INTRODUCTION

With the institution of the Family Health Program, which was later on elevated to the Family Health Strategy, Primary Care gained a preferential model for assisting and managing care processes, especially children's health, focused on the use of light technologies, both relational and attitudinal, in welcoming and qualified listening to the health needs of this population segment⁽¹⁾.

Primary Care assumes its role as care coordinator and organizer of health care networks, qualifying, among others, surveillance of child development and childcare assistance, strategic measures to reduce the morbidity and mortality that affect children. It is worth noting the drastic decrease in infant mortality since PHC implementation within the scope of the Unified Health System⁽²⁾.

In the meantime, nurses assume the essential role of vital members of the teams operating in the territories and Basic Health Units, establishing their work procedures based on community and social requirements and ensuring that they prioritize the needs of children, families and caregivers⁽³⁾.

With Childcare Nursing Consultations, nurses monitor children's growth and development, an essential practice for health promotion and prevention. The consultations present an ideal opportunity for nurses, children and families to establish bonds and harmonious relationships, exchange knowledge and practices, engage in health education activities, and receive guidelines that aid in daily child care and maximize the potential of being a child^(3,4).

The study highlights nurses' potential to capillarize practices and disseminate low-cost and highly effective actions within the Primary Care scope, praising Nursing consultations as an effective means for promoting health, distinguishing genuine child and family needs, and implementing Nursing care that is in line with the family and social realities of these subjects⁽⁵⁾.

Nonetheless, a thorough literature review has identified potential weaknesses in childcare Nursing consultations, particularly in relation to discrepancies in medical records and booklets, rendering it impracticable to evaluate the comprehensiveness of the Nursing assistance provided⁽⁶⁾. The study also pointed out weaknesses in the anthropometric assessment and predictions of morbidity states in children, such as obesity and malnutrition^(7,8), which highlights vulnerabilities in the use of Nursing consultations and in achieving their potentialities.

In this way, recognizing the actions that nurses can use for good quality child care and recognizing the different characteristics that growth and development surveillance assumes in national Primary Care, the question is as follows: Which are the nurses' actions in childcare Nursing consultations at the Primary Care level?

With this, the objective is to identify nurses’ actions in childcare Nursing consultations in the Primary Care network of a municipality from the Brazilian semi-arid northeastern region.

METHODS

A qualitative and descriptive study. Qualitative research fulfills the function of describing the occurrence of phenomena and their subjective constructions, in addition to portraying their meanings that emerge from individual and collective subjectivity⁽⁹⁾. Writing of the article followed the COREQ checklist for qualitative research⁽¹⁰⁾.

It was carried out in the municipality of Pau dos Ferros, in the inland of Brazil’s Rio Grande do Norte semi-arid region, which was chosen for being a medium-sized city, intermediary between small and large urban centers, regulator of economic and social flows in the region, headquarters of the sixth health region in the state, the second largest economy in the West Region of the state of Rio Grande do Norte, and for being located within the drought polygon, a region marked by significant social inequalities⁽¹¹⁾.

The study population consisted of nurses working at the aforementioned care level. A non-probability and intentional sample was used, for understanding the need to exhaust data for effective validity in qualitative research⁽¹²⁾.

Nurses who had been working in Primary Care for more than 6 months were included and those who were not present in the Basic Units after three recruitment attempts were excluded, which led to a sample comprised by 11 nurses, of which 9 agreed to participate in the research based on availability and non-interruption of their work routine. There was sample loss of 2 nurses due to the exclusion criteria defined.

The researcher contacted the nurses in person at the Family Health Units where they worked, using a printed invitation letter attached to the terms of consent and audio recording authorization. The letter was read and the research objectives and reason were explained.

Data collection took place with prior consent from the participants, through interviews guided by a semi-structured script. The script comprised questions about the childcare Nursing consultation structure, developmental milestones, growth patterns, parental/caregiver participation, children's health booklet completion, care guidelines and humanization. It was formulated based on an integrative literature review conducted by the researcher on the primary points of assessment and guidance for nurses in child care.

The interviews took place at the participants' workplaces at the end of the working day, in a room reserved for the researcher and participant, with only both of them present in the room, minimizing interference in the service routine. They were conducted between January and March 2021, lasted a mean of 20 minutes and were recorded in audio format (.mp3) with a Galaxy A30S smartphone device exclusively used for this purpose. The participants' anonymity was preserved using an alphanumeric code with the letter “N” followed by a numeral (1,2,3...) to identify the interviews and replacing their names.

Data analysis took place after transcribing the interviews into a Word® document, using the thematic analysis technique, which comprises three stages¹³. In the first stage, a floating reading and selection of interviews was carried out based on exhaustiveness, homogeneity and relevance to the topic researched.

They were divided into registration units (excerpts) that were alphanumerically coded according to the theme: WB (Welcoming and Bonding), APE (Anthropometry and Physical Examination), GDS (Growth and Development Surveillance), HE (Health Education) and CHB (Children's Health Booklet), followed by a number that corresponds to the sequence of the excerpts (1, 2, 3...) and the interview code that corresponds to the nurse (N1, N2, N3...).

In the second stage, the registration units are categorized according to thematic aggregation and in-depth exploration of the material. The last phase corresponds to inference of the results through a comparison to findings in the scientific literature⁽¹³⁾. Five thematic categories emerged from the interviewees' testimonies that were not previously established and which arose from the aggregation of meanings exposed by the interlocutors.

The research was submitted to the Research Ethics Committee of the State University of Rio Grande do Norte, in compliance with resolution 466/12⁽¹⁴⁾ of the National Health Council, and was approved on February 13^th, 2020 under opinion No. 3,835,550 and CAAE No. 28811320.1.0000.5294.

RESULTS

The interviewees were 9 nurses from the Family Health Strategies in the municipality of Pau dos Ferros, Rio Grande do Norte. All had worked for more than 6 months in Primary Care, 2 of them for more than 20 years. The group was made up of 3 (33%) male and 6 (67%) female professionals.

It is worth noting the existence of five outstanding thematic categories that comprise nurses' work in childcare: “Welcoming for the bond”; “Anthropometry and Physical Examination”; “Child Development Surveillance”; “Health Education: Caring attitude”; and “Difficulties completing the Children's Health Booklets”.

The categories and testimonies that contribute to describing and characterizing nurses' activity in child care will be presented below.

DISCUSSION

The research showed the nurses' interest in monitoring children's growth and development and devoted time, opportunities, knowledge, techniques and attitudes so that this moment is beneficial for children and their families.

By pointing out the indispensable need for bonding, the professionals show the importance of maintaining lasting relationships between children, family and professionals. This is fundamental to the childcare line of care, allowing both parties to act together for dynamic and lively care that can be carried out in the face of the different realities that arise^(1,3).

In childcare, nurses develop actions that include the health levels related to promotion, protection, prevention, treatment and rehabilitation, when necessary, in addition to being trained to detect early delays and deviations in child development, a central point of all children's health surveillance⁽¹⁾.

To this end, nurses undertake in their practice the use of methods to achieve full health care, highlighting the Nursing Process, which is called Nursing Consultation (NC) in outpatient environments. Supported by the Professional Practice Law and COFEN resolution 358/09⁽¹⁵⁾, an NC is a working method that systematizes nurses' assistance regarding health assessments.

Consisting of five interdependent components (history, diagnosis, planning, implementation and evaluation), the NC is designed to mediate nurses' work, guiding them in their assistance and health assessment of different life cycles and social groups, especially children, offering low cost and great effectiveness^(15,16).

NCs have the premise of ensuring care quality, individualizing actions, directing nurses' work towards each individual, being their center and object of care. In a study carried out using Wanda Horta's Theory, the NC proved to be effective in identifying and covering the health needs of children and their families cared for by nurses in Primary Care⁽⁴⁾.

The number of annual consultations recommended by the Ministry of Health for a child's first year of life totals 7; 2 in the second year of life and 1 every year until the age of 10. In addition to paying attention to the current needs of the child and family, childcare Nursing consultations should focus on the early identification of problems and considering each child in their environment and family and social structure, expanding the concept of health to understand their social determination⁽⁴⁾.

However, Nursing consultations cannot be something fixed in themselves, with a mechanical and automated sequential logic. As a guiding method, they should allow nurses to feel free to increase and renew their aspects, granting creative freedom capable of making them recognize their work and themselves at the same time as they carry it out⁽¹⁶⁾.

In the study, it was possible to notice that the nurses did not mention Nursing consultation in their usual structure, not delimiting the stages and not even pointing out Nursing diagnoses. However, it is noted that they were able to structure their actions based on their responsibilities, such as constructing the health history, assessments through physical examinations, assessments of needs, guidelines and management of situations and continuous reassessments of the children, which in the end correspond to the consultation stages⁽¹⁵⁾.

Thinking from this perspective, a study⁽¹⁷⁾ points out that nurses' clinical practice in Primary Care should overcome the hegemonic curative and biomedical logic of health services and provide care that adds knowledge and attitudes arising from the fields of health promotion and prevention. They point out that instituting protocols that increase the action scope can improve these workers' performance, conferring them autonomy. Therefore, nurses should be able to evaluate and analyze children's development milestones, noticing when they are not present in the expected time and thoroughly investigating to prevent further distortions or problems⁽¹⁸⁾. In the research, the nurses encourage parental collaboration in this surveillance, as children spend most of their time at their homes and many milestones may not be visible during the consultations.

However, this practice should not exempt professionals from the responsibility of monitoring during consultations and timely recording whether or not the milestones have been reached, in addition to making the necessary referrals if required. Nurse play an essential role to avoid complications and assist parents and caregivers in encouraging adequate development, understanding that it is a social, environmental, family, political and economic reality^(18,19).

At times, the children's booklets suffered detriment in relation to records in the Electronic Medical Records, leading to discourses that the reality of the practice is underutilization of the instrument by nurses. Some authors⁽²⁰⁾ emphasize that Electronic Citizen Records and CHBs are not distinct and contradictory realities, but instruments that preserve care longitudinally in Primary Care and beyond, as in the case of CHBs.

Some studies indicate that the CHB is a guiding instrument for monitoring children's growth and development, rich in details and information for parents, caregivers and families who pay attention to children in their everyday lives⁽²¹⁾. It is a sign of care transversality and integrality, as it is able to maintain permanent and good quality information at different levels and points of the health care network, and its correct and timely completion is essential for this purpose^(22,23).

In the meantime, nurses' role as health educators becomes the culmination of their work in childcare and monitoring children's growth and development⁽⁷⁾. During Nursing consultation, nurses have an opportune moment to clarify the caregivers' or parents' doubts about their children and to build new knowledge based on the health education that is engendered in a horizontal dynamic of relationships and listening to the others’ knowledge⁽²⁴⁾.

By starting from the knowledge of others and with others, nurses can recreate their own work process and perceive themselves as not centralizing care, but as a part of it. Awareness of the existence of others also emerges, of their wills, desires and subjectivities that develop knowledge based on their experiences. This process enables greater autonomy and empowerment for parents and caregivers in their own child care decisions⁽²⁴⁾.

It is important to highlight the limitations found during the research regarding the method used to collect the data. Perhaps, adding direct observations of the interviewed nurses' practices in childcare consultations, guided by a script and consolidated in field diary notes, might add more elements to enrich the discussion.

Nevertheless, it is recommended to use Children' Health Booklets as a guiding principle for the consultations and/or the elaboration of childcare Nursing consultation scripts that incorporate the main axes of nurses' performance in recognizing needs, preparing individualized care plans, and follow-up in the monitoring of growth and development.

FINAL CONSIDERATIONS

It was noticed that nurses are able to carry out comprehensive health assessments of children, encompassing care through bonding, welcoming and health education. They reported using various actions to provide good quality and humanized Nursing childcare within the personal, structural and service capabilities and care level where they work.

Health education was identified as the flagship of Nursing leading role in child care. The study reveals certain deficit among nurses in appropriating the Nursing Process within the consultations and the difficulties using the Children's Health Booklet, a material symbol of care integrality and transversality and of children’s right to health, which cannot be underused in appreciation of other instruments. Organizing work processes that include all recording modalities is something to be structured by professionals and by SUS and Primary Care managers.

Finally, it is recommended to carry out research studies that address Nursing consultations based on the theoretical frameworks of the profession itself, knowledge and recognition of how to use children's health booklets, Nursing taxonomies in Nursing consultation qualification, and research that evaluates the quality of childcare Nursing consultations from the perspective of those for whom they are intended: children, family and community.