Esta investigação sobre o trabalho da enfermeira, na atenção básica em saúde, tem como questão central a especificidade desse trabalho e, como objeto de estudo, as competências gerais e específicas da enfermeira e sua contribuição para a construção do Sistema Único de Saúde (SUS) e para a constituição das Funções Essenciais de Saúde Pública (FESP), com os objetivos: 1) identificar e analisar as competências gerais e específicas requeridas da enfermeira para atuação na saúde pública, a partir do trabalho realizado na rede básica de saúde; 2) compreender como essas competências estão contribuindo para o desempenho das FESP, considerando-se a forma como estão sendo construídas no atual estágio de implementação do SUS. A determinação dos locais do estudo e da escolha dos sujeitos deu-se em função da utilização da Técnica Delphi como método de investigação. Foram selecionados dois grupos de participantes: um de 131 enfermeiras que atuam na rede básica do Município de Porto Alegre, e, outro, de 144 especialistas, enfermeiras que ocupam cargos na Secretaria de Saúde do Município de Porto Alegre e docentes de enfermagem em saúde publica/comunitária/coletiva das escolas de enfermagem do estado do Rio Grande do Sul. O projeto foi aprovado pelo Comitê de Ética da Escola de Enfermagem de Ribeirãoreto/USP. Aceitaram participar da pesquisa, e assinaram o termo de consentimento informado, 52 enfermeiras e 57 especialistas. Para a coleta de dados utilizamos três questionários. O primeiro solicitou que as participantes indicassem três competências gerais e três especificas necessárias para o trabalho da enfermeira na atenção básica. Essas foram reunidas em uma listagem para cada grupo, que foi compilada, resultando em 84 competências, 44 gerais e 40 específicas no grupo das enfermeiras e 93 no grupo de especialistas, 49 gerais e 44 especificas. O segundo questionário foi composto dessas duas listagens adicionadas de uma escala de Likert, com valores de 1 (discordo muito) a 5 (concordo muito). Devido à estabilidade das respostas em torno do escore 5, foi adotado como critério de consenso, para a análise quantitativa, o percentual de 75% para os escores 4 ou 5, resultando em 17 competências gerais e 8 específicas no grupo de enfermeiras e 19 competências gerais e 9 específicas, no grupo das especialistas. Essas competências foram classificadas em áreas de domínio: valores profissionais; comunicação; trabalho em equipe; gerência; orientada a comunidade; promoção da saúde; resolução de problemas; atenção à saúde; educacional; em ciências básicas da saúde publica. Na análise qualitativa, foram discutidos os motivos pelos quais as competências são necessárias para o trabalho da enfermeira na atenção básica, frente ao percurso da enfermagem na implantação do SUS, aos preceitos da atenção primária, aos conteúdos da atenção básica, aos enunciados de competências existentes na literatura e a como estas competências estão contribuindo para o desempenho das FESP na realidade estudada. As competências específicas refletiram atividades tradicionalmente desempenhadas pela enfermeira, a sua posição na equipe de enfermagem, a especificidade da atenção prestada por essa profissional e a necessidade de seu desenvolvimento na profissão. / This study on nursing work in primary health care focuses on the specific nature of this work and investigates nurses’ general and specific competencies, as well as their contribution to the construction of the Single Health System (SUS) in Brazil and to the constitution of the Essential Public Health Functions (EPHF). The objectives were: 1) to identify and analyze general and specific competencies required for public health nursing practice, based on primary health care practice, and 2) to understand how these competencies are contributing to the performance of the EPHF, considering how they are being developed in the current implementation stage of the SUS. Places of study and subjects were determined according to the Delphi Technique, which was the method of study. Two groups of participants were selected: one with 131 nurses who work in the primary health care system of Porto Alegre, and another with 141 specialists, who were nurses working at the Porto Alegre Health Secretariat and public/community health faculty at nursing schools in the state of Rio Grande do Sul. The research project was approved by the Ribeirão Preto College of Nursing/USP Ethics Committee. Fifty-two nurses and fifty-seven specialists accepted to participate in the study and signed an informed consent term. Three questionnaires were developed for data collection. The first asked participants to indicate three general and three specific competencies nurses need to work in primary health care. These competencies were joined in a list for each group and then compiled into 84 competencies, 44 of which were general and 40 specific, for the nursing group and 93, 49 of which were general and 44 specific, for the specialist group. The second questionnaire was composed of these two lists with a Likert scale from 1 (completely disagree) to 5 (completely agree). In quantitative analysis, due to the stability of answers around score 5, 75% was adopted as a consensus criterion for scores 4 or 5, which resulted in 17 general and 8 specific competencies for the nursing group and 19 general and 9 specific competencies for the specialist group. These competencies were classified into action areas: professional values, communication, team work, management, community oriented, health promotion, problem solution, health care, educational, in basic public health sciences. In qualitative analysis, we discussed the reasons why these competencies are necessary for nursing work in primary health care, in view of the trajectory of nursing in the implantation of the SUS, the principles and concepts of primary health care, what literature says about competencies and how these competencies are contributing to the performance of EPHF in the reality that was studied. Specific competencies reflected traditional nursing activities, the specific nature of nursing care and the need for nurses’ development in the profession.

Orientador: Maria de Lourdes da Silva Marques Ferreira / Banca: Ana Maria Lombardi Daibem / Banca: Vera Lúcia Pamplone / Resumo: O objeto de investigação desta pesquisa é a prática pedagógica do docente orientador de estágio curricular em enfermagem na Saúde Coletiva, em instituições de ensino público e privado, de duas cidades do Centro-oeste paulista. O preparo pedagógico do docente, da área da saúde, frente às exigências da educação contemporânea e das Diretrizes Curriculares Nacionais tem relação direta com a formação de profissionais para atender às necessidades do SUS. Assim, este trabalho tem por objetivo analisar, a luz das Diretrizes Curriculares e das políticas públicas de educação e saúde, a prática pedagógica do docente de enfermagem, orientador de estágio na saúde coletiva. Os dados obtidos foram submetidos à Análise de Conteúdo, modalidade temática. A análise empreendida aponta que a prática pedagógica dos docentes entrevistados sofre influência da cultura institucional da educação superior brasileira. As atividades rotineiras estão calcadas em conteúdos das ciências biológicas e da saúde, organizados sob a égide da assistência de enfermagem; na exposição oral e reprodução de técnicas biomédicas; na desarticulação entre teoria e prática; na avaliação centrada no aluno e não no processo e no isolamento do trabalho docente. Conclui-se que as competências docentes precisam ser ampliadas em direção ao planejamento da ação pedagógica, aproximando-se dos referenciais teóricos e filosóficos do Sistema Único de Saúde, da Saúde Coletiva e da educação contemporânea / Abstract: The object of investigation is the pedagogic practice of the teaching advisor of traineeship curricular in nursing in the Collective Health, in institutions of public and private teaching, of two cities of Middle West of São Paulo state. The pedagogic preparation of the teacher, working in the health area, according to the demands of the contemporary education and of the National Curricular Directives has direct relation with the professionals' formation to pay attention to the necessities of the SUS. Therefore, this work has as the objective of analyzing, the light of the Curricular Directives and of the public policies of education and health, the pedagogic practice of the teacher of nursing, traineeship advisor in the collective health. The obtained data were subjected to the Analysis of Content, thematic kind. The undertaken analysis points that the pedagogic practice of the interviewed teachers suffers influence of the institutional culture of the Brazilian superior education. The routine activities are based on contents of the biological sciences and of the health which are organized under the aegis of the presence of nursing; in the oral exhibition and reproduction of biomedical techniques; in the dislocation between theory and practice; in the evaluation centered in the pupil and not in the process and in the isolation of the teaching work. The teaching competence needs to be enlarged towards the projection of the pedagogic action, approaching the theoretical and philosophical referential systems of the SUS, of the Collective health and the contemporary education / Mestre

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Reconhecendo a magnitude do problema de saÃde pÃblica que o cÃncer de mama se tornou ao longo dos anos e considerando a mamografia como procedimento especÃfico para detecÃÃo precoce, elegeu-se a realizaÃÃo da mamografia como comportamento desejado para esta investigaÃÃo. O objetivo geral foi avaliar a intenÃÃo comportamental de realizar mamografia e seus determinantes, entre mulheres de uma comunidade rural, submetidas ou nÃo a uma mensagem persuasiva. Trata-se de estudo experimental, do tipo apenas-posterior, tendo a Theory of Planned Behavior como referencial teÃrico-metodolÃgico. O estudo foi realizado em municÃpio da ParaÃba, com amostra composta por 148 mulheres divididas nos grupos Experimental 70(47,3%) e Controle 78(52,7%). As participantes eram, em sua maioria, casadas, com ensino fundamental incompleto, do lar, catÃlicas, com rendimentos mensais atà 2 salÃrios mÃnimos e idades entre 35 e 78 anos. A Coleta de dados foi realizada em duas etapas, sendo o levantamento das crenÃas (n= 33) em outubro/2009 e a avaliaÃÃo da intenÃÃo e seus determinantes em novembro/2009. As crenÃas compuseram as questÃes, formuladas em escalas de diferencial semÃntico de adjetivos bipolares tipo Likert. Os dados foram analisados comparativamente entre os grupos, sendo aplicados os testes de Fisher-Freeman-Halton, Mann-Whitney e o coeficiente de correlaÃÃo de Sperman. Utilizou-se o procedimento Forward para regressÃo logÃstica, com testes de Wald, Hosmer-Lemeshow e Omnibus, alÃm do R2 de Nagelkerke para poder de prediÃÃo. As anÃlises utilizaram os softwares PASW 18.0 e R versÃo 2.8.1, com nÃvel de significÃncia de 5%. As crenÃas comportamentais modais salientes positivas foram prevenÃÃo do cÃncer de mama, diagnÃstico precoce e se cuidar, e as negativas foram dor e medo. As crenÃas normativas mais frequentes foram o mÃdico, a televisÃo, vizinha e amiga. Quanto aos fatores facilitadores, foram mais citados: encaminhamentos, dinheiro, disponibilidade do exame pelo SUS e facilidade na marcaÃÃo. Entre os fatores impeditivos estiveram a demora para marcar/realizar o exame e a falta de dinheiro. Atitude foi considerada positiva em ambos os grupos, contudo o grupo controle apresentou melhor desempenho. Os escores maiores da norma subjetiva foram apresentados pelo grupo experimental, com predominÃncia do item que avaliava se a maioria das pessoas achava que a participante deveria realizar a mamografia nos prÃximos trÃs meses (p= 0,000). Os referentes com significÃncia estatÃstica foram: mÃdico, mÃe, irmÃ, enfermeira e agentes comunitÃrios. No tocante à percepÃÃo de controle comportamental, o grupo experimental(79,34) teve melhor desempenho em relaÃÃo ao grupo controle(70,15). A medida da intenÃÃo comportamental obteve tendÃncia positiva em ambos os grupos, sendo a mÃdia do grupo experimental (81,92) relativamente superior ao grupo controle (67,84). As variÃveis preditoras que melhor explicaram a intenÃÃo foram a atitude e a norma subjetiva, com coeficiente de determinaÃÃo de aproximadamente 50% (R2=0,503). O conhecimento das intenÃÃes comportamentais favorece o desenvolvimento de estratÃgias de trabalho para a enfermagem e demais profissionais de saÃde, a exemplo de aÃÃes de educaÃÃo em saÃde, que desperte a mulher para a importÃncia do rastreamento, bem como possibilite busca ativa de mulheres em idades apropriadas para a realizaÃÃo dos exames de detecÃÃo precoce. / Recognizing the magnitude of the public health problem that breast cancer has become over the years and considering mammography as specific procedure for early detection, mammography screening was elected as desired behavior for this investigation. The aim was to assess the behavioral intention and its determinants to perform mammography screening among women in a rural community, with or without a persuasive message. This is an experimental study, only-posterior type, and the Theory of Planned Behavior was a theoretical and methodological framework. The study was conducted in a city of Paraiba, with a sample of 148 women divided into experimental groups 70 (47.3%) and Control 78 (52.7%). The participants were, mostly, married women with incomplete primary education, work at home, catholic, with monthly incomes up to 2 minimum wages, aged 35 to 78 years. The data collect was performed in two steps: a survey of beliefs (n = 33) in October/2009 and assessment of intention and its determinants in November/2009. Beliefs composed the questions formulated in semantic differential scales of bipolar adjectives Likert type. The data were analyzed comparing the two groups, being tested by Fisher-Freeman-Halton, Mann-Whitney test and correlation coefficient of Spearman. It was used the procedure for Forward logistic regression, Wald test, Hosmer-Lemeshow and Omnibus, in addition to R2 Nagelkerke for predictive power. The analysis used the software PASW 18.0 and R version 2.8.1, with a significance level of 5%. The modal salient behavioral beliefs positive were breast cancer prevention, early diagnosis and itself care, and the negatives were pain and fear. Most frequent normative beliefs were physician, television, neighbor and friend. As facilitating factors, were most often cited: referent, money, availability of the examination in SUS and ease of marking. Among the impediments were taking so long to check / perform the examination and lack of money. Attitude was positive in both groups, however the control group showed better performance. The higher scores of subjective norm were presented by the experimental group, with predominance of the item that assessed whether most people thought that the participant should perform the mammogram in the next three months (p = 0.000). The referent with significant statistically were: physician, mother, sister, nurse and community agents. Regarding the behavioral control perception, the experimental group (79.34) had better performance comparing to the control group (70.15). The measure of behavioral intention received positive trend in both groups, with the mean of the experimental group (81.92) bigger than the control group (67.84). The predictor variables that best explained the intention were the attitude and subjective norm, with coefficient of determination of approximately 50% (R2 = 0.503). Knowledge of behavioral intentions should improve the strategies development of nursing work and other health professionals, like shares of health education to awaken women to the importance of mammography screening and make possible active search for women of appropriate ages to perform exams for early detection.

As mudanças sociais ocorridas nas últimas três décadas fizeram com que o respeito à autonomia do usuário e o direito ao consentimento livre e esclarecido assumissem posição de destaque na ética em saúde e fossem incorporados aos Códigos de Ética Médica e de Enfermagem vigentes no país. Estudos desenvolvidos em serviços de saúde, mormente os hospitalares, têm evidenciado que os usuários obtêm poucas informações sobre suas condições de saúde, tratamento, cuidado e que a prática profissional tem oscilado entre o paternalismo, o autoritarismo e o respeito à autonomia. Esta investigação foi realizada com o objetivo verificar como o consentimento esclarecido é concebido na prática das enfermeiras de quatro Centros de Saúde Escola (CSE) de São Paulo. A análise do material empírico, obtido através de entrevistas junto a essas profissionais foi feita à luz da ética principialista. O resultados demonstram que essas profissionais, apesar de desconhecerem o termo consentimento esclarecido, respeitam as suas normas básicas, reconhecem o direito dos usuários em participar de decisões que digam respeito à sua saúde, oferecem informações para subsidiar essas decisões. O padrão de informação é personalizado, porém, alternativas de decisão, além daquelas estipuladas em programas e protocolos, raramente são apresentadas. Assim, o consentimento esclarecido na prática das enfermeiras em CSE é limitado por esses programas e protocolos. As enfermeiras têm como preocupação o benefício do usuário, o estímulo às participação dos usuários no seu cuidado e a prevenção ou remoção de riscos e danos. No geral, estas enfermeiras acatam a decisão tomada pelo usuário, mesmo quando há recusa em seguir a orientação dada, mas por vezes demonstram dificuldade em aceitá-la quando a mesma põe em risco a saúde de terceiros. Enquanto profissionais que participam na implementação políticas de saúde demonstram preocupação com sua \"missão\", sentem-se impotentes e demonstram desconhecer aliados e instrumentos que poderiam ser utilizados nessa situação. / The social changes occurred in the last three decades were instrumental for causing the customers\' autonomy and right to free-informed consent to be respected assuming a leading rank in the health ethics as well as being incorporated into the Nursing and Medical Ethical Codes in force in the country. Studies carried out in health services, moreover in hospital facilities, disclosed that the customers usually obtain few information on their health condition, treatment and, care and that the professional practice has been oscillating among being either paternalistic, authoritarian or respecttul regarding the patient\'s autonomy. The purpose of this investigation was to ascertain how the informed consent is conceived by the nurses\' practice in four School/Health Centers in São Paulo, State of São Paulo. Brazil. The empirical material obtained in interviews along with these professionals was analyzed in the light of Bioethics principles. Results were as follows: these professionals do not know the term informed consent; however, they act in accordance with its basic norms, recognizing the customers\' right to participate in the decision-making regarding their health, besides providing information in order to subside these decisions: the pattern of the information provided is personalized, although decision alternatives other than those stipulated in programs and protocols are rarely presented. Informed consent, in nursing practice in School/Health Centers is restricted within these programs and protocols. These nurses are concerned about users\' beneficence, their participation in self care and about preventing or removig risks or harm. In general, these nurses respect the decision taken by the customers, even when they refuse to comply with the orientation provided, however showing sometimes difficulties in accepting it when the health of a third-part is in jeopardy; while professionals participating in the implementation of health policies, they demonstrate being concerned with their \"mission\", sometimes feeling themselves impotent to deal with this situation, disclosing therefore a lack of knowledge concerning allied institutions and instruments which might be used to face these kind of circumstances.

BACKGROUND Public Health Nurses (PHNs) in the Province of Eastern Finland are facing a new situation when the families attending maternal and child health (MCH) services represent increasingly diverting cultural backgrounds. Cultural competency is a part of PHNs’ qualification demands in Finland, however little is known on the phenomenon in the study area at the moment. AIM This study aims to describe how cultural competence is understood and constructed among PHNs and PHN students working and training in the MCH clinics in the Province of Eastern Finland. METHODS Qualitative design was employed. Data were collected in five semi-structured individual interviews and two focus group discussions conducted in Finnish by author. Data were audio-recorder, transcribed and analysed through qualitative content analysis (QCA). Translation to English took place during the QCA process. The total number of participants was 15. FINDINGS The participants perceived culture as a multi-dimensional phenomenon, and that specific skills are needed when meeting clients from different cultures. Cultural competence in this sample refers to a four-staged process which is highly affected by social processes and interaction between the PHNs, students, clients and other stakeholders in MCH care and community. CONCLUSION This study can serve as an explanatory material to fill the knowledge-gap between the previously published theoretical studies on cultural competence and the grass-root level MCH work. The findings represent perceptions and experiences of highly educated, native Finnish sample working in a relatively rural province, and thus their transferability should be viewed with criticism.

Nurse-client relationships are inherently valued in descriptions of the nature of public health practice and require consideration as intentional work that demands knowledge, skill, and personal engagement. They are also matters of place. In public health, they are largely taken-for-granted, particularly in the area of infectious diseases and the tuberculosis (TB) program specifically. TB nursing is structured within an explicit population focus, which challenges such relationship ideals as client-centered care, autonomy, and empowerment in everyday practice. This interpretive phenomenological study (Benner, 1994) of the relational work of TB nurses was undertaken to understand the nature of nurses’ relational work, wherever it happened, and how it was understood within the mix of assigned program tasks. Carried out in one of Canada’s largest TB programs, this study involved observing nine nurses and 24 clients in their respective visits over time, and interviewing 16 participants. Visits happened in homes and cars, and other assorted locations, highlighting how place shows up in these relationships and how nurses help clients to make sense of TB and broader life concerns shaping the experience of it. How they involve themselves interpersonally in these situations is the stuff that relational work is made of. Through the use of thematic analysis (Benner, 1994; Chesla, 1994), notes and transcripts were analyzed. The resulting interpretation of the nature of relational work is that of ‘welcome intrusions’, a notion that along with three key thematic dimensions: ‘getting through the door’, ‘doing TB but more than that’, and ‘beyond a professional’, addresses the central control-care tone of relational work. Together these themes identify key areas of knowledge and skill. That is, honesty and respect for privacy, ‘expertise’ in TB, dismantling the effects of stigma and displacement, and socializing-with-purpose. This emphasizes the value of articulating the everyday practices of nurses in population-focused programs that can contribute to successful treatment, and client healing and well-being. This relational work of TB nurses may be supported and enhanced when framed as the skill of involvement (Benner et al, 1996; Benner et al, 1999) and critically examined as part of providing comfort and enacting surveillance.

Nurse-client relationships are inherently valued in descriptions of the nature of public health practice and require consideration as intentional work that demands knowledge, skill, and personal engagement. They are also matters of place. In public health, they are largely taken-for-granted, particularly in the area of infectious diseases and the tuberculosis (TB) program specifically. TB nursing is structured within an explicit population focus, which challenges such relationship ideals as client-centered care, autonomy, and empowerment in everyday practice. This interpretive phenomenological study (Benner, 1994) of the relational work of TB nurses was undertaken to understand the nature of nurses’ relational work, wherever it happened, and how it was understood within the mix of assigned program tasks. Carried out in one of Canada’s largest TB programs, this study involved observing nine nurses and 24 clients in their respective visits over time, and interviewing 16 participants. Visits happened in homes and cars, and other assorted locations, highlighting how place shows up in these relationships and how nurses help clients to make sense of TB and broader life concerns shaping the experience of it. How they involve themselves interpersonally in these situations is the stuff that relational work is made of. Through the use of thematic analysis (Benner, 1994; Chesla, 1994), notes and transcripts were analyzed. The resulting interpretation of the nature of relational work is that of ‘welcome intrusions’, a notion that along with three key thematic dimensions: ‘getting through the door’, ‘doing TB but more than that’, and ‘beyond a professional’, addresses the central control-care tone of relational work. Together these themes identify key areas of knowledge and skill. That is, honesty and respect for privacy, ‘expertise’ in TB, dismantling the effects of stigma and displacement, and socializing-with-purpose. This emphasizes the value of articulating the everyday practices of nurses in population-focused programs that can contribute to successful treatment, and client healing and well-being. This relational work of TB nurses may be supported and enhanced when framed as the skill of involvement (Benner et al, 1996; Benner et al, 1999) and critically examined as part of providing comfort and enacting surveillance.

Thesis (Ph.D.)--York University, 2006. Graduate Programme in History. / Typescript. Includes bibliographical references (leaves 261-280). Also available on the Internet. MODE OF ACCESS via web browser by entering the following URL: http://proquest.umi.com/pqdweb?index=2&did=1251850601&SrchMode=1&sid=4&Fmt=2&VInst=PROD&VType=PQD&RQT=309&VName=PQD&TS=1195659877&clientId=5220

Thesis (Ph. D.)--University of Virginia, 1991. / Includes bibliographical references (leaves 139-152). Also available online through Digital Dissertations.

Thesis (M.P.H.)--University of Michigan, 1944.