Redefining Primary Care through the nurse’s perspective and action

The Spanish National Health System (SNS) was created in 1986, since then society, families, citizens, the competencies of health professionals, and health model have changed. In fact, the current crisis in our National Health System (SNS) is now being highlighted, and primary care (PC), in particular.¹ The pandemic has been a watershed moment in the rethinking of provision models and their response capacity, and in particular, the organisational model of primary care (PC).

Knowing the consequences that the PC situation has for citizens and the role played by nurses in health centres, and the great potential of specialist nurses in family and community nursing, we believe it necessary in this paper to highlight their contribution as a strength of the model itself. An adequate response to current social needs and guaranteeing the sustainability of the system require the development of strategies that highlight the autonomous role and specificity of the PC nurse.²

Historically, nursing has strengthened as a discipline and profession, demonstrating its capacity to update, redefine, and adapt to different historical periods and to the needs, social movements, and currents of thought over the last centuries.³ Despite systemic obstacles,⁴ the Spanish nursing profession has been able to reconstruct itself,⁵ and act interdependently within health teams and independently with its own responsibility. This balance has marked the development of the nursing profession in primary care, which has often been limited in its potential problem-solving capacity. Although the profession has strengthened in prevention and adherence work for people with chronic conditions, it has nevertheless been hindered in innovating care services aimed at empowerment and training in self-care.

Nursing care during the 20th century essentially focussed on disease, on its prevention and on eliminating the problems it generated. At the end of that century care focussed on people, understood as bio-psycho-socio-cultural-spiritual beings, and the aim was to work with them.⁶ We should now be moving towards more global, more intersectoral care, considering the person as an indivisible whole and placing them at the centre of care where the care provided by nurses constitutes a tool that empowers decision-making. From this perspective, the patient would guide care according to their individual needs, priorities, and perceptions in their immediate environment and the nurse would accompany them in their experiences of health and of falling ill, offering personalised care and collaboration in delivering it,⁶ including substitution or compensation⁷ when necessary. Despite the current talk of organisations offering person-centred care,⁸ the PC service and the SNS in general are based on a biomedical model in which nurses are relegated to a secondary role. Their practice is not considered a service in itself, and they are not able to develop leadership for care, where they provide care from the perspective of disease and its prevention, with structural and systemic limitations to offer comprehensive and continuous care in which the promotion of healthy behaviours, health promotion, wellbeing, and accompaniment in self-care is a priority.⁹ In this system, nurses prioritise care aimed at the human dimension, relegating and often omitting a large part of care aimed at promoting autonomy, control of discomfort, wellbeing, and safety,^10,11 and thus the essence of nursing care is rendered invisible.¹²

Despite the rigidity of the system, just as there have been changes at different social levels, nursing practice has also evolved and therefore the value of what nurses can offer the system becomes a strength that should not be ignored. It may be precisely this specificity of current nursing practice that can give meaning to the change in healthcare required to meet citizens’ current demands. The following fall within the specific areas of current nursing practice¹³ (p. 35):

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  Being health facilitators.

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  Acting as managers of care actions.

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  Accompanying in self-care throughout life.

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  Training the person to take better care of themselves and replacing them in their self-care until providing comfort care at the end of life for both the person and their family.

We believe, therefore, that the survival and efficiency of PC depends on collaboration and commitment to a model of care that requires adjustments. Among others, a change of focus from disease-centred care to promote healthy behaviours, health, wellbeing, and self-care. This change should be led by family and community nurse practitioners as they have the capacity to develop strategies and solve health problems at these levels.¹⁴ The value of nursing care has been “neglected” in this respect. It should be redefined and consolidated by incorporating the roles of specialist and advanced practice nurses, including the input of generalist nurses and, where necessary, synergy-based approaches to nursing care should be reinforced.

In conclusion, interdisciplinary collaboration in primary care requires making visible the specificity that nurses bring to teams and their ability to solve citizens’ problems conclusively in their own right. There should be particular focus on the role of nurses as crucial in facing current and future challenges in the provision of health services, in the promotion of quality of care, the coordination between the health and social sector, and the efficiency of services. Care requires connection and that is why many autonomous communities have made the choice of nurse a citizen’s right; this is a basic pillar of the visibility of people’s rights, because in choosing their nurse they can trust their ability to help them.¹⁵ It is the responsibility of all, especially the leaders of our institutions and health policies, to recognise and promote the specific contribution of community nurses. Ignoring nurses’ potential, not including them in the design of future services, and continuing to consider nursing a profession without specificity is a great mistake that directly affects the sustainability of the health and social-health system.

Nurses can and must lead the change in PC through their comprehensive vision of personal care and their capacity for care management, for solving problems linked to the care needs of the population, and their proven ability to adapt and respond to social needs. This change must be worked on with citizens, making them aware of what they can find when they consult their nurse. To gain acceptance, such change also requires incorporating other ways of viewing the nurse consultation and what a home visit or community intervention means. Without acceptance there will be no change. This has nothing to do with the argument that “there are no doctors”, but with analysis and commitment to use resources appropriately and work with citizens on how their nurse can really contribute to their personal health. This approach will enable citizens to discover what community nurses can really offer them, care as an added value because it addresses both real and felt needs.

Funding

The authors declare that no funding was received for this work. Open Access Funding provided by the University of the Basque Country.

Conflict of interests

The authors declare that they have no conflict of interests to declare.