Introduction

The prevention and control of cervical cancer has been a major challenge to services and professionals with priority on health agendas, demanding strategic actions throughout Brazil, and is considered a public health problem. According to estimates, in Brazil, for the 2018-2019 biennium, an estimated 16,370 new cases of cervical cancer in Brazil, with an estimated risk of 15.43/100,000 women.¹

The Northern Region ranks first in incidence, with an estimated 2,300 new cases for the same year. The State of Pará is in fourth place in gross disease rate with 860 new cases, and the estimated incidence for 2018 is 20.55/100 thousand inhabitants, with significant concentration in the capital Belém (280 cases - 33.69/100 thousand inhabitants),being the second most common cancer in women in the state of Pará, preceded only by breast cancer (excluding non-melanoma skin tumors).¹

Because it is a disease that slowly evolves into invasion, cervical cancer and its precursor lesions are susceptible to screening, early detection and treatment when diagnosed in its early stages. The main strategy used for the screening of the disease is by oncotic colpocytology examination or Pap smear due to its sensitivity, specificity, low cost, safe execution and acceptance by women, being recommended in Brazil for sexually active women and aged between 25 and 64 years old.^2-3

According to Federal Nursing Council Resolution (COFEN) No. 385/2011, the collection of material for oncotic colpocytology examination, which could previously be performed by nurses, nursing technicians and nursing assistants, must be performed exclusively by nurses for considering the epidemiological, economic and social magnitude of cervical cancer, because it is a complex procedure with technical and scientific demands that requires an organized and systematized work process of nursing care.⁴

However, there is controversy in the application of this Resolution, since it covers the entire national territory and does not take into account the diversity in the epidemiology of the disease, the structure of health services and the particularities of each region, which led the National Institute of Cancer (INCA) to warn of possible consequences in the application of this legal instrument, considering that the collection performed not only by nurses, but also by nursing assistants and technicians, provided they are well trained, are strategies for expanding the coverage of the exam.⁵

Also in this context, the State Department of Public Health of Pará (SESPA) issued a Technical Note contrary to Resolution COFEN No. 385/2011 authorizing the collection by technicians and nursing assistants in order to ensure women's access to the exam, considering that in the state most of the collections were performed by nursing technicians. Regarding this Note, the Regional Nursing Council (COREN-PA) responded by stating that SESPA was trying to transfer a management problem to nursing rather than seeking new strategies to ensure health policies. This discussion was brought to the State Health Council, which ratified SESPA's position, recommending cooperation among several institutions for the re-evaluation of the Resolution. However, the legal determination deliberated by COFEN to nursing professionals remains in validity.⁶

From this scenario, the following questions were asked: What is the perception of nurses regarding the exclusivity in the collection of material for oncotic colpocytology examination after determination of COFEN Resolution No. 385/2011? And it was defined as objective: to analyze the perception of nurses regarding the exclusivity of the collection of material for the performance of oncotic colpocytology.

Method

This is a descriptive study of qualitative nature, conducted in 18 Municipal Health Units (UMS) managed by the Municipal Health Secretariat (SESMA) of the municipality of Belém, State of Pará, representing 85.7% of the total UMS of the city. About the participants, were selected according to availability at the time of collection, a nurse from each UMS, totaling 18, being as inclusion criteria to be collecting material for examination of oncotic colpocytology, regardless of the time of practice in this service.

To obtain the data we used a semi-structured interview script prepared by the researchers, composed of two axes: sociodemographic data that included the age range, gender, professional training, length of service and performance in collecting colpocytology; and specific questions related to the object studied, including knowledge about Resolution 385/2011 - COFEN and personal opinion about the exclusivity of collection by nurses; implications that they recognize in the execution of the activity, as well as the level of preparation and satisfaction.

The interpretation of the results was based on content analysis, observing the steps: general reading of the material; coding for categorization of the material; cutting the material into similarity record units; grouping of registration units into common categories; progressive grouping of categories in a technical and systematic manner until final categorization; inference and interpretation of results based on the theoretical framework of the study.⁷

The study was approved by the Research Ethics Committee of the Undergraduate Nursing College of the University of State of Pará on May 26, 2017, under the opinion No. 2.084.826.

Results

The data correspond to the sociodemographic characterization of the participants and concern the age group, gender, professional training, length of service and performance in collecting colpocytology. The results regarding the object of study are organized in one category: perceptions about the oncotic colpocytology exam collection that is subdivided into four subcategories that address the collection of material performed by the nurse, the collection performed by the nursing technician, the easiness and difficulties in the collection of material and changes in the routine of nurses who express their different perceptions regarding the exclusivity in the collection of oncotic colpocytology.

Regarding the age of the participants, 7 (38;89%) were in the age group of 31 to 40 years, followed by the intervals of 41 to 50 years old and 51 to 60 years old with 5 (27;78%) participants each, and 1 (5;56%) between 18 and 30 years. Regarding gender, females predominated with 16 (88;89%) participants. Regarding professional training, 13 (72;22%) had graduate studies. Considering the time they worked in primary care, 7 (38;89%) developed activities between 1 and 5 years, followed by intervals of 6 to 10 years with 4 (22;22%) nurses, and more than 10 years with 7 (38;89%) participants. Regarding the experience time in collecting material to perform the exam, 4 (22;22%) collected for less than 1 year, 10 (55;56%) nurses worked between 1 and 5 years, and 4 (22;22%) collected for over 5 years.

When asked about their knowledge of COFEN Resolution 385/2011 and how they had access to it, 17 (94;44%) reported various sources of access to information, 9 (52;94%) were informed by the institution in which they work, 3 (17;65%) through COFEN/COREN and 5 (29;41%) had access through social media.

Regarding the offer of training in the service, 10 (55;56%) participants reported having been trained by offering of SESPA or SESMA, and 8 (44;44%) participants said they had no training in the service, having only the knowledge acquired upon under graduation:

[...] it was only though the college, the basic, we train in only one patient, during all the college period. (E8)

Perceptions about oncotic colpocytology exam collection

The category includes the participants' view of the collection of material for oncotic colpocytology examination performed by the nurse, about the performance of the same examination by the nursing technician, the difficulties and easiness for its performance and changes in the routine of nurses.

Perceptions about the nurse's collection

Among the study participants, 13 (72.22%) acknowledged the high complexity of collecting material for oncotic colpocytology examination. It was observed that most nurses who expressed this position showed affinity with the execution of the technique and developed only this activity in the health unit, what appears expressed in the statements:

I think the nurse is a qualified practitioner for collecting the CCP [Cervical Cancer Preventive], as it is a procedure that requires decision making and guidance for each patient, besides requiring knowledge about the pathology and diseases that affect the female reproductive system. (E11)

I think it is very good that it is done by more capable people, with more education, with more discernment [...] I think it is important. (E3)

Nevertheless, the nurses acknowledged that the exclusivity of the collection caused work overload, considering that the UMS kept the same number of professionals with the same attributions, without expanding the nursing staff, according to statements:

it is a bit complicated because we cannot stop attending the programs to be exclusive only for the preventive collection. There are many programs to attend and there are few people to attend it. (E1)

I think we already have a lot of work; we already have a lot to do [...] From the assistance to the administrative sector is already ours, got it? I think it was another service for us. There are some of our colleagues who think it was good that we get space and everything, but I don't see it like this. (E4)

Perceptions about the collection performed by the nursing technician

According to the opinion of 5 (27.78%) nurses, the collection of the exam may be performed by the nursing technician, provided it is well trained and supervised by the nurse. It is a speech that demonstrates credibility in the performance of the technician to perform the procedure. The nurses who expressed this position were responsible for several health care programs in the UMS:

the technician would help a lot, a trained technician. (E1)

the collection itself is only technical and as such I can teach anyone. The technique itself I do not see as ‘must be unique to the nurse’, because I think the technique well learned by the nursing technician himself can be performed [...]. (E17)

It was also evidenced that 3 (16.67%) participants criticized the collection by the technicians because they believe they do not have the same quality as that performed by the nurse. Still, they strengthened their speeches referring to the lack of skill at the patient's reception, without the necessary reception, even compromising the return to access to the exam results and the therapeutic follow-up, illustrated in the statements:

[...] lie here, put your foot here [...] They are not careful to ask a patient to relax, to talk to her, to really look at her situation [...] The techniques talk too much, they say that the cervix is bleeding, that it is red, make of it a terror for the patient, that they do not even seek the result, understand? They end up giving unnecessary information. (E5)

Perceptions about the difficulties and easiness for the oncotic colpocytology exam collection

Among the difficulties reported by nurses with direct implications for the exam, the lack of material resources was highlighted; inadequate or shared physical space; work overload and collection performed by male professionals. Such situations are illustrated in the following statements:

my difficulty here is with materials. There was a period here, for example, did not have the collection tubes. (E17)

we do not have a room exclusive for the collection of the CCP, this room here is also a doctor’s practice. (E16)

because I am a man is a very large wall. I have to give a talk, talk to all and only the elderly who already accept, the others do not accept it. (E9)

For the nurses, the easiness identified in the routine of the UMS concern the care by spontaneous demand that favors the search for the exam and facilitates access; to the management support; be an exclusive nurse to collect the exam, illustrated in the statements:

the easiness is that we serve every day and is open door, it is just arriving. (E2)

management support, unit management, for us to do this work. This is a very large easiness. It has the minimum necessary equipment [...]. (E5)

the unit here, in relation to some others, has a different profile, we have a much larger number of nurses, so I can be exclusive to the CCP [...]. (E17)

Perceptions about changes in nurses' routine

It contemplates speeches that point out the implications in the nurses' routine after COFEN Resolution No. 385/2011 is in validity, being, in most cases, related to the human resources deficit and the work process organization, causing overload and accumulation of functions.

The advent of the Resolution prompted decision-making by some nurses regarding the collection service, to the detriment of the guidance of the managers of the Units and health management in the city of Belém, aiming at not interrupting the collection of material for CCP examination, standing out in the following statements:

yes, we are taking the technician who has the nursing course [Nursing Technicians who attended undergraduate nursing school], so as not to have so much trouble for us, or for them. If I had to actually be collecting, it would hinder the care of patients, I would have to stop the care of programs. (E1)

one day I stop attending to pregnant women, children, tuberculosis, leprosy [...] then the other days we have to schedule more people. (E3)

we had to have a meeting and say: this day we do not schedule prenatal, we have to juggle in order to start prenatal on the recommended date, so, yes, that already changes my routine! [...] They put this resolution counting on they were going to hire more nurses and they didn't, understand? (E16)

I went, right after the resolution, to the CCP, because I was previously a nursing technician. So, I think it has changed a lot more the unit's routine to fit the resolution than mines. I was of urgency, I came to the clinic with this intention, to come to the CCP [...]. (E17)

Discussion

The sociodemographic profile of the participants showed a prevalence of females, since nursing is a markedly female profession since its origin, and because this is a procedure related to women's intimacy. In this case, gender becomes a relevant element for the performance of the function and may contribute or compromise the screening and prevention of cervical cancer.^8-9 This is an aspect to be valued, especially in units where there is only one nurse, not allowing women to choose.

In this study, most participants worked on the collection of material for oncotic colpocytology for up to 5 years, coinciding with the period in which COFEN Resolution 385/2011 came into validity, showing that the decision of the regulatory organ was the motivation to allocate nurses in the collection room. And only 55.56% (10) of respondents went through training, and part of them stated that it was the need to meet the resolution of COFEN, causing implications not only for nurses, but also for service management.

However, although this percentage is relatively low, a study conducted with nurses in the state of Bahia indicated that the search for qualification has been increasing among nursing professionals, especially with regard to graduate programs.¹⁰ Continuing education should take place systematically in primary care to qualify health practices, and all practitioners who collect oncotic colpocytology examination material should be trained.⁵

Although the change in the nurses’ routine is perceived differently, indicating positive and negative perceptions for the service, the participants' speeches show consistency with the justifications contained in Resolution 385/2011 - COFEN regarding the complexity of the examination, demanding not only technical knowledge as scientific and citation of the nurse's attributions laid down in the Law of the exercise of the profession No 7.498/1986.⁹

In this sense, the role of nurses is considered essential in the prevention of cervical cancer, since primary care ranges from welcoming and sensitizing women to diagnosis through the collection of material for oncotic colpocytology examination. Thus, it is understood that there is a need for nurses to be trained to work in various activities to control the disease.¹¹

Also, in this perspective, a study related to the importance of nursing care in the prevention of cervical cancer, evidenced the differentiated view of users assisted by nurses with approval of their approach and appropriate guidance to their demands. In addition, they recognize that their performance is essential for the reduction of new cases of the disease.¹²

The decision to incorporate the collection of material for oncotic colpocytology as exclusive to the nurse changed the routine and the work process in the UMS, causing, in the perception of professionals, accumulation of tasks and need for reorganization of services. This scenario was a major difficulty for participants as a result of Resolution 385/2011.

In their speeches, the participants acknowledged that the implementation of the resolution implied work overload, considering that the numerous attributions and activities that nurses perform within the context of primary care, directed to individuals and their communities were not considered. Let these be: health education focused on prevention and health promotion, care and management of health services in all life cycles, as well as diagnosis, treatment and recovery of health problems. ^13-15

Excessive work demand correlates with the statements of nurses who admitted delegating the collection to the nursing technician, in order to enable the development of all their duties in the UMS, although they recognize that to do so, they need direct training and supervision, essentially for the reception of women. This is because although nursing is essential for access and functioning of health services, there are still imbalances and gaps in the availability, distribution, composition, qualification and productivity of these professionals.¹⁶

The perception of work overload as the most impacting implication was due to the insufficient number of nurses in the services, making them attribute to this fact the possible compromise of coverage and quality of the material collection service. Thus, health institutions/organizations should promote adequate working conditions, number of professionals and remuneration compatible with the service, thus reducing the risk of harm to the patient. It is noteworthy that most nursing professionals have several jobs and that there is high turnover in services due to low pay in the profession and inadequate working conditions that expose them to alarming levels of stress¹⁷, which also was identified during the interviews.

It can also be stated that nurses are not the only professionals who provide patient care. However, they assume a leadership position in front of the multi-professional team and the community. They are responsible for training and qualifying other nursing categories, as well as evaluating, systematizing and deciding the most appropriate conduct for each individual, putting into practice management skills and resource management, professionals and health information^17-18, causing the accumulation of functions identified in the routine of the UMS.

Final considerations

Nurses' perceptions regarding the exclusivity in the collection of oncotic colpocytology, imposed by COFEN Resolution No. 385/2011, are not homogeneous, however, although there is divergence of opinion, there is convergence in recognizing the need for nurses to add technical and scientific knowledge for carrying out the activity, given its high complexity. They also recognize that the implementation of the COFEN resolution causes work overload for the category.

The exclusive collection by nurses was carried out as an addition of tasks, amid (dis)structuring of the local public health service, mediated by the supervision of the class organ, causing implications for the routine of health units. These implications are not the consequence of a wrong and unfounded attitude of the class council that governs the profession, but rather of the municipality's lack of preparation for the readjustment of units in the face of change.

It is appropriate to highlight the importance of this resolution, considering that its implementation may contribute to a more qualified service to users, and also to a better demarcation of the nurses' professional space. However, it is concerned with the better structuring of the collection service for the exam, including ministerial norms, the implementation of permanent training programs for nurses and the readjustment of staff to ensure the proper functioning of all programs and actions in primary care. Empowerment by nurses is essential to exercise their profession with commitment and quality, always striving for the ethical precepts established in the law of professional practice, in order to ensure improvements in care to users.

Based on this scenario, it is suggested to extend this study to other municipalities and States, as the validity of the resolution applies throughout the national territory, as well as conducting comparative research in public and private services, as well as studies related to quality of care and collection of material for the oncotic colpocytology exam performed by the nurse and the nursing technician, in order to justify or not the implementation of the resolution by COFEN.

The limitations of this study relate to the lack of comparisons with other sectors or instances that perform the collection of oncotic colposcopy, being limited to the professionals of the Basic Health Units, without including nurses from the Family Health Strategies, as well as the professionals who perform collection in the private network.

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Corresponding author

Suzana Rosa André

E-mail: suzanarandre@gmail.com

Address: R. Afonso Cavalcanti, 275 - Cidade Nova, Rio de Janeiro - RJ,

ZIP CODE: 20211-130

Authorship Contributions

1 – Letícia Lima de Oliveira

Conception and planning of the research project, analysis and interpretation of data, writing

2 – Marllon Rodrigo Sousa Santos

Conception and planning of the research project, analysis and interpretation of data, writing

3 – Ivaneide Leal Ataíde Rodrigues

Interpretation of data, and critical review

4 – Suzana Rosa André

Interpretation of data, and critical review

5 – Ingrid Fabiane Santos da Silva

Interpretation of data, and critical review

6 – Laura Maria Vidal Nogueira

Conception and planning of the research project, writing and critical review

How to cite the original article

Oliveira LL, Santos MRS, Nogueira LMV, Rodrigues ILA, André SR, Silva IFS. Exclusividade na coleta de material para exame de colpocitologia oncótica: percepção dos enfermeiros. Rev. Enferm. UFSM. 2020 [Accessed on: Year Month Day];vol.10, e15: 1-16. DOI:https://doi.org/10.5902/2179769233721