-3161-9669. E-mail: sjhd.ufms@gmail.com

ABSTRACT

Objective: To identify the main irregularities and illegalities in professional nursing practice within primary health care units. Method: A quantitative, documentary study analyzing administrative proceedings from 2019 to 2023, using an instrument with variables related to institutional profiles and notified irregularities and illegalities. Results: 22 health units were analyzed. Regarding irregularities, the study observed the absence or inadequacy of documents for managing nursing work processes, particularly duty rosters, and a lack of nursing staffing level calculations. As for illegalities, the most significant was the absence of a formally registered Technical Lead. Conclusion: The weaknesses observed compromise patient safety and highlight the need for management actions and continuing education in nursing within Primary Health Care. It is believed that the oversight process can lead to measures to remedy these deficiencies and ensure an adequate nursing practice to meet the needs of users and the community.

Descriptors: Health Care Coordination and Monitoring; Professional Review Organizations; Nursing Services; Nursing; Primary Health Care.

What is already known:

• Oversight of professional nursing practice aims to ensure the legality and safety of practices in health services.

• Primary Health Care is the main field of practice for nursing in Brazil's Unified Health System, but it faces challenges related to management and staffing levels.

• There are gaps in knowledge regarding the prevalence of illegalities and irregularities in professional nursing practice in Primary Health Care units, especially at the local level.

What this study adds:

• The study identified that the main illegality in Primary Health Care units was the absence of a registered Technical Lead, which compromises the safety of care.

• The most frequent irregularities included failures in creating duty rosters and the absence of nursing staffing level calculations as required by current legislation.

• The study highlights the need to strengthen professional training and continuing education to support the Technical Lead, improve the creation of duty rosters, and ensure staffing levels are determined according to legislation.

INTRODUCTION

In Brazil, the Federal Council of Nursing (Cofen) and the 27 Regional Nursing Councils (Corens) jointly form an independent federal public body tasked with regulating nursing practice, in accordance with the precepts of Laws 2,604/55, 5,905/73, and 7,498/86(1-3). In formulating disciplinary policies, Cofen is responsible for publishing resolutions and normative opinions, which are to be implemented by the Corens among nursing teams.

At the national level, the nursing profession comprises two university-level roles, represented by registered nurses, and three high school-level roles: nursing technicians, nursing assistants, and midwives. According to 2023 data from Cofen, the country has approximately 3 million registered nursing professionals(4).

Regarding the work process, Law No. 7,498/86 and Decree No. 94,406/87 outline the duties of each professional nursing category(3,5). Other documents also guide the activities to be performed, such as protocols from the Ministry of Health, opinions from the Corens, and technical notes. Given the importance of the documents that guide nursing practice, each professional must be aware of the standards that support them in ethical and legal matters, both within the Cofen/Corens system and before other public oversight bodies(1,3).

It should be noted that the main purposes of the Cofen/Corens System include: 1) standardization, which guides actions to be undertaken in professional practice; 2) corrective discipline, through ethico-disciplinary proceedings in cases of ethical code violations; and 3) oversight, with the objective of preventing legal infractions and ensuring that nursing is practiced by qualified individuals, among other measures of public and social interest(6).

During oversight, illegalities and irregularities can be cited. Illegalities constitute infractions of laws—both those that regulate the profession and those of the judicial system. Irregularities, in turn, are situations of total or partial non-compliance with normative acts and, therefore, lead to the adoption of ethical and/or administrative measures by the Nursing Council itself(7).

Regarding the field of practice for nursing professionals, it is noteworthy that the majority work in the Unified Health System (SUS), across all levels and services offered to the population. They represent more than 60% of the workforce in the SUS and, together with the multiprofessional team, contribute to improvements in health indicators by ensuring universal access to health care networks, especially the Primary Health Care (PHC) network(8).

In Brazil, PHC is the main gateway to the SUS, with a high potential for resolving most health problems by promoting care centered on the individual, family, and community. The implementation of PHC occurs through the Family Health Strategy (ESF), which covers 62.6% of Brazilians, and through basic health units(8).

According to the Ministry of Health, in 2020, the country had 43,286 ESF teams, which demonstrates the significant sociopolitical participation of nursing in building this level of care, along with other health professions(9-10).

The activities carried out in PHC are predominantly of low technological density; however, they involve numerous complexities arising from the characteristics of the territory and its assigned population, as well as from the level of vulnerability of the social determinants of health(11).

Given the relevance of the health actions offered to the population, as well as the significant number of nursing professionals working in PHC, it is essential that the Corens prioritize activities in this area of care—especially the oversight of professionals and the fulfillment of managers' obligations—to ensure safe professional practice for society.

In this context, this study aimed to identify the main irregularities and illegalities in professional nursing practice in primary health care units.

METHOD

Study Design

This is a retrospective, descriptive-exploratory, documentary study with a quantitative approach, using secondary data from documents related to the oversight activities of Coren-MS. The recommendations of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist were used for the design and reporting of this study.

Setting

The research was conducted at the headquarters of Coren-MS, located in Campo Grande, the state capital. Mato Grosso do Sul is a state in the Center-West region of Brazil with an estimated population of 2,833,742 inhabitants(12) distributed across 79 municipalities. In addition to its headquarters in the capital, Coren-MS has two sub-offices: Três Lagoas and Dourados.

Sample Definition

The municipality's health care network is divided into 7 health districts, which, in this study, are referred to by names of Cerrado biome plants to preserve the institutions' identities. They are: 1) Bromelia, 2) Fern, 3) Orchid, 4) Water Hyacinth, 5) Ipê, 6) Fig Tree, and 7) Carandá. This network comprises a total of 74 health units (53 Family Health Units - USF and 16 Basic Health Units - UBS), with a primary care coverage of 88.4% of the population(13). To define the sample, simple random sampling was performed to select four units from each district, resulting in a sample size (N) of 22, consisting of 14 USF and 8 UBS.

Data Sources and Selection Criteria

Administrative proceedings (known as PADs in Brazil) initiated from 2019 onward were included. PADs related to the evaluation for releasing a Technical Lead from their duties were excluded, as these do not contain a standard oversight report. PADs prior to 2019 were not included in the sample due to a change in the oversight process, which was previously conducted by family health team rather than by health unit.

Data Collection

Data were collected from October 2022 to January 2023. The data collection instrument was developed by the researchers based on the initial inspection form proposed by the Oversight Manual of the Cofen/Corens system, which guides the oversight visit and includes variables related to the notified irregularities and illegalities.

Data Analysis and Processing

The obtained data were coded and entered into Microsoft Excel spreadsheets. Data analysis was performed descriptively, using tables with absolute and relative frequencies (%) that categorized the notified illegalities and irregularities.

Ethical Aspects

This study is part of a macro-project titled "Regional Nursing Council of Mato Grosso Do Sul: an analysis of normative, disciplinary, oversight, and ethical implications", approved by the Research Ethics Committee of the Federal University of Mato Grosso do Sul, under CAAE (Certificate of Presentation for Ethical Appraisal) number: 58753722.9.0000.0021.

RESULTS

A total of 22 (29.7%) of the municipality's health units were analyzed. The distribution of professionals per unit is presented in Table 1.

Table 1 – Distribution of nursing professionals by health district and unit. Campo Grande, MS, Brazil, 2025. (N=22)

*Fictitious name given to the health districts. *Family Health Unit with a Multiprofessional Residency Program in Family Health.

Source: Prepared by the authors.

Chart 1 presents the illegalities by district and the corresponding notification issued. The absence of a registered Technical Lead for the nursing service was observed as the main illegality.

Chart 1 - Notified illegalities by health district and notification issued. Campo Grande, MS, Brazil, 2025. (N=22)

F = Frequency.

Source: Prepared by the authors.

Chart 2 presents the irregularities by district and the facts observed. A predominance of irregularities was noted regarding the standing of professionals with the council and the lack of nursing staff dimensioning calculations according to current legislation.

Chart 2 – Notified irregularities by health district and facts observed. Campo Grande, MS, Brazil, 2025. (N=22)

F = Frequency.

Source: Prepared by the authors.

DISCUSSION

In primary health care, where nursing is integrated, its actions—carried out through specific knowledge and articulated with other health professionals—aim to provide effective care in PHC within a socio-political context that supports this practice(14-15).

Professional nursing practice in PHC is established by Law No. 7,498/86 and by regulatory norms of the Cofen/Corens system, and it is also guided by the National Primary Care Policy (PNAB), which defines the managerial and care-related competencies for nurses' work within the Unified Health System (SUS)(3,16). Actions are directed toward individuals, families, and communities, involving activities for health promotion, maintenance, and recovery within the spheres of management, teaching, research, and political participation(17).

Within the scope of nursing work in PHC, care-related, managerial, and educational activities stand out. Among the managerial activities, the duty to comply with all legal provisions of the profession is prominent, such as maintaining necessary and updated information on all nursing professionals working at the institution, as well as organizing the service using administrative instruments like internal regulations, norms, routines, protocols, and standard operating procedures (SOPs)(16).

In this context, the study's findings indicate that the main illegality identified was the absence of a registered Technical Lead for the nursing service in the participating health units. That is, in the analyzed units, the nurse acting as the Technical Lead (TL) did not have their position formally registered with the council(17).

The technical responsibility for a service within an institution is granted autonomously and requires a Certificate of Technical Responsibility (CTR), which designates the TL as the liaison between the institution and the Coren of that jurisdiction. In addition to being a liaison, the TL must ensure ethical and safe nursing care and integrate the areas of care, administration, teaching, and research. Therefore, they must understand the interaction of organizational processes to contribute to the success of the institution's outcomes(17-18).

A difficulty in communication between professionals and the council is observed, as it is the responsibility of the nurses designated for the role to report any change in personnel holding the position. This makes it impossible for the council to cancel the CTR, as it is unaware of the professional's transfer from the institution. This finding may be related to the high turnover of professionals in basic health units, a fact already noted in the literature, and a lack of information about the need for registration.

Considering that civil service exams and hiring are often conducted without specifying the exact position or workplace, PHC units experience high turnover among professionals until there is an alignment of interests, whether from the institution or the professional. This rotation is detrimental to building bonds between the unit, the team, and the community, but in many institutions, both private and public, it is an established principle of professional management(19).

Turnover can influence the quality and safety of care provided to the user, as well as create difficulties in the service regarding the completion of managerial and productivity documents. When professionals are reassigned to other units without the cancellation of their CTR, they remain responsible for all occurrences related to the nursing team, the development and knowledge of work processes, norms and routines, care-related records, and interpersonal relationships with the team(20).

In this regard, concerning the regulation of managerial documents—identified as an irregularity—the inadequacy of documents related to the management of work processes was also observed, particularly regarding the inadequacy of the duty roster. This finding is directly related to the absence of a registered TL, as this professional oversees its preparation.

The proper creation of a duty roster is a recurring problem in the profession. Understanding the intervening factors in the development of work schedules is necessary, among which the following stand out: the number of employees, working hours, medical leave certificates, limitations, and productivity of the staff involved, and the type of care provided. All these points must be evaluated to ensure the creation of a schedule that promotes effective care(21).

The absence of a supervising nurse in locations where nursing activities are performed was verified in only two units of the sample. According to Law No. 7,498/86, nursing activities in health institutions, both public and private, and in health programs, can only be performed under the guidance and supervision of a nurse. Therefore, this is a concerning fact, because if more invasive procedures or decision-making in urgent and emergency cases are needed, their absence can put the user's health at risk(3).

Furthermore, by supervising, the nurse helps to foster healthy work environments by valuing interactions, building trust, strengthening teamwork, and supporting workers—aspects that result in the promotion of psychological safety within primary care(22).

This justifies the need for adequate human resource dimensioning through tools that allow for the systematization of nursing care, so that professionals do not expose users to risks or face ethical sanctions for negligence.

Nursing staff dimensioning can be linked to enabling quality of care. Contrary to this progress, the PNAB, updated in 2017, represents a setback by making population coverage and the number of professionals more flexible, rendering the calculation undefined, unlike what was stipulated in the 2011 policy(16).

In some units, the need to adjust the staffing dimensioning was verified, while in others, there was no record of the calculation being performed. These findings indicate that nurse TLs face difficulties in performing and/or adjusting the staffing dimensioning calculation in PHC. This may be related to a lack of knowledge of current legislation, as this tool was introduced only a few years ago at this level of care, and it implies an urgent need for better training for professionals on the topic(23-24).

Therefore, it is important for nurses to use managerial instruments to perform adequate staffing dimensioning, aiming to promote changes in the work of the nursing team and improve the care provided(24).

It should be noted that staffing dimensioning is related to the number of professionals and the activities carried out at the health institution. While hiring personnel is not the responsibility of the TL, mapping the indicators of activities performed is essential for the dimensioning calculation and for strengthening the request to hire more professionals, if necessary.

Only professionals who are duly registered with the council are fit to practice nursing. It was observed in 50% of the units that some professionals were not in good standing regarding their professional identity card. This irregularity may be related to issues with annuity payments, issuance of a permanent ID, document expiration, or transfer of jurisdiction.

The lack of knowledge about the work carried out by the councils on the part of some professionals may be associated with the mistaken view that oversight—especially of the professional ID and supporting documents—is a merely punitive action. However, being in good standing provides ethical and legal protection for professional practice(25-26).

A lack of information about the norms, ethical and legal precepts, and the rights and duties of the profession, whether during undergraduate studies or after entering the job market, contributes to a failure to recognize the due importance of the professional council, teaching associations, and unions for the profession. Thus, it is increasingly important to have training that addresses this gap and for continuing education strategies to provide support for professional practice and ensure quality care for society.

Another aspect to consider is the role of SUS health units as drivers of professional training, as many of them have multiprofessional residency programs. These settings, therefore, enable not only specialized training but also greater experience in teamwork and interprofessionality(27). However, to serve as practice fields that contribute to training, the units must comply with health regulations, the legal practice of professions, and labor conditions.

The limitations of this study include the lack of follow-up on the outcomes of the oversight process in these units, as well as the specific nature of Brazilian nursing legislation, which makes comparison with other realities not feasible.

CONCLUSION

The research made it possible to identify, albeit from a sample, that PHC health units have weaknesses related to the regulation of nursing services. In this context, it is believed that the oversight process should culminate in active measures that can remedy these deficiencies and ensure a nursing practice adequate to meet the needs of users and the community. Thus, it is necessary to subvert the logic of oversight as being linked to punishment and instead frame it as a tool for education. As implications for practice, it is considered important to strengthen the theme of ethico-professional oversight within the scope of the National Policy of Continuing Education, and for educational institutions to better develop this topic within their curricula for future professionals.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.

FUNDING

This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Financing Code 001 and the Federal University of Mato Grosso do Sul – UFMS/MEC – Brazil.

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Submission: 30-Jul-2025

Approved: 15-Sep-2025

Editors:

Rosimere Ferreira Santana (ORCID: 0000-0002-4593-3715)

Geilsa Soraia Cavalcanti Valente (ORCID: 0000-0003-4488-4912)

Cristiano Bertolossi Marta (ORCID: 0000-0002-0635-7970)

Corresponding author: Andrezza Gabrielly dos Santos Soldera (andrezzasoldera@usp.br)

Publisher:

Escola de Enfermagem Aurora de Afonso Costa – UFF

Rua Dr. Celestino, 74 – Centro, CEP: 24020-091 – Niterói, RJ, Brazil

Journal email: objn.cme@id.uff.br