The Sight of the Nurse about the Availability of Transport Services in the Urgencies of the Primary Health Care

Amanda Soares1, Olga Feitosa Braga Teixeira2, Thiago Lívio Barbosa Pereira3, Bárbara Letícia de Queiroz Xavier3, Tito Lívio Ribeiro Gomes do Nascimento4, Najara Rodrigues Dantas1, Angélica da Silva Soares5, José Iran Oliveira das Chagas Júnior6, Flaviana Dávila de Sousa Soares7, Ícaro Tavares Borges1, Ana Cláudia Martins Rodrigues3, Brenda dos Santos Teixeira3, Paula Frassinetti Oliveira Cezário8, Anna Mikaelly de Sousa Tavares Assis9, Maria Mônica Paulino do Nascimento10, Denise Pinheiro Leite11


Introduction
The organization of regionalized health services networks formed the premise about which historically the proposed reform of the Brazilian health system have been debated, forming part of the belongings of health planning for decades.However, throughout the 1990s, by the very course of the decentralization process, the establishment of networks ceased to be the central axis around which it built the service organization, returning to the center of the debate from the publication of the Standard Operational Health Care in 2000, and especially with the Pact for Health in 2006 [1].
The care networks organized health care of the population so that services were linked to each other by a single mission, common goals and a cooperative and interdependent action, allowing offer a continuous and comprehensive care to a given population.In order to fulfill the principle of universality and fairness of the National Health System in 2003 approved the National Policy for Urgency being assigned to each level of care, responsibilities for certain portion of the population in urgency demand, as the limits of its complexity and ability to solve [2][3].
Conceptualizing urgency, one can set it as the occurrence of unexpected health problem with or without potentially life whose carrier needs immediate medical attention.In this case, the Primary Care being constituent of the network urgencies, qualified as a fixed pre-hospital component enables immediate response to urgent low and medium complexity, welcoming cases and classifying them, providing first aid.Thus, professionals in the Primary Care should be prepared to recognize urgencies in its area of operation [4][5][6].
To the effectiveness of urgency attendances in Primary Care, it is necessary to guarantee material resources, staff training and an adequate transportation to the unit's needs.According to the Federal Council of Medicine Resolution Nº 1.671/03, the health system must ensure an ambulance to support pre-hospital services and training for every professional who works in the transport of patients [7].
Considering the impossibility of transport and its realization inadequate and time-consuming way can lead the patient to death or result in irreversible consequences, it sought through this study identify the availability of transport for urgencies occurred in Basic Health Units according to the report of nurses.

Method
The methodological approach followed was the qualitative approach, being carried out in Basic Health Units (BHU) belonging to the Strategy of Health of the municipality of Varzea Alegre, located in the South Central region of the State of Ceara.The population consisted of all nurses working in primary care, and selected 8 (eight) participants after the use of the inclusion/exclusion criteria.
Inclusion criteria were: being in the BHU at the time of completion of the research and not be away temporarily or permanently from service.
Data were collected through interviews with structured questionnaire, in the period from September to October 2014, with the following guiding question: "Does the health unit in which services are provided offer transfer/appropriate vehicle to transfer users to the secondary care in cases of urgency?" The interviews were transcribed in full, and the data analyzer according to Thematic Content Analysis, which is divided into three stages defined by: pre-analysis (systematization of initial ideas, resorting to repeated and exhaustive reading, in order to get closer the material); material exploration (codification of material, by predefined rules) and treatment of results/data interpretation [8].The speeches of the participants were identified by the letter "E" followed by the ordinal number corresponding to the interview order (E1, E2, ...) tending to preserve the anonymity of participants.
The research project was approved by the Research Ethics Committee of the Faculty Santa Maria/ FSM/Paraiba with opinion Nº 1.027.222,complying with all the provisions of Resolution Nº 466/12 of the National Health Council.

Characterization of the research participants
The study included 8 (eight) nurses, most of which was inserted between the ages of 25 and 34 years old and had service in the Family Health Strategy ranging from 6 to 10 years (50% for both), as shown in Table 1

Availability of transport for transfer of patients in urgency situations
For transporting patients in urgency situations, there was reported by the majority of the nurses, the use of the Municipal Department of Health vehicles; however, these are not available in a timely manner, so that the professional and users opt to use of private transportation for quick transfer to the secondary service.E1.
Usually we have transportation.Because of the delay we take our own transportation.

E5.
A car at the disposal of the unit at all times there is not.When we professionals need to transfer a patient to the hospital, he goes on his own.

E8.
The transport issue is of the responsibility of the Health Department, which sometimes does not have any vehicle or driver for an immediate transfer. E4.
The questioning also covers BHUs in the countryside, being more distant from a highly complex service should have a more dynamic service, aiming at solving the local problems.Nurse's speech 02 highlights the lack of accessibility to the network of services, which, despite the existence of municipal ambulances, their use is limited to patients in the urban area, considering that these are stored in the county seat.

Discussion
It was observed that there is a predominance of female nurses, highlighting the existing reality in most of this professional field.Despite the expressiveness of the data, the generalization of nurses' class as exclusively female is inappropriate, because men also work in the nursing profession, though in a smaller quantity.A man faces entrenched prejudice and imposed by society, as far as the feminization of nursing, is challenging and tends to decrease the demand for these by the nursing profession.
Nursing was the first university female profession in Brazil, designed to give sustainability to public health programs and support to health services.The divided image of women "home" due to social struggles coincided with the stabilization of the nursing profession, which made the woman of the nineteenth century in search of autonomy, engaging in nursing because the requirements were not complex like other professions [9].
It is observed that female characterization in the category of nurses is also proven in research [10] performed with Graduate Course of Nursing students, Faculty of Medicine of the ABC Foundation in Santo André -SP, where 92, 44% of students were female.
The age range presented by 50% (n=4) of the nurses was between 25-34 years old, which corro-borates the data from the survey [11] conducted by the National Council of Nursing in 2010, which states that the majority (35.98%, n=521.527) of nurses in Brazil is among the age group 26-35 years old, implying that stage as the pinnacle of productive force and productive professional.
A wide range of factors explains the predominance of nursing professionals in the age group described above, the search for financial stabilization, developed in nursing the need to dedicate themselves to the service with greater commitment, constantly seeking scientific improvement and practical, gaining agility, which does stay longer inserted in the institution.
The time of service in primary care lies mostly in the range of 1 (one) to 10 years, totaling 75% (n=6) of the participants.The analyzed data are similar to a survey [12] carried out in the core network of Porto Alegre -RS, showing that approximately 77% (n=40) of nurses present the same period of activity in BHUs.
The insertion of the Health Care Networks provided the health care organization in integrated systems that can respond with effectiveness, efficiency, safety, quality and equity, the health conditions of the population [13].
The increased demand for care throughout the care network by adding the determinations established by Care National Policy for the Emergency demanded the Basic Professional Attention knowledge about the health units that make up the network of care urgencies, not limited to hospital as the only system gateway, and managers to comply with all the requirements established by policy [14].
For the realization of urgent care when it is not capable of resolution in primary care, transportation assistance is necessary to ensure continuity of care.It emphasizes the need for this service in a context both quantitative and qualitative, due to recommendations that are required for the transfer of patients preventing those who are conducted by inadequate transport.
The municipality has ambulances to transport the patient from his residence to the hospital or Basic Health Unit to the hospital; however, as work in the countryside and we cannot call the responsible sector and the delay of arrival to the site, usually transportation is done in the car that leads health professionals to the unit.Then, the driver of FHP takes the patient, if necessary, the nursing technician goes with the patient in the car, to the hospital.

E02.
Lack of transportation in the Basic Health Units, makes the integrated care in poor health, resulting in the absence or shortage of nursing care for users who need to monitor highly complex.The demands require that in all health facilities, whether basic or secondary care, have the help of a unique transport continues to care.Thus, recommended activities for nurses of Primary Care as the reference and counter reference, are made vulnerable by the arrangement of how the user is allocated in the network services [15].
The ordinance Nº 2,048 in his chapter VI, says that after the stabilization of a patient in a unit of low complexity, forwarding this to a specialist/ structured service should be provided immediately, but must also be guaranteed support for the return of patients outside the emergency situation on discharge are unable to move around because of his medical restrictions [16].
The client transfer delay of one unit to another is a factor that interferes with the quality of care, generating unresolved cases, which can result in severe consequences and deaths.Therefore, it is necessary to consider the distances between municipalities of small and medium-sized and reference municipalities and highly complex at the time of transfer [17].
In India, significant cases on the delay or unavailability of health care transport are evidenced by the high rates of maternal mortality, as well as the quantitative low institutional transfers.About 10.4% of cases of poor care pregnant women are related to inadequate transportation.Although 71% of Indian villages having primary care centers, only 55.5% had help of some urgency transport service [18].The exposed situation demonstrates the need to support the care network with the necessary resources for assistance.In Brazil, there is a pertinent need to studies that relate the effectiveness of urgency transport with mortality data and sociodemographic factors, which prevents one from exploring what their real effects.The locality of the population homes interferes with the degree of urgent care needs, characterizing them according to the risks to which they are exposed.The rural population plays risky and unhealthy activities for executing various activities without the use of personal protective equipment, in addition to desktop and leisure be enabler of various occupational risk factors, such as orthopedic disorders, muscle and skin [19].Thus it can be seen that the welfare aid of urgency for rural community demands a special attention of managers, focusing on care planning, and priorities for each region.
Complementary strategies may be associated to reduce clinical complications in patients, especially in those units without the aid of transport, an example is the use of screening to ascertain the real necessity of the transfer and not allow the delay of care.Screening should emphasize the perception of risk, expanding the knowledge of unanticipated through signs and health symptoms [20].
Seen the need to expand the units to offer urgency services, wonders about what keeps at the level of management, the inclusion of the National Attention to Emergencies policy in primary care that was instituted in 2006, and its main ordinances of 2002 and 2003, after nine years of its implementation, it is inefficient to support a transport to urgency at BHU.A deficiency that generates losses at all levels of care, generating the consequences mainly for users of the health system [21].
As the Regulation of Emergency Medical pact between the services must ensure the support of transfers with ambulances, fast, safely and with quality.The fact is that usually found lacking health services in materials, human resources and physical structure, away from the envisaged by law [22].In the case of health care facility located in the countryside, even with the protection of a Basic Support Unit of the Mobile Emergency Service, would not be enough to solve the problem as the difficulty to streamline the user's transfer would remain for be located in urban areas, a situation that requires a plan that aims to meet the demands of all users.
The forwarding of user inside the network of attention have organizational standards to be effected successfully.Before removing the user must make sure that all been exhausted technological features of the unit, as well as checking their clinical stability and define the most suitable transport, the choice being made according to the needs.For the path it is necessary to provide the accompaniment of a professional so that the revaluation is carried out along the way and the user-responsibility must be maintained for this until another team takes care [23].

Conclusion
Faced with the exposure of operations, highlights the worrying questioning the availability of vehicles suitable for Primary Care, primarily for the purpose of transferring customers requiring more complex care.The lack of a unique transport to the Basic Health Units takes the provision by the Secretary of Municipal Health ambulances and other vehicles, which are assigned to units where possible.The fact that there are few ambulances, compromises patient care network with urgent state, violating the principles of universality and equity of the Unified Health System.
Thus ensuring resources for transportation in emergencies should be organized through the development of a care plan to health systemized and implemented, favoring nursing interventions to ensure the quality and effectiveness of care and enabling an urgent/emergency care early, which reflects in a better prognosis for the user.Where Doctors exchange clinical experiences, review their cases and share clinical knowledge.You can also access lots of medical publications for free.Join Now! http://medicalia.org/

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