Regulation in health care : the role of nurses

Objetivo: compreender as atividades desenvolvidas por enfermeiros no contexto da regulação em saúde. Métodos: estudo qualitativo com técnicas de grupo focal com oito sujeitos por meio da observação participante e análise documental. Resultados: as subcategorias Trabalho do enfermeiro no setor de Regulação e Interface das atividades do enfermeiro da Regulação com os demais profissionais, revelaram a presença do enfermeiro em posições de liderança, e sua articulação com gestão e gerência. Foram identificadas competências como comunicação, liderança, tomada de decisão, planejamento, gerenciamento de pessoal e trabalho em equipe, sendo a educação permanente percebida como estratégia de melhoria dos processos e capacitação da equipe. Conclusão: os enfermeiros participantes compreendiam as atividades por eles desenvolvidas no contexto da regulação em saúde voltadas para comunicação, liderança, tomada de decisão, planejamento, gerenciamento de pessoal e trabalho em equipe, instrumentos para atuação autônoma no contexto gerencial. Descritores: Enfermagem; Enfermagem em Saúde Pública; Gestão em Saúde; Regulação e Fiscalização em Saúde; Equidade.


Introduction
Regulation in health care is a management strategy in constant interface with planning, control and evaluation actions, which seeks to guarantee equitable and comprehensive care, in accordance with the principles of the Unified Health System and the constitutional law of Brazilian citizens.The difficulty of accessing specialized health care actions in care network services causes a loss of the quality of this care, making it difficult its continuity.Deficiencies related to physical structure, management and human resources generate dissatisfaction and insecurity of professionals and users (1) .
Regulation in Health care is understood as the set of actions to organize the provision of services according to the needs of the population, in order to guarantee access with quality and solubility.It comprises, therefore, the set of actions used to intermediate the distance between the demands of users and their access to health services (1) .
The ability to monitor the health system attributed to the Regulation Centers allows this sector to be able to generate significant improvements to the health sector, being considered a privileged observatory capable of generating effective and agile actions.To the extent that it is capable of providing important information to decision-making in management, such as supply and demand matching, contracts, or permanent education actions, it has the power to facilitate meeting the demands of the health care network (2)(3) .
The Regulation Center is a link between health care elements and users.It also structures and empowers access (2) by enabling comprehensive care to the individuals, articulating actions and health services necessary for each case, in the different levels of care, so that these function as a network (4) .The Regulation of Access to Health Care aims at the management and prioritization of access and care flows within the scope of the Unified Health System, guaranteeing access based on protocols, risk classification and other prioritization criteria (5) .
The literature shows four lines that lead the actions of Regulation in Health: the State, represented by the managers; the service providers; the professionals in their daily action; and users (2) .The identification of the attributions of professionals involved in this process results in taking responsibility for carrying out the actions under their scope, which contributes to the development of an interdisciplinary work (6) .The definition of the dimensions of nurses' performance in the context of Regulation in Health Care allows their practice to be focused on the managerial and administrative actions of the regulatory process, which justifies the importance of the development of this study (7) .
The nurses' role in collective health, especially in management positions, provides greater empowerment and autonomy to the professional.In order to strengthen the independence of these professionals, it is necessary that they have an understanding of public health policies, and can thus promote the objectives of collective health (7) .
The search in literature revealed the lack of scientific studies that guide the attributions of the professionals involved in the activities of Regulation in Health Care, especially studies related to nurses' work.The development of this work aimed to fill this gap in the scientific literature, in order to qualify the work of nurses in the Regulation in Health Care.From the presented context, the question arises: what are the activities performed by nurses in the context of Regulation in Health Care?Thus, this study aimed to understand the activities developed by nurses in the context of Regulation in Health Care.

Methods
This is qualitative research with techniques of focal group, documental analysis and participant observation.The research site was the sector of Regulation in Health Care of a large municipality located in the south of Brazil, nationally recognized by the good indicators in public health.The Municipal Regulation Center is responsible for the management of the Regulation of a macro-region totaling more than one million inhabitants (8) .
As the authors did not have a professional link with the institution, they conducted a meeting with the managers to clarify the objectives and methodology of the research.The data collection took place from September to November 2013 and began with the documentary analysis that lasted approximately 30 days, based on the documents: Municipal Health Plan 2011/2014; Municipal Normative Instruction 003/2013 that regulates the process of scheduling of specialized consultations and examinations through the National Regulation System; Municipal manual of Good Practices in Health; and the Proposal for the Implementation of the Regulatory Complex of Florianopolis and its surroundings.This data collection technique aims to answer the author's questions that cannot be answered through other methods (9) .Afterwards, the research followed with the participant observation meetings.At this stage of data collection, it was possible for the authors to take the position of direct contact with the context and take the same point of view of the subjects, identifying details of the work routine that could only be revealed by this technique (9) .
The researchers attended the Municipal Health Department for three days, in full time, in order to observe the performance of the team and the functioning of the sector.The focus of observation was the work dynamics of the professionals involved in the sector of Regulation in Health Care of the studied municipality, and the whole process involved in their daily actions.The observations occurred prior to the focus group in order to provide knowledge to researchers about the local work dynamics, set them in the context to be observed and adapt the professionals/participants to their presence.The participant observation included the performance of all 15 employees: seven regulators (five physicians and two dentists), four administrative technicians, and two nurses, as well as a Regulation manager and a director of Regulation, Control, Evaluation and Audit.
The Focal Group technique is based on group interviews that seek to obtain information from the interaction between the members, generating consensus and divergences on a specific topic that can lead to the understanding of perceptions, beliefs, and attitudes about a theme, products or services (9) .
The group was led by the first author of this article, whose research served as the basis for her master's dissertation.All 15 employees of the Regulation management were invited to participate in the data collection through email, and the invitation was personally reinforced.Since some of them only worked during part of the day, six of them could not attend the meeting, and one had to remain in the sector during the activity, the focus group had eight participants.The focus group included a nurse, four regulators (two physicians and two dentists), and three managers (including the Regulatory manager, the Control and Evaluation manager and the director of the sector of Regulatory, Control, Evaluation and Audit).Participants were asked about their work, their perception about Regulation in Health Care and the relationship with equity, and were encouraged to reveal the limitations faced and suggestions for overcoming them.The meeting lasted 2 hours and was guided by the guiding question: what is the interface of the work done by you in the Regulation sector with the principle of equity?There was active participation of all involved.The speeches were recorded and transcribed integrally for later analysis.
Authors used the Thematic Analysis as data analysis technique, which follows the notion of theme, in which a word, phrase or summary about a particular subject indicates the essential meaning of the speech, and it can be divided in three stages: pre-analysis; material exploration; and treatment of results obtained and interpretation (9) .
The study allowed the construction of three main categories: Actions of Regulation in Health Care, Equity in Regulation in Health Care, and Professionals' performance.In this article, researchers analyzed the third category found, Professionals' performance.Speeches are identified throughout the text by the professional category and the order in which the participants spoke.
The study complied with the formal requirements contained in the national and international regulatory standards for research involving human beings.

Results
The category Professionals' performance emerged from the subcategories: Nurses' role in the Regulation sector and Interface of the activities of the nurse working in the Regulation sector with the other professionals.

Nurses' role in the Regulation sector
This first subcategory presents the nurse as the person in charge of monitoring the waiting queue of the National Regulation System, training of the private providers and attending the difficulties directly with the markers of the health centers with respect to the information system.According to the participants, nurses were constantly in contact with the Regulation management, dividing the managerial and coordination functions: I open agenda, I close agenda, I am responsible for removing all private providers nowadays.In addition to training private providers, we teach how to use the system, we follow up on these agendas, I also monitor the queues, monitor the Regulation, whether undue things that should be on the waiting queue are inserted.I help the manager in some things, I help a little in the audits, a little bit of everything (Nurse 1).
In the managerial context, the most present activities were the management of the information system, planning, personnel management and teamwork, in which the permanent education was perceived as an instrument of improvement in the service.Participants identified the competencies inherent to the performance in the managerial scope, such as communication, leadership and decisionmaking, as the speech suggests: It is necessary to involve the staff, insert the coordinator of the unit and make the coordinator know what is happening.It involves the entire team in the process of knowing the information system, understanding the criteria, and understanding that it is worth everybody knowing and everybody participating (Nurse 1).
Permanent education is used as a strategy by nurses and allows transmitting knowledge to professionals of the other services that constitute the health care network, mobilizing knowledge and ensuring the updating of the teams.Providing correct guiding for workers of this network avoids overloading regulation professionals, which is recognized by the managers of the sector, as demonstrated by the speech: The more qualified the primary care, the more training we do, either biweekly or weekly, we must call physicians, nurses, the more people trained, the less work we will have, the fewer e-mails we will respond.The professional will call only when it is an urgent matter (Manager 3).
According to participants, the nurse seeks to establish a partnership relationship with the coordination, participating in internal planning meetings, together with other external directors and providers.Decision-making was perceived at times of problem-identification and later attitude to address or solve the situation, in order to resume the usual activities.In the studied scenario, the presence of nurses in leadership positions was highlighted, with emphasis on Regulation in Health Care, in which nurses occupy positions such as the Regulation management, and the Board of Regulation, Control, Evaluation and Audit.
It was observed that the Regulation manager is responsible for articulating the relations with the State Department of Health, and together with the Ministry of Health regarding the difficulties faced by the municipality in the use of the information system.Also, this professional is responsible for the development of access protocols together with regulators and medical specialists.The function of the manager is to keep the Regulation sector functioning in communication with the entire network (sector not only at the central level).So, basically we have to first keep the schedule system up and running, which is already a very laborious thing, and do the coordination of the prioritization of specific cases, which is part of the Medical Regulation, the Regulation of dentistry, and physical therapy (Manager 3).
In the organization chart of the municipal health department, the Regulation Management is subordinated to the Board of Regulation, Control, Evaluation and Audit.It was observed that the functions related to the Regulation attributed to this board concern the representation of the municipal secretariat in the integration with the other municipalities, and articulation in the contractual processes with the private providers of services.This function is performed by a nurse, who shows the incentive to decision-making, autonomy, and leadership, factors that encourage other professionals to participate in the management processes: My intention is to involve everybody.I do not want the employee to be only an operator, I want them to be managers.They have to be more than regulators.I do not want me to be a director, I have to be more than a director, did you understand?We have to articulate with the planning, to see deep down there [Municipal Health Fund].So our demand is very great, because we need this requirement (Manager 1).

Interface of the activities of the nurse working in the Regulation sector with the other professionals
In this second subcategory, participants pointed out that, according to clinical protocols, chronological order, or priority criteria, the professional Regulator is responsible for verifying the clinical evidence of the requests, to give the correct referral: approving, according to the municipal offer, denying, or returning for insertion of new information on the clinical case that justify the completion of the procedure.
However, the work of these professionals is broader, interacting with the demands of the sector.In this sense, the nurse articulates with these functions, since it has a more contextualized view of the Regulation system, which leads these professionals to discuss the demands with the team: The basic function of the regulator is to classify the risks, the priorities.But when we enter the Regulation, we realize that it is impossible to fulfill only that operational function.We end up getting involved with the whole team, end up detecting or diagnosing problems when we are analyzing the referrals, and bringing them to the team, discussing, and even interacting with other boards to discuss problems (Regulator 1).
The requesting operator, a Primary Health Care professional who intermediates the Regulation Sector with the user, is responsible for inserting medium and high complexity procedure requests into the information system.This professional has the responsibility of intermediating the contact with the user, through the contact with the patient in case of cancellations and authorizations, as well as the maintenance of the updated registers.Thus, the articulated performance of this professional with the Regulation Center facilitates the performance of professionals at the central level, and qualifies the regulatory process, as indicated by the participant: And another very difficult point that we feel here in Regulation: we In order to qualify this integration, the nurse is the professional responsible for the training, from the introductory training of use of the system, to the continuous training, in order to broaden their understanding about the functioning of Regulation in Health Care, especially the manipulation of the information system.
Although the employees have well-defined and understood functions, there was evidence to the interaction between the workers, with emphasis on the important articulation promoted by the nurse in the team.This is a necessity in the analyzed context, revealed as an important factor to understand the totality of the Regulation process by the professionals involved, as the speeches show: And I see that here we have always known about everything.Everybody on the team.
The regulator physician has never been placed in a chair and only regulating.And more important than regulating, it is to understand how the whole management process works.And that, maybe it does not work directly, but they know what is an Integrated and Agreed Programming, they know that there is a withdraw from an agenda and what this will cause, they know the protocols, know the management pact, what is involves, and this is always like this.For all health professionals it was clearly spoken and discussed....Here the functions are well-defined, however, the employee works where there is need.There are definite activities, but if there is need due to a leave, everybody helps (Manager 2).In general everybody has a general understanding, how it works, what is needed.I think everybody knows how the system works, but with the daily needs you end up just turning to your final activity, basically.But when it is necessary everybody does everything (Regulator 2).
There is need of an articulated and integrated action of the nurse with the other professionals, in an interdisciplinary way, integrating knowledge and practices in order to qualify the team's performance.

Discussion
Although this study was carried out in a large municipality with central-level professionals responsible for the Regulation sector, there was as a limitation the non-inclusion of the operators and professionals who use the information system in the other points of the health network, such as the Primary Care and specialized service providers.Whereas the development of a strong national Regulatory system is therefore a critical component of a national health system (10) , the first contribution of this study is to present the Regulation in Health Care as an important tool for the operationalization of management of the Unified Health System and a space for nursing work, since it enhances through its activities the guarantee of the universal , comprehensive and equal right to health.
Nurses have been increasingly occupying in the health sector, and they have been indicated for being able to integrate care and ensure access to health in an efficient and effective way, since they act with emphasis on ethics and humanism, facilitating the achievement of autonomy and emancipation (11)(12) .
Aiming to improve the Regulation System, a normative chain model is as a possibility to guide managers in the investments aimed at consolidating guidelines based on clinical trials, reconciling the quality control of public and private services.In this way, the stakeholders of a given health region might identify and prioritize investments according to which more value is attributed to the Regulation process (13) .Especially in the Regulation Sector, the literature presents as functions to be developed by professionals responsible for coordination the guarantee of comprehensive, agile and qualified care to the users of the Unified Health System, based on the evaluation of the requests received, considering the production capacity agreed with service providers (14) .
Interestingly, Regulation in Health Care in the United Kingdom comprises two essential elements: the regulation of the quality and safety of the health service provided (15) .Although in Brazil this process has not been so well-articulated, nurses have been gaining highlight in the development of a Brazilian network focused on patient safety in healthcare institutions of different technological densities (16) , thus evidencing an important contribution of this professional to the development and consolidation of managerial practices that guarantee actions of resolute, safe and quality care.
Leadership has been identified as a competence inherent to the managerial performance of nurses, with emphasis on encouraging participation and involvement of employees in the sector's activities.The clinical leadership of nurses requires interdisciplinary communication, strengthening of personal relationships, support to the staff and support to personal engagement, which promotes the qualification of teamwork (17) .Understanding the health-disease process and its determinants allows nurses to identify regional and local health demands, considering their priorities (18) , which justifies the need for their performance in Regulation in Health Care.Also, the insertion of nurses into interdisciplinary teams and management practices of the work process generates valuation of the professional, through the recognition of their managerial competences (12,18) .
Conducting the agreement relations, observing the guidelines established in the federal, state and municipal spheres, besides defining work scales are functions developed by the Regulation Manager.According to the literature, this professional is responsible for monitoring the contractual situation of the available services, mapping the number of referrals, making available reference and counterreference flows, which provides important information for the planning of the offer.It is considered a link between the management and the service network, and must work together with the Board in contracting private providers (3,14) .In this way, the nurse manager working in this position will develop his/her duties as recommended by the literature.
The attributions of the Board of Regulation, Control, Evaluation and Audit include the functions of studying the planning, the programming, formulation and systematization of standards, defining parameters and indicators of results, as well as assessing the results of an action in a population (14) , which corroborates with the results of this research, since the nurse director works with leadership in all the functions described.
The duties of the Regulator must include the verification, analysis and evaluation of the justifications presented in each request sent by the Primary Care professional, and deciding whether or not to authorize the specialized procedure or consultation, considering the need to prioritize the cases considered most urgent, favoring an equal access (4) .Faced with this function, the nurse does not develop regulatory activities, but works in the support of the information system, knowledge of protocols and interface with management, in contrast to what happens in countries such as the United Kingdom, where there is a regulator for each health professional, including nursing (15) .As in the Brazilian reality, the regulators are responsible for protecting the patients' interests, guaranteeing the quality of the service offered.However, the focus of the Regulation is on the individual that is service provider, rather than on the organization (19) .
The description of the responsibilities and competencies of the professionals that work in the Regulation in Health Care is fundamental for the efficient and effective execution of their activities (14) .The difficulty in defining the attributions to the professionals involved in the Regulation can influence the functioning of the defined work routines.This situation may also lead to unequal accountability among employees, unnecessarily demanding more from some workers.Thus, the development of a model of work in the Regulation Center with expanded and defined attributions has the potential to qualify the organization of supply in relation to demand, in order to facilitate the work of managers and qualify health care (2) .

Conclusion
Participating nurses understand the activities they develop in the context of regulation in health care aimed at communication, leadership, decisionmaking, planning, personnel management and teamwork, which are instruments for autonomous work in the management context.
It was evidenced the benefits of work-sharing among professionals in special cases, in order to facilitate the understanding of the entire process by each worker involved.Also, permanent education was used as a strategy to improve processes and staff training.At the same time, it was highlighted the relevance of defining the responsibilities and competencies of professionals working in Regulation in Health Care to facilitate the workflow of the regulatory process.
regulate and we prioritize according to what is described there, as the [Primary Care] professional describes to us.We are not seeing the patient.We do not see, we just read what is in the system.So one of the very difficult points of the Regulation sector still ... is to make them [the requesting operators] understand that we are a reflection of what is described there, and that Regulation begins in primary care (Regulator 1).