Nurses’ perceptions on nursing supervision in Primary Health Care

Objetivo: compreender as percepções de enfermeiras sobre supervisão em enfermagem no processo de trabalho. Métodos: pesquisa qualitativa, com entrevista semiestruturada, realizada com 16 enfermeiras. Análise dos dados realizada por meio de análise de conteúdo. Resultados: dois núcleos de significados emergiram das falas das participantes: Atividades de enfermeiras nas Unidades de Atenção Primária à Saúde e Percepções de enfermeiras sobre o que é supervisão em enfermagem. Na primeira categoria, elencou-se como ações o preenchimento de formulários e relatórios, em detrimento da supervisão do serviço de enfermagem. Na segunda, a supervisão foi percebida como função de gerenciamento e acompanhamento das atividades planejadas pela equipe, contrapondo a concepção clássica de supervisão, a de fiscalizar. Conclusão: a supervisão em enfermagem configurou-se, para as enfermeiras da Atenção Primária à Saúde, como uma função de natureza administrativa que envolve planejamento, organização, coordenação, avaliação, acompanhamento e de apoio para a equipe de saúde. Descritores: Supervisão de Enfermagem; Atenção Primária à Saúde; Enfermagem.


Introduction
The organization of public health services proposal in Brazil is based on the consolidation of the Family Health Strategy, with a great contribution by nurses (1) .In the Primary Health Care Units, the place for the development of Family Health Strategy activities, nurses develop actions aimed at health promotion, disease prevention, treatment and rehabilitation (2) .
With the implementation of the Family Health Strategy, new attitudes and skills of nurses (3) were required to effectively exercise their role in primary health care.The nurse has been working in the assistance and in supervising and motivating the team (1) to ensure that the work is executed by the principles of the Unified Health System (4) , giving the highest quality of care to the population.
The nurses can administer, coordinate, plan and direct the nursing service.These attributions have been expanded to the management of the health service, mainly in Primary Health Care according to the law of professional practice 7498/86 (5) .In this scenario, many of them assume the dual function of nursing care management and the management of the Health Unit.
In the work process in primary health care, the nurse performs the supervision function of the nursing team, understood in this investigation as a continuous process of team orientation, of active and collective participation of the workers (6) , with the purpose of develop it and enable it to perform quality nursing care (7)(8)(9) .Also, it is characterized by the development of articulating and organizing activities of collective work.The supervisor acts as a mediator of institutional policies in the development of health care and the implementation of nursing care (6) .
The nursing supervision process can vary according to the team, the location, the institutional culture and the level of care in which it develops, as well as the skills and competencies of the supervisor.Some of them may be mentioned: scientific knowledge, clinical skills, management, communication, ethics, professional behavior, teaching and supporting the team (9) .In Brazil, the nursing actions carried out by professionals of technical and elementary level must be linked to the supervision of a nurse (5) .
This study is justified considering the proposals of the national curricular guidelines for nursing undergraduate courses, which determine the training directed to the Unified Health System, as well as the development of skills and competences to administer and manage, where the supervision is a tool, providing the professional with the knowledge required for professional quality work (10) .Another justification is due to the Brazilian health care policy, which determines that primary health care is responsible for coordinating the health care network, in which nurses are one of the fundamental members (2) to consolidate this policy.There is also a shortage of national and international studies on the subject (6) , especially those that point out the perception of nurses regarding the practice of nursing supervision (9) .
In this scenario, the objective was to understand the perception of nurses about nursing supervision in their work process.

Methods
This is a qualitative study carried out with nurses working in the Primary Health Care Units, with a Family Health Strategy implemented, located in the northern of the urban zone of a city in Zona da Mata Mineira, Brazil.
The selection of the place for the study and the potential participants was for convenience due to the development of academic activities in the area.Twenty-four nurses from 12 primary care units were previously contacted.After receiving information about the research, 16 nurses from eight units agreed to participate.Eight nurses from four units refused to participate because having an incomplete team, which overwhelmed the nurses in the period of data collection, making it impossible to participate.The interviews were previously scheduled, according to the availability of each participant and carried out in the workplaces, individually, in a reserved environment.For data collection, semi-structured interviews were used, based on the following guiding question: What is your understanding about nursing supervision?The interviews were conducted by one of the researchers using a face-to-face approach and recorded in digital equipment, after consent of the participants not to lose any information provided by them.The duration of the interviews ranged from 15 to 30 minutes, with an average time of 22 minutes, totaling 6 hours and 26 minutes.Data collection was February and March 2014.
The data analysis was performed through content analysis, with the following steps: organization of the speeches and their transcription; Depth reading of interviews; Categorization and classification of the meanings topics, the inference of the results and interpretation of the data obtained with the help of theoretical basis (11) .
The letter "E" was adopted and sequential numbers were assigned according to the interviews to preserve the anonymity of the nurses (E1 to E16).
The study complied with the formal requirements contained in the national and international regulatory standards for research involving human beings.

Results
Eight of the 16 nurses participating in the study (50.0%) graduated after 2001; 13 (81.2%)had specialization; 10 (62.5%) had primary care between one and 10 years, and nine (56.2%) had between 11 and 20 years of experience in the profession.As for the teams, 12 (75.0%)were incomplete, and the professional categories absent were doctors (n=5) and community health agents (n=13).
After the analysis of the nurses´ statements, two meanings topics emerged: Nurses´ activities in Primary Health Care Units and Nurses´ perceptions about nursing supervision.

Nurses´ activities in the Primary Health Care Units
The nurses were asked about their activities developed in the Primary Health Care Units.Among the activities performed by the nurses, the most developed were the ones of assistance.Supervision was included in the managerial/administrative category (Figure 1).The nurses reported that nursing activities are essential for the working of the units, as the speeches pointed out: And it is just that we do everything.When you need it (E6).So, I think it is... the nursing, she is always and... so, participate in... 100,0% of the service of the basic unit...I even say that the nursing takes care of the house (E7).
When questioned about what activities they considered as supervision, some nurses reported administrative/managerial activities: Monitoring of educational groups (E2).I think they are actions... the supervision of the curriculum internship, the performance evaluation (E3).

The setting of daily and holiday schedules, supervision of trainees, planning of actions, records of actions, the request of equipment, request for vaccines (E5). Supervision is to do the scales, make rules of procedures (E6).
It was noticed concern in the speeches of some nurses with the administration of the Primary Health Care Unit, filling of forms, reports, among others, to the supervision of the nursing service.

Nurses´ perceptions about nursing supervision
It emerged from the nurses´ statements that supervision was an inherent function: I think it is important for us to supervise because it is our job and we then respond to it (E10).Because it is the duty of the nurse to carry out the supervision of the technicians, the community health agents, which is also our responsibility (E15).

Most of the nurses considered nursing supervision as an administrative function. It is to plan
nursing actions together with the work team, using improved health services to improve patient care.The evaluation of this supervision should take place throughout the planning process, opening for possible changes.The supervisor must organize the service (E5).
Well, I understand that supervising is... you are... along with the nursing team, coordinating the actions, distributing the actions, evaluating and planning along with the team (E8).Supervision I see as a way for you to organize... your work.The place where you stay to improve the quality of service.Without supervision, without an organization, it is difficult for you to achieve this quality (E13).

alternatives, aimed at improving the quality of nursing care (E16).
Accompaniment, evaluation of the assistance provided by the nursing team and the actions developed by the community health agents, planning the actions to be developed by the Family Health Strategy (E4).Supervision comprises the monitoring of the activities planned by the team to perceive difficulties in their development, as well as the result and the evaluation, with the purpose of always providing the best assistance to the patient, guaranteeing their wellbeing.
Regarding nursing supervision, most of the nurses answered that they performed it daily.In dayto-day activities, we are always following the nursing team (E2).The nurse as coordinator of a team, he should be supervising the work of those under his coordination every day (E8).
However, the work overload of the participating nurses was a complicating aspect for supervising: Yes (I carry out supervision), as far as possible.Because the activities to be developed by the Family Health Strategy, such as preventive, prenatal, etc., they are many, and the supervision of the nursing team (E4) ends up being a bit in the background.No (carry out supervision), due to work overload (E3).Some nurses pointed out in their speeches aspects related to the classic vision of supervision, in which the nurse has an inspection supervision, emphasizing the need to "take care" to supervise the professionals of the nursing team.Nursing supervision is also understood as a "bureaucratic part", to do all the work related to completing forms, bulletins, productivity, reports of information systems, among other activities.Moreover,... it ends up being a bureaucratic part too.Supervision I think the nursing takes everything!Part of care and part is... bureaucratic (E6).
When referring to nursing technicians, nursing assistants, and community health agents using the term "subordinates," the following speech evidences the social and technical division of work in nursing, as well as the permanence of the historical conception of hierarchy and associated power to the position of a nurse.Supervision goes since you are working together with your subordinate, who is the nursing technician and community health agent, being taking these doubts, to be correcting failures, to be doing health training to improve the quality of the service.I get it.One more thing, it is monitoring the workload, the compliance of schedules, this is all of the supervision (E14).Some nurses considered supervision as an activity to support the work developed by the other professionals of the nursing team.Daily, we as nurses responsible for the nursing service.So, in addition to providing support, we also supervise the technician's service (E7).Nursing supervision is performed daily.For us, professional nurses, and... in the moments of procedures, when the nursing techniques need assistance in some procedure, to evaluate some wound, some... of some patient that awaits care (E11).It is then made daily because here being a small place.Only with two employees, and we are very close to the activities, so whatever I should talk to them, any supervision is done at the moment (E13).
Supervision can also allow the identification and correction of problems in the daily work, as well as the possibility of contributing to the educational process of the entire nursing team.It is up to the nurse to supervise the activities of the nursing team in their daily lives.The technical guidelines, in the correction of some fault, and... while also passing new information (E14).Supervision goes through orientation, goes through monitoring, goes through assessment, goes through the correction of some attitude that you did wrong, goes through, is... continuing education (E2).

Discussion
The participants in this study were female, which enables to infer that cultural construction that attribute care to female attributions justify the prevalence of women in the Nursing profession (12) .
Research on the topic of nursing supervision in primary health care is scarce.There are many obstacles faced by nurses in daily work, such as the number of professionals, structure, equipment and resources insufficient for the development of work (13) , which makes the health promotion model advocated as a restructuring of the health care network.Low resolution and incompatible to provide quality assistance.These difficulties considerably affect the supervision of the nursing team, since they try to solve the daily difficulties of the team, without interrupting the care.
It was verified that many nurses' activities carried out in the Family Health Strategy, including managerial, care, educational (2) and popular participation enabled the nursing staff to have recurrent supervision.Also, the lack of professionals in the team may imply work overload, generating nonperformance of some activities of the nurse, to the actions of responsibility of other team members.In some situations, this may impair the quality of work and, consequently, the nursing care offered to the individual.
The focus of the activities developed by the nurses in this study was assistance, which demonstrates that the organization and the work process are still based on the biomedical model focused on the individual, on the cure, on the illness, characteristics also present in other studies.This care model, centered on disease and curative activities, is contrary to the one by the primary health care policy proposed by the health promotion model (2) .
In this study, it was observed that, because it is the professional category most present in primary care and because it administers and manages the nursing service, supervision has been neglected by the management of the unit, even among those who did not perform the function of management.Nurses, when performing the nursing supervision function, evaluate the service in which they are inserted, since their conditions will directly influence the quality of care (8) .Some nurses assumed the dual function of managing unit and nursing care overloaded them.Thus, nursing supervision has been in the background.Work overload can cause difficulty in reconciling care management, health service administration, and management, and the development of activities of assistance, educational and social control nature, which can cause suffering and frustration in the performance of the nurse's duties (14) .
It is perceived that supervision is an important action in the nurse´s work process, and must be part of the daily work, regardless of the role that the nurse performs (8,15) .Therefore, even if the nurse assumes more than one function, which in this research is that of unit supervisor, this does not relieve her or exempt her from the supervision of the nursing team, since this is a private activity of the nurse, and cannot be delegated to another professional (5) .
Nurses understand supervision as a function inherent to the attributions of the professional category, so they reported doing it daily.It is an administrative function that involves planning, organization, coordination, evaluation, follow-up and support for the health team, aiming at the quality of care provided (9) , but not all of them performed in a systematized way.Nursing supervision is characterized as an administrative function, which integrates the work process (3) , enabling nurses to carry out a continuous process of orientation of their team, allowing them to plan, execute and evaluate with her the means to guarantee an efficient and effective nursing care (7)(8)(9) .
In the Family Health Strategy, the nurse is characterized as an important member of the health team, since, when practicing supervision in nursing, in democratic and appropriate actions, it allows the health needs of the patients to be contemplated (2,9,16) .Therefore, supervision is also understood as a tool that facilitates the monitoring of team work, and the efficiency of the service provided (9) .Thus, it is understood that the supervision should be prioritized, since the excess of other activities may distract the nurse from this assignment, generating tension and pressure for nurses and other workers, due to the complexity of meeting the health needs of the population.
Supervision was understood as the supervising action of the development of the activities of the nursing team.For a long time, supervision was an inspection function, focused on error detection and punitive character, whose supervisor was responsible for ensuring compliance with established activities (8)(9)15) . Howeer, after industrialization, supervision takes on an administrative character, making it necessary to create a link between the supervisor and the supervised, valuing human relationships and considering education as a most important factor (9,15) .
For other nurses, supervision included the development of bureaucratic activities, such as filling in forms, reports, among others.The influence of bureaucratic theory is in the reality of most nursing services and contributes to the organization of work and, consequently, an organization of the health service as a whole.However, mistakenly understood bureaucracy makes activities slow, making access difficult, preventing the implementation of changes, and serving as an argument for not carrying out processes.This can be detrimental to the nursing team, the service and the client/patient, which often requires fast results in the care (17) .
Aiming at supervision as being with subordinates demonstrates the historical hierarchy in the nursing service, and it is often reinforced in the exercise of supervision, maintaining the classic perception marked by the division of social and technical power of work in nursing (1) .However, from the 2000s, a horizontal relationship between work relationships and the development of human capital was advocated to reach a broader understanding of the work process, allowing for qualified and resolutive assistance.
Supervision is considered as a technology for nursing work, which contributes to the quality of services and the assistance provided (16,18) , since it organizes the work, identifies the needs of the work process, especially those related to training (18)(19) .In this way, it must be planned, executed and evaluated (8) in a systematized manner (18) .The interviewed nurses' speech pointed out that nursing supervision has been carried out in a non-systematized way, which leads to inferring that the steps described are not contemplated in their totality daily.Planning is an allowance for nursing supervision (8) , as it enables nurses to direct what should be done, who should be done, when it should be done and for what purpose, in addition to assigning the person responsible for each activity and stage.
Helping the other team member to improve is part of the nurse´s supervision, since this is aimed at improving the service provided and, consequently, the patients´ well-being, since it allows the nurse to perceive the difficulties of the team and to solve it, in a timely manner and reaching the goal (4) .Encouragement, help, and guidance must be present in the supervision process, leading the team to reflect on its performance, regarding care and aiming at the efficiency of care provided (19) .
Supervision was also understood as guiding and facilitating in the work environment, appropriating the functions of management and administrative functions to improve the work capacity of individuals, as verified in another research in the Family Health Strategy (18) .The nurse is responsible for consolidating the Unified Health System in collaboration with the other social actors since it participates in the organization and production of health services (11) , which reinforces the political character in the role of mediator exercised by the nurse supervisor.
The research was carried out in a medium-sized city whose municipal health policy is influenced by national and state, a scenario of constant changes.The results obtained are showing the reality experienced by the participants during the period of data collection, which is the limitation of the qualitative method, hindering the generalization.

Conclusion
According to the perceptions of the participating nurses, some factors were cited as challenges to be overcome, as they interfered negatively in the development of nursing supervision, such as work overload, characterized by the concomitant development of nursing activities and the unit supervision function, besides the lack of professionals in the team and, sometimes, the understanding of supervision as an inspection activity, the lack of systematization in the supervision of the nursing team.
Nursing supervision has been defined as an administrative function that involves planning, organization, coordination, evaluation, follow-up and support for the health team.It is a management tool of the utmost importance because it enables the nurse to monitor, evaluate and contribute to the permanent training and performance of the nursing team professionals, with the purpose of providing adequate assistance to the patients´ health needs, being able to recover the satisfaction in the professional exercise and the commitment to the quality of the assistance to be provided by the team to the patients of the system.

Collaborations
Farah BF, Dutra HS, and Ramos ACTM contributed in the concept, design, analysis and interpretation of data, writing the manuscript.Friedrich DBC contributed in the relevant critical revision of the content and approval of the final version to be published.

Assistance
Preventive care of cervical and breast cancer, prenatal, curative childcare, medication, vaccine, nursing consultation in Mental Health; Nursing consultation for hypertensive, diabetic, women's health; home visit; Visit to the puerperium, newborn, bedridden patients.Educational Educational Groups: Pregnant women, sexual and reproductive rights, hypertensive and diabetic, elderly, mental health, adolescent, child, smoking, and walking.Managerial Administrative Scale setting, supervising the work of nursing assistants and community health agents; Performance evaluation of probationary period; Supervision of curricular internship; Requesting equipment from the primary health care unit; Action planning; staff meeting; Coordination of team meetings; Evaluation of the work of the vaccination room team; Guidance and discussion of new immunization measures; Administrative evaluation of the movement of vaccines.Social Control Participation in the Local Health Council

Figure 1 -
Figure 1 -Activities developed by the nurses of the Primary Health Care Units/Family Health Strategy Nursing supervision is performed daily, on all working days.You accompany the accomplishment of the procedures, vaccine, dressing, blood pressure gauging; all activities performed during the working day (E9).It is to "take care".It is to look.It is you... so see, follow your employee, see what he is doing, what he is doing wrong.Moreover,... and we try to change that, to sit, to be talking and to be... empowering.I think it is supervision (E6).