Inglês (pdf)
Artigo em XML
Referências do artigo
Tradução automática
Enviar este artigo por email
Citado por SciELO 
Similares em
SciELO 
Permalink
Introduction
The Consultório na Rua (Street Clinic) is a strategy within Primary Health Care (PHC) that emerged in Brazil in the 1990s, responding to the health needs of the homeless population. The National Policy of Primary Health Care (Lei nº 7.498, 1986) , outlines a specific model of primary care team known as the Street Clinic team (eCR), and the Policy for Health Equity Promotion (Decreto Presidencial nº 7.053, 2009) includes the Homeless Population (HP) as one of the vulnerable groups, emphasizing the importance of the implementation of such team models.
The teams in the Consultório na Rua can be organized into three modalities: Modality I - a team with at least four professionals; Modality II - a team with at least six professionals; and Modality III - Modality II with an additional medical professional. It is up to the municipality to decide which modality will be implemented (Portaria nº 2.488, 2011).
In Suzano, the Street Clinic was established in 2014, in modality 1, and initially began with a psychologist, a social worker, and a nursing technician, who received remote supervision from the nurse at the Prefeito Alberto Nunes Martins Basic Health Unit. Since November 2023, the CR has remained in modality 1, with the team now consisting of a nurse, a social worker, a psychologist, a nursing technician, and a doctor, who is part of the "Mais Médicos" program from the Ministry of Health and is temporarily assigned to the CR.
The selection of modality should consider the characteristics of the local homeless population as well as the available infrastructure and resources for implementing the strategy. Monitoring and evaluating the actions of the eCR helps propose intra- and intersectoral guidelines aimed at reducing harm and evaluating risks of neglect, inadequate treatment, and exclusion of specific groups. In this context, it is essential that health professionals are dynamic, strategic, creative, and empathetic in the development of practices and knowledge that promote comprehensive and longitudinal health care to be carried out in various urban spaces.
The holistic view of the Primary Health Care (PHC) nurse involves management, supervision, organization, planning, implementation, and evaluation of actions that address the specific needs of a community.
Therefore, the nurse in the eCR has exclusive responsibilities, including nursing consultations, requesting diagnostic tests, and prescribing medication according to Ministry of Health protocols. Moreover, the nurse plays a crucial role in team training and coordination between different sectors and professionals involved in health prevention and promotion (Brasil. Ministério da Saúde, 2012a, 2012b, 2019, 2024).
1. Theoretical framework
Leadership is understood as an essential skill in the nurse’s professional practice, enabling them to influence their team in order to provide care focused on the health needs of patients and families (Brasil. Ministério da Saúde, 2024).
The nurse’s role as a leader in PHC goes beyond coordinating daily activities; they also play a key role in training and integrating the various health professionals within the team to ensure holistic and personalized care. This leadership involves making strategic decisions that take into account the health specifics of the population being served, ensuring an efficient and culturally sensitive service (Cotta et al., 2006; Engstrom et al., 2020; Lanzoni & Meirelles, 2011; Lanzoni et al., 2016; Matumoto et al., 2011).
A study in the central region of São Paulo found that having a nurse in a leadership role in the eCR strengthened the care provided to the homeless population, addressing their needs and ensuring humanized care and social reintegration (Peduzzi, 2000).
The strategy employed in PHC allows nursing to focus on the health needs of users, directing actions towards specific care rather than just optimizing medical work. In the Consultório na Rua (CR), teams with variable compositions provide comprehensive health care to the homeless population, working itinerantly and collaborating with other health services, public institutions, and social services to ensure an effective and broad care model. The presence of a nurse, in accordance with their responsibilities and specialties, makes the care implementation and coordination more effective, in line with the norms established by the Regional Nursing Council (COREN) in its Opinion No. 014/2020 (Conselho Federal de Enfermagem [COFEN], 2021; Matumoto et al., 2011; Prates & Rezende, 2021; Serafino & Luz, 2015).
2. Methods
This is a documentary analysis research, quantitative, descriptive, and exploratory. Since it makes use of documents, these being the records, with the aim of understanding and interpreting the service framework of the Consultório na Rua in Suzano, in an objective manner, using the compilation of the numerical data extracted, describing the context of the service provided and investigating the impact of the nurse's role.
2.1 Location
The study sample consisted of medical records of patients attended by the Consultório na Rua team in Suzano from its implementation in 2014 to the present year, 2024.
2.2 Data Collection Instrument
For data collection, a form was used to record activities carried out by the team at the street clinic, which recorded: Offer and performance of rapid tests, offer and performance of sputum smear microscopy, dental complaints and follow-up, referrals to UBS, Secondary and Tertiary Care, requests for laboratory tests, conducting educational actions, immunization, consultation assessment and Links with the UBS.
2.3 Statistical Analysis
Convenience sampling was used. The sample size calculation was based on the completeness rate of each medical record and the proportion of filled items. The sample was designed to estimate this completeness rate, which had a standard deviation of 0.1194 in this pilot sample, with a margin of error of 0.015 and a confidence level of 95%. In order to meet these conditions, a minimum of 244 medical records was necessary.
The data were tabulated using Excel®. Descriptive analysis was performed, compiling frequency/percentage measures and occurrences of collected variables to analyze the care produced by the team.
3. Results
A total of 244 medical records were analyzed, with 69 consultations exclusively for social assistance and 175 directed towards health care.
Table 1 Activities performed by the eCR nursing team in Suzano
| Nurse team | Nurse | ||
|---|---|---|---|
| Nurse’s request for laboratory tests* | N | - | 13 |
| % | - | 5,7 | |
| Skin lesion evaluation | N | 6 | - |
| % | 2,63 | ||
| Wound evaluation | N | 8 | - |
| % | 3,51 | ||
| Immunization | N | 55 | - |
| % | 24,13 | ||
| Rapid testing | N | 77 | - |
| % | 33,77 | ||
| Sputum bacilloscopy | N | 27 | - |
| % | 11,84 | ||
| Educational action | N | 42 | - |
| % | 18,42 |
*Note: Activities exclusive to the nurse as per the Nursing Practice Law No. 7.498/1986
Table 1 shows the activities performed by the nursing team at the Consultório na Rua (CR) in Suzano. It is observed that 24.13% (n=55) are related to procedures such as vaccination, with 5.70% (n=13) being exclusive activities for nurses. Rapid testing had the highest rate of implementation, with 33.77% (n=77).
Table 2 Types of referrals made by the eCR at the three levels of Health Care in Suzano*
| Referral for care | N | % |
|---|---|---|
| UBS | ||
| Yes | 36 | 20,57 |
| No | 139 | 79,43 |
| Secondary Care | ||
| Yes | 29 | 16,57 |
| No | 146 | 83,43 |
| Tertiary Care | ||
| Yes | 24 | 13,71 |
| No | 151 | 86,29 |
*Note: It is important to highlight that more than one referral is made depending on the patient, as it covers the entire period during which the patient remained under care by the Street Clinic.
Considering the Street Clinic network, Table 2 shows the types of referrals made by the eCR at the three levels of Health Care. It is noted that there is a closer connection with Primary Health Care (UBS), with 20.57% (n=36) of cases, while secondary care comes second, with 16.57% (n=29) of reported occurrences.
4. Discussion
The request for laboratory tests represents 5.70% (n=13) of the activities identified in the medical records. This practice, as it is exclusive to nurses, cannot be performed by nursing assistants or technicians, according to Law No. 7.498/198618 and COFEN Resolution No. 195/1997, Article 1º (Lei nº 7.498, 1986) Therefore, it is essential to have a nurse present, both for performing their exclusive activities and for leading and supporting the team, due to their qualifications in management, coordination, care handling, and technical skills specific to the profession (Brasil. Ministério da Saúde, 2012; Conselho Federal de Enfermagem [COFEN], 1997, 2021). In accordance with the principles of the Unified Health System (SUS), the right to health should be comprehensive and universal. Considering the specifics of the Homeless Population (HP), prevention, treatment, and diagnosis of Sexually Transmitted Infections (STIs) should be prioritized due to the high incidence rates resulting from the population's exposure. This is evidenced by the high rate of rapid testing, accounting for 33.77% (n=77) of all actions. Rapid testing is an effective tool for quick identification of HIV, syphilis, and hepatitis B and C at the sample collection site and for compulsory epidemiological notification, helping to map risk zones and incidence rates, which facilitates planning specific precaution and care actions (Prates & Rezende, 2021). A study on the prevalence and vulnerability to HIV infection in the HP in São Paulo, with a sample of users of shelter institutions from 2006 to 2007, indicated a high prevalence of syphilis and susceptibility to infections due to lack of information, exposure to unsafe sexual practices, substance use, and limited access to preventive services (Grangeiro et al., 2012; Graciano et al., 2021; Ministério da Saúde, 2019). Regarding tuberculosis, diagnosed through sputum bacilloscopy, the risk of disease for HP is approximately 56 times higher compared to the general population, according to the Manual of Recommendations for Tuberculosis Control in Brazil (Ministério da Saúde, 2024). Factors such as financial vulnerability, lack of prevention knowledge, HIV co-infection, immunosuppression, and high-risk substance use increase the chances of infection (Brasil, Ministério da Saúde, 2012; Jagodziński et al., 2012; Souza et al., 2014; Pinheiro et al., 2021; Andrade et al., 2020)
Another aspect considered in the eCR service was the implementation of educational actions during consultations, including interventions for social inclusion, harm reduction, contraceptive methods, STI prevention, and personal care. Forty-two occurrences of such actions were identified, with a highlight on group therapies and social inclusion activities. These educational actions are crucial for informing the population about their rights and health needs, empowering them to take charge of their care and fostering a break from the traditional vertical healthcare model, with the nurse acting as a facilitator of knowledge (Lacerda et al., 2013; Muchagata et al., 2023).
Immunization, with 24.13% (n=55) of records, is a challenge due to the population's social vulnerability, poor living conditions, lack of documentation, and limited access to healthcare services. The itinerant nature of this population necessitates active search and adapted vaccination strategies, such as the campaigns carried out by the eCR (Bonalume, 2011).
Regarding Table 2, it is observed that there is a closer relationship with Primary Health Care (UBS), accounting for 20.57% (n=36) of cases, although the direct linkage to the service remains low. Secondary care follows with 16.57% (n=29). It is important to highlight that the complexity of the homeless population requires an integrated approach, overcoming fragmented service structures to ensure effective, complete assistance and respect for the rights of this group (Engstrom et al., 2020; Serafino & Luz, 2015; Monnerat & Souza, 2010).
Conclusion
This study aimed to identify the role of the nursing team in the Consultório na Rua (CR) of Suzano. It is evident that the nurse's role extends beyond management, with leadership being one of the essential elements in this care process. Through the analysis of medical records, it was possible to identify the critical role of the nursing team in providing primary health care to the homeless population. Regarding primary health care for the homeless population in Suzano, the analysis concluded that the highest demand is related to comprehensive patient evaluation, such as physical examinations to identify risk conditions early, thereby facilitating care. Furthermore, educational actions were implemented to raise awareness among the population, enabling them to take ownership of their health. The nurse’s presence is crucial not only for performing their exclusive activities but also for leading the nursing team and guiding and supporting the care provided by other professionals.
Authors' contribution
Conceptualization, C.R., J.T., A.P.S. and M.N.S.; data curation, C.R., J.T., A.P.S. and M.N.S.; formal analysis, C.R., J.T., A.P.S. and M.N.S.; funding acquisition, C.R., J.T., A.P.S. and M.N.S.; investigation, C.R., J.T., A.P.S. and M.N.S.; methodology, C.R., J.T., A.P.S. and M.N.S.; ; project administration, C.R., J.T., A.P.S. and M.N.S.; resources, C.R., J.T., A.P.S. and M.N.S.; software, C.R., J.T., A.P.S. and M.N.S.; supervision, C.R., J.T., A.P.S. and M.N.S.; validation, C.R., J.T., A.P.S. and M.N.S.; visualization, C.R., J.T., A.P.S. and M.N.S.; writing-original draft, C.R., J.T., A.P.S. and M.N.S.; writing-review and editing, C.R., J.T., A.P.S. and M.N.S.
