Práticas de enfermeiras da Estratégia de Saúde da Família na continuidade do cuidado aos usuários com condições crônicas

Abstract

The change in the population's illness profile, characterized by the increasing incidence of chronic conditions coupled with population aging, has emerged as a public health problem, requiring a closer look at the longitudinality of care. Aimed at proximity to the territory, disease prevention, health promotion, and reduction of harm, the FHS stands out as a care model for primary care, where the nurse as coordinator of the FHS team plays a fundamental role in identifying individual needs and building a bond with the user. However, deficiencies in the continuity of care process for users with chronic conditions can still be identified. The present study aimed to: analyze the practices of FHS Nurses in the continuity of care for users with chronic conditions. Method: This is a descriptive and exploratory research with a qualitative approach, conducted with 12 nurses assigned to an FHS unit in the municipality of Rio de Janeiro, in accordance with the requirements of Resolutions No. 466/12 and No. 510/2016 of the National Health Council and Official Letter No. 02/2021 of the National Research Council. Data analysis was performed using Bardin's content analysis, which allowed us to identify three categories: Challenges in the Journey for the Completeness of Care in the FHS, Promoting Care Continuity: Nurses' Practices, and Strengthening Longitudinality: Essential Actions and Services. From this study, it was possible to observe the practices carried out by nurses in the pursuit of care continuity for users with chronic conditions. These practices are based on the implementation of actions and services in the territory, the organization of work processes with the support of technology, and actions focused on health education. The challenges faced by the participants were also highlighted, which directly impact the completeness of care, the work process, and the identification of each individual's needs. As strategies to overcome these challenges, the strengthening of multiprofessional work, active management participation, more effective intersectoral coordination, a holistic approach, active listening, and support networks were highlighted. These actions were identified as essential for the provision of quality services, focused on the needs of the territory, promoting the strengthening of bonds, individual empowerment, and effective participation in the therapeutic plan, in pursuit of continuous care for users with chronic conditions.