CARACTERIZAÇÃO DAS DISSERTAÇÕES E TESES BRASILEIRAS ACERCA DA INTERFACE PROCESSO DE ENFERMAGEM E ATENÇÃO PRIMÁRIA BRAZILIAN DISSERTATIONS AND THESES ON THE INTERFACE BETWEEN NURSING PROCESS AND PRIMARY CARE CARACTERIZACIÓN DE DISERTACIONES Y TESIS BRASILEÑAS SOBRE LA INTERFAZ PROCESO DE ENF

The authors aimed at characterizing dissertations and theses on nursing process in primary care. The theses were available in the database of the Coordination for the Improvement of Higher Education Personnel (CAPES). This is a bibliometric research. Data was collected throughout May 2013, in pairs, following research guidelines established and validated previously by the registered nurses. Of the 120 documents surveyed only six (5.0%) dealt with the interface between nursing process and primary care, and those constituted the research sample. The studies were then analysed according to the following indicators: academic level, research setting, year, authorś academic training, methodological design, themes, nursing theory employed, classification system used, advances and difficulties experienced. We observed that scientific production is incipient and highlight the need for the development of new investigations. Positive experiences on the use of nursing processes in primary care helped to assert its benefits and the essential nature of this interface. Difficulties were also highlighted, demonstrating the challenges that still need to be overcome.


INTRODUCTION
The promotion of scientific research (which supports economic growth and improves quality of life), is directly related to everyday life, to more immediate demands, and also strives to answer universal questions 1 .Scientific investigations should have a social role and meet the needs of a community.
Since the seventies, research has been developed mainly at postgraduate level.It reflects the academic community concerns over potential and real problems, focussing on intellectual and practical improvements. 2,3 rsing research attempts to establish a scientific basis for quality of care and professional credibility.Over the years, the number of scientific publications originating from postgraduate nursing courses has increased. 4n this context, nursing research defends that nursing practice should be a communicative exercise, in a dialogical and emancipatory sense.It should strive for the autonomy of individuals, 5 via nursing visits throughout the various life stages and different levels of health care, in the health care unit, as well as in medical care at home.
Nursing visits should comprise strategic and autonomous practices guided by comprehensive care principles.They should be developed according to the Systematization of Nursing Care (SAE), which is based on the Nursing Process (PE), as established by Resolution No. 358/2009 of the Federal Board of Nursing (COFEN). 6AE is legally recognised as an essential nursing tool that enables a critical and reflective nursing care process, through clinical reasoning and individuality of nursing actions.
The main difference between PE and SAE is that the latter refers to the organization of nursing practices and includes methodology, human resources and tools.The former is a methodological and systematic health care tool. 7E is a practical tool for the fulfilment of SAE ideals.In literature it is described as a process of dynamic and interdependent stages, which differ as per number and organization.According to COFEN (Resolution No. 358/2009), for example, PE comprises five key steps, as follows: history, diagnosis, planning, implementation and nursing evaluation. 6E organizes care and qualifies nursing practice. 8Its consolidation in nursing visits at all levels of complexity, with emphasis on primary care is, therefore, mandatory.
In Brazil, primary care is ruled by Ordinance No. 2488/2011.It encompasses health promotion and protection, disease preven-tion, diagnosis, treatment, rehabilitation, damage reduction and health maintenance and aims at providing comprehensive care. 9rdinance No. 2488, dated 21 October 2011, brought the necessary improvements that gear health care towards the principles and guidelines of the Unified Health System (SUS), with respect to its structural axis: Primary Health Care (APS).
This legal tool reviews norms and guidelines of Ordinance No. 648, dated 28 March 2006.In the course of five years, changes in the Brazilian context highlighted the need of improvements and emphasized aspects already consolidated but in need of being disseminated.The ultimate goal is to carry out APS objectives.
Ordinance No. 2488/2011 represents a renewal of ideas, an adaptation to a context that requires new strategies.Initially, the new ordinance replaced the term "Family Health Program (PSF)" by "Family Health Strategy (ESF)".It was a much demanded conceptual change that needed to be incorporated into legal texts.The new term reinforces the new approach by replacing "program" for "strategy" given the former´s finite nature.
It is important to highlight that Ordinance No. 2488/2011 does not invalidate the earlier one (No.648/2006) but widens its guidelines and principles, especially with regard to basic care, now synonymous with APS.Aspects that were still incipient in the previous document are more detailed in the second one, delineating conceptual framework, professional support, priorities and significant adjustments to this level of complexity in SUS.
APS is the users preferred point of contact, but not always the first one.It considers multidisciplinary and interdisciplinary team work as an important tool and its professionals must have a holistic approach to nursing.Cartesian work processes, characterized by fragmentation of care, are replaced by an adjustment to the users' experiences, avoiding schedule inflexibility and providing more time for spontaneous requests.
Research questions were based on the assumption that nursing visits are essential within primary care, that their effectiveness depends on clinical follow-up via PE, and that scientific research should aim at the production of knowledge to improve care practices.Proposed questions were: "What are the characteristics of papers and theses available in CAPES (Coordination for the Improvement of Higher Education Personnel) database that deal with nursing process in primary care?" and "How is nursing process in primary care addressed in scientific literature?" Bibliometric analysis of studies on the interface between PE and APS aims at describing the stage of nursing development, primaria, que contribuyen a afirmar sus beneficios en tal nivel de complejidad y la esencialidad de esta interfaz.También se señalan las dificultades que muestran los retos que faltan superar.Palabras clave: Planificación de Atención al Paciente; Procesos de Enfermería; Atención Primaria de Salud.
trolled descriptor) through two combinations: Nursing Processes -Primary Health Care and Nursing Theory -Basic Health Care.
The non-controlled descriptor Basic Health Care surveyed all Brazilian studies on the subject since this was the term for Primary Health Care before Ordinance No. 2488/2011.
The combinations of descriptors previously mentioned were defined after critical analysis and testing to prevent sample loss.
The survey was conducted in the search field subject via option all words.The selected abstracts met the following inclusion criteria: electronic availability in CAPES database, and focus on nursing process in primary care.Exclusion criterion was failure to approach research subject.
The criterion publication year was not an exclusion indicator since the researchers sought to analyse when Brazilian publications on the topic started.
Studies whose abstracts were not available electronically were excluded since documents were selected after their titles and abstracts being read and analysed.
After data collection the selected abstracts were submitted to critical analysis.A database in Microsoft Excel 2010 was created, comprising the following analysis indicators and respective standardization:  advantages and difficulties to consolidate the interface between nursing and primary care.
The above indicators were descriptively and quantitatively analysed, using absolute and relative frequencies, according to bibliometrics 13 .
Data will be displayed in tables and charts and results will be critically analysed considering relevant literature.

RESULTS
Of a total of 120 documents from the initial survey, only six (5.0%) dealt with the interface between nursing process and primary care, making up the research sample.Such finding reveals the small number of studies on the subject.
There were five master´s theses (83.3%), one PhD dissertation (16.7%), and no professional master´s thesis.considering that PE should not be limited to hospital environment, but pervade nursing visits at different levels of complexity.
The present study aims at adding knowledge to the still incipient scientific production on the subject.The authors expect it will consolidate the use of PE in the context of APS, reporting its advantages and obstacles, in order to improve nursing visits.

OBJECTIVES
The study aims to characterize papers and theses on nursing process in primary care.Documents were obtained from CAPES database.

MATERIAL AND METHODOLOGY
This is a bibliometric research on the interface between nursing process and primary care.Bibliometrics is a research method used to map academic papers which aims to evaluate scientific production and promote reflection on a given area.It is a descriptive and quantitative technique for measuring academic output and disseminating scientific knowledge.Its main objectives are to: a. analyse scientific production; b. seek its immediate and pragmatic applications.It has, therefore, an important role in the analysis of a country´s scientific production, since its indicators reveal the behaviour and development of a knowledge area 10 .
Scientific documents were chosen by their personal quality (addressing significant issues experienced by the investigator); autonomy (the result of the author´s efforts); creativity (that contributes to the development of science); and strictness (which presupposes logical structure and capacity) 11 .
Furthermore, we understand that "[…] the construction of knowledge is based on the realities of professional practice, recognizing their state of development and pointing to prospects for progress 12:676 ."In other words, the analysis of theses dealing with the interface between nursing process and primary care highlight lived experiences, positive outcomes and changes needed.
Data was collected in May 2013 in pairs following a research protocol.Nurses critically analysed the latter´s content and intelligibility, evaluating and agreeing on the tool's value to assess what had been proposed.
The "Protocol for Documentary Research" consisted on the following elements: theme, goal, guiding questions, search strategies, study selection, strategy for data collection, strategy for critical evaluation of documents, and data synthesis.
CAPES database was explored using the following descriptors: Nursing Process, Primary Health Care, Nursing Theory (controlled descriptors) and Basic Health Care (non-con-Three studies (50%) were carried out at the State University of Ceará; The Federal University of Rio de Janeiro, The Federal University of Santa Catarina and The University of São Paulo had one research each (16.7%).
The researches were carried out between 1998 and 2011; all of them were developed by nurses.They were mostly descriptive studies (83.3%); one was a quasi-experimental research (16.7%); and one was a clinical trial with experimental and control groups.
Among the thematic area, two studies dealt with hypertension (33.3%); others with child health, diabetes mellitus, heart disease and mood disorders.
Nursing theories were used in five theses (83.3%), namely: Callista Roy´s Adaptation Theory, Imogene King's Theory of Goal Attainment, Dorothea Orem's Theory of Self Care, Jean Watson´s Theory of Human Caring, and Madeleine Leininger´s Transcultural nursing theory.Table 1 displays data relating to theme and focus of nursing theories on the studies.
The PhD dissertation entitled "Potentialities and limits of CIPESC ® for recognizing and addressing child health needs" did not use PE principles in the APS. 19Only two studies (33.3%) focused on Classification Systems and used the International Classification of Nursing Practice (ICNP ® ) and the International Classification of Nursing Practice in Public Health (CIPESC ® ).Only one paper (16.7%) used both nursing theory and classification system, combining Roy´s Theory and ICNP ® .
The advantages of using nursing process in primary care were: feasibility; 14, 15 provides quality care; 14 contributes to nurses' autonomy; 14 improves identification of users' needs; 19 encourages nurse-user interaction; 15,16,18 contributes to a reflective nursing practice; 17 enables nurses to develop a humanistic approach; 17 and assists in the implementation of humanized and scientific care. 14,19e identified difficulties were: individualized visits focused on biological issues; 14,17,19 training based on biomedical model; 19 users' inferiority complex towards health care professionals; 16 and techniques taking priority over human care. 17

DISCUSSION
The scarceness of studies that deal with the interface between nursing process and primary care is one of the most worrying elements since only 5.0% of the 120 analysed documents concerned primary care.A survey carried out in 2009, aiming at analysing national bibliography (Brazilian papers, theses and essays published between 1980 and 2005) available in SAE, demonstrated the problem and revealed that authors carried out their researches mainly in a hospital setting. 8hat prevalence could be explained by the fact that the first attempts at the implementation of nursing process occurred in hospitals, associated with the patient´s hospitalization, follow-up and continuity of care. 8he little emphasis given to the interface between nursing process and primary care may reflect a misguided notion about the working process in primary care, which is often associated with low complexity cases, once it is a "basic task" in the previous terminology.
It is vital to demystify this assertion: primary care is responsible for the largest number of cases, it is the main point of contact between the various health care networks and it is repository of "complex and varied care technologies". 9herefore, it is an area that requires a keen clinical reasoning, able to identify the users' objective and subjective aspects, providing the APS characteristic longitudinal care, an aspect that can be consolidated with the support of PE.Diabetes mellitus Dorothea Orem's Self-Care Theory To explain the importance of communication as a self-care learning strategy to people with diabetes mellitus Domiciliary clinical care to women with heart disease: an analysis according to Watson´s principles 17

Heart disease Jean Watson´s Theory of Human Caring
To analyse domiciliary nursing care to women with heart disease Nursing care to people with mood disorders in primary care 18 Mood disorders

Madeleine Leininger´s Transcultural nursing theory
To identify beliefs, values and different sociocultural practices used by family caregivers of patients with mood disorders The use of classification systems was not much explored, and only one dissertation discussed the association of nursing theory with a classification system, namely Roy´s Adaptation Theory and the ICNP. 14The adoption of a language of its own, enabling nursing visits guided by nursing theories and classification systems is an essential element in the effectiveness of nursing as science.
The analysed studies highlight the numerous advantages of the interface between nurse practice and primary care and emphasize the growing need to ground nursing practice on solid scientific basis, in order to qualify care and contribute to the fulfilment of APS humanistic principles.
Moreover, nursing visits guided by PE and based on a nursing theory enable professionals to see the user as a whole being that interacts with the environment and is capable of making decisions about health and contributing so that nursing actions achieve their goals within APS. 23 However, while identifying the unquestionable advantages of the interface between nursing and primary care, we recognize the challenges to be overcome, especially regarding the reductionist view of the health/disease process, result of an education system still ruled by the biomedical model.
Such obstacle was also cited in a study that aimed to characterize the working process of a Family Health Strategy (FHS) nurse, identifying its object, aim, means and instruments.In this research several limitations regarding nursing visits were identified: as the individual was the subject of nurses' attention, social dimension was neglected and nurses adopted a prescriptive approach; besides, nursing visits were considered a way to free up the doctor´s schedule and the family group was ignored; moreover, the individual was considered guilty of not following treatment adequately whereas neither social nor economic issues were discussed as family health -illness determinants. 5nother research pointed the same difficulties and described such visits as "pseudo-medical consultations" -the opposite of ideal clinical care, where people's needs are taken into account, focussing not only on the patient but also on his family and environment. 24he recognition of the importance of PE within APS as a means to overcome Cartesian visions is essential.The elimination of factors that hinder its implementation, especially through nursing education, is very important as well.Health care could then be geared towards user's needs. 8t is vital to highlight the structural aspects that undermine the consolidation of PE in nursing practice.They are consistent with a study that aimed at summarizing the aspects that jeopardize the implementation of the SAE.They were identified as follows: In this sense, nursing care -to account for the complexity and dynamism of issues surrounding individuals, families and/ or population groups' health/disease process -encompasses, in addition to scientific and technical aspects, ethical, aesthetic, philosophical, humanistic and cultural factors. 10Thus it requires organization and a scientific stance of nursing practice that can be consolidated through PE.
The analysed studies confirm this assumption: the sound interaction between nursing professionals and users, as well as the consolidation of nursing practice guided by humanistic and scientific care are among the advantages of the nursing process in primary care. 14,19e highlight the state of Ceará's scientific output on the subject: 50% of the dissertations were developed in the State University of Ceará. 14,15,17A similar result was found in an analysis of essays on nursing theories published between 1998 and 2007: 49 articles were produced in Ceará (26.5%). 20n the state there are also study groups and lines of research interested in exploring and developing this topic.Such prevalence is also mentioned in a study that examined the output of the postgraduate program in nursing of the Federal University of Ceará from 1993 to 2002, in the area of women's health.It revealed that 66.7% of the studies used nursing theories. 21egarding nursing theories associated with nursing process in primary care, 83.3% of the studies used different nursing theories in their investigations. 14,18Theory" is defined as the abstraction of reality for a specific purpose.In nursing, scholars point out that theories promote reasoned decisions about practices and highlight purposes, limits and relationships between professionals and users.22 Nursing theories bring fundamental epistemological contributions to the construction of knowledge and professional practice.They guide clinical models and enable professionals to describe and explain daily care aspects.20 Therefore the use of a theoretical model helps nurses to define their roles.Through a better understanding of the context and consequent adaptation and quality of performance, it contributes to the consolidation and recognition of nursing as a science and art.The adoption of a specific language assigns meaning to the constituent elements of their being, knowing and doing.20,23 Thus, nursing seeks to guide its practices in the light of humanistic theories that consider care as its most valuable element, and the human being worth of respect and appreciation, as shown by the theoretical basis of the analysed documents.
The use of humanistic nursing theories, moreover, contributes to the fulfilment of APS principles.It is based on a broad concept of health condition, humanization, receptive stance, and qualified listening as key elements in the work process of a primary health care nurse.This research could help primary care nurses understand the advantages of the nursing process as a qualifying element in their visits so as to consolidate and recognize nursing as a science.a. personal/professional factors: inadequate undergraduate education, lack of commitment, involvement and responsibility, lack of leadership and organization, limited availability and overwork, interpersonal relationship problems, lack of role definition and salary issues; b. organizational factors such as shortage of nursing staff, concomitant administrative responsibilities, managers and institution unwillingness, inadequate physical structure of the units and inefficiency of support services; c. factors related to the theoretical model, highlighting the absence of stages, identification of problems as mere mental exercise and the complexity of PE. 25 Thus, although personal and professional aspects were emphasized, it is essential to understand that a dialogical confrontation of the factors mentioned above is required for PE consolidation in APS.Health care effectiveness requires structural and organizational adjustments for professionals to perform effectively in their jobs.
The importance of APS teams' continuing education and the need of its consolidation at all levels should be stressed.Binomial health/education could then be actually practiced.

FINAL CONSIDER ATIONS
The present study showed that scientific production on the subject is still incipient and reinforced the need for new investigations.It described positive experiences that contributed to assert the benefits of the interface between the two processes and also identified difficulties and challenges that still need to be overcome.
The present research contributes to highlighting the importance of the interface between nursing process and primary care.It emphasizes the unique role of this level of complexity within the Unified Health System and recognizes the major role of the nurse, whose actions should be guided by critical and reflective thinking, from PE perspective.
The limitations of the study comprise the elements that hindered the selection of the research sample: lack on standardization of the abstracts; absence of relevant information in the abstracts; documents were not available in full on virtual libraries; and the scarcity of studies that discuss their methodological limitations.In addition, this research was restricted to the Brazilian context.
The authors suggest, therefore, the development of new studies in an international setting.
Furthermore, it is necessary to re-evaluate this publication in international journals so that Brazilian studies are not restricted to the national public.Once published abroad, it could contribute to professional awareness and encourage the incorporation of PE in APS.

l
academic level: master's, professional master's or doctorate; l research setting: name of the university l year of publication: indicated in web portal l author´s academic level: according to Curriculum Lattes l methodological design: bibliographic, descriptive, experimental or exploratory research 13 l research theme: thematic area in which the nursing process was performed l nursing theory: used in the study l classification system: used in the study. l

Table 1 -
Theme, nursing theory and focus of nursing theory on the selected studies -Natal, 2013