Introduction

The choice to investigate the territory from the perspective of nurses working in Primary Health Care (PHC) invariably calls for the identification of practices in the field of public health. This is because these professionals are daily confronted with individual health needs, called upon to think about collective care strategies, perform technical analyses of the areas under their responsibility, and face ethical, human, and existential dilemmas in the territories where they work.

The watchword territory carries meanings that transcend the geographical boundaries of a given place and can be expanded to understandings about people. In this sense, the process of territorialization not only allows for an understanding of the ways of life of social groups but also the perception of their health needs, being also considered a management technique that aims to propose interventions based on real experiences lived by nurses in the care territories.¹

Due to its important social character, territorialization strengthens the insertion of nurses in community spaces, in such a way as to enable epidemiological readings of people's contexts and to build health actions with them in the territories where they live. Therefore, the importance of discussing territory and territorialization in the context of PHC as a place of valuing life and as a tool for organizing care practices is observed.²

In light of these contextualizations, the territory emerges as a fundamental element for health, as it contains specific dynamics of living, epidemiological and demographic profiles, and political movements. Territory signifies nature and society; economy and culture; idea and matter; identities and representations; appropriation, domination, and control; discontinuities; connections and networks; domination and subordination; environmental degradation and protection; land, spatial forms, power relations, diversity, and unity.³

Guided by these concepts that establish existing relationships between territory and territorialization, it is important to highlight the regional characteristics and the value of these (trans)cultural phenomena circulating in the city of Boa Vista, capital of the State of Roraima, located in the far North of Brazil. This particular region shares national borders with the States of Amazonas and Pará, and international borders with the Cooperative Republic of Guyana and the Bolivarian Republic of Venezuela.⁴

Here, it is pertinent to underline the social and cultural aspects contained in the territory that subjectively impact the caregiving actions produced by nurses working in PHC. In this sense, it is necessary to consider the historical memories related to a new state, established by various mixed-race individuals, of which eighty percent of the people who have been there since its creation migrated from the regions of South, Southeast, North, and Northeast Brazil, reaffirming the presence of nurses trained in various parts of Brazil. Additionally, it highlights the current and ongoing migration process from neighboring countries, which is shaping new existential territories and a new geography of health in the region.⁵

These debates highlight the political dimensions that position Brazilian nurses, especially in the region of Roraima, as powerful protagonists in the territories assigned to Basic Health Units (BHU). Among their specific valuable tasks are the development of interprofessional and collaborative care plans with the health team, focused on the singularities of the people present in the territory; carrying out welcoming with qualified listening, continuity of health actions guided by routines, protocols, and care flows related to their area of competence in the BHU.^6,7

Alternatively, the nurse's role in the territory also involves active search practices, home visits, coordination of multiprofessional teams and community health agents, recording of actions and activities linked to health education and promotion, disease prevention and control, protection, and recovery, as well as creating strategies for family and social approach.⁸⁾ This is because when encountering individuals, families, and communities, the BHU nurse acts as an administrator, producer of preventive, promotional, care practices, and social controller, contributing to the smooth functioning of health dynamics in the territory.⁹

To these important thematic contextualizations, the inclusion of the idea of the territory assigned to BHU as a place for the implementation of caring practices guided by an epidemiological dimension is pertinent. At this point, the Annual Epidemiological Surveillance Report published in 2023 by the General Coordination of Health Surveillance of the State of Roraima, indicates that the capital Boa Vista had the highest HIV detection rate in pregnant women equivalent to 11.97 (per 1000/live births) in 2021 and 14.89 (per 1000/live births) in 2022. Regarding syphilis in pregnant women, 448 cases were reported in 2021 and 466 cases in 2022, representing a 4% increase in the number of notifications from one year to another. Cases of Sexually Transmitted Infections (STIs) totaled 2,255 in 2021 and 2,193 in 2022. The most significant conditions were cervical discharge syndrome in women, Candidiasis, and inflammatory conditions of the vagina and vulva.¹⁰

Based on the sociocultural and epidemiological implications that influence caring practices in the territory, the need for nurses capable of integrating multiple roles in the scope of PHC is acknowledged here. Among them, management, assistance, social control, and health education stand out as fundamental pillars of the production of effective health care in the territory. Given the issues raised, the following guiding question emerges in this study: What are the caring practices produced in the territory by primary care nurses? In line with this question, the following objective is presented: to identify the caring practices produced by primary care nurses in the territory.

Method

This is an exploratory-descriptive study with a qualitative approach. From a paradigmatic perspective, this methodological approach can be defined as a systematic and subjective approach to describing or understanding life experiences and giving them meaning. It is used for various purposes: to gain a comprehensive understanding of a phenomenon or situation; to study the depth, richness, and complexity of phenomena; to understand human experiences, processes, or group culture and how these are experienced by the people who shape them.¹²

The study was conducted in the primary healthcare network of the municipality of Boa Vista, the capital of the state of Roraima, located in the far north of Brazil. The primary healthcare network consists of eight macro areas with a total of thirty-four BHU. Out of this total, the study selected ten units conveniently located in macro areas five and six. The total number of services was defined by data saturation provided by the selected participants for interviews.

The social group involved in this study comprised fifteen nurses working in PHC, of which eight agreed to participate in data production. The selection of participants was based on these inclusion criteria: nurses actively working at the BHU for at least six months, conducting monthly home visits in the territory of their unit as evidenced by the unit's activity report, and being part of the municipal workforce of Boa Vista. Foreign nurses, professionals on medical leave, and vacation were excluded. These criteria were justified to ensure the selection of participants knowledgeable about the regional, territorial, and micro-territorial realities in which they work, especially in planning actions according to the needs of the community cared for and aligned with the principles and guidelines of the Brazilian health system.

Data collection was conducted by an interviewer, a female nursing student accredited and trained theoretically and practically in handling semi-structured qualitative interviews. Specifically, data production occurred from December 2022 to February 2023.

Firstly, a personal invitation was extended to the research participants, and any emerging doubts about the investigation were clarified. Subsequently, the interviews were scheduled for a date suitable for the interviewee-interviewer in reserved locations within the BHU, including nursing offices, medical rooms, and meeting spaces. Once this stage was completed, the participants were informed about the study's objectives and then signed the Informed Consent Form (ICF) and the Voice Recording Authorization Form (VRAF), demonstrating their willingness to participate in the interviews.

Throughout the interviews, there were no interruptions during the data production process recorded using the "Recorder" application available on a smartphone. The audio files totaled approximately one hour and were made available in MP3 format for transcription and analysis.

The data produced were manually analyzed by a nursing PhD researcher responsible for the investigation and with expertise in the theoretical-analytical framework of Bardin. This type of analysis is divided into three chronological stages, namely: pre-analysis, data treatment, and interpretation. After going through all three chronological stages of content analysis in the transcribed interviews, illustrative statements were presented descriptively in two categories. Among the set of content analysis techniques, category analysis is widely used. It operates by breaking down the text into units, into categories according to analogical regroupings.¹³⁾ Guided by the research question and objective, two thematic categories were specifically identified, titled: "Health education practices produced by nurses in the territory" and "Vaccination as a caring practice performed by nurses in the territory."

This study was approved by the Ethics Committee under Certificate of Presentation and Ethical Appreciation number 45126221.4.0000.5302. All research complied with the norms and guidelines of the National Health Council Resolutions No. 466/2012 and No. 510/2016. Finally, anonymity in the illustrative testimonies of the nurses was maintained through the use of initials corresponding to the professional group they belong to (N), followed by a sequentially increasing ordinal number according to the conduct of the interviews.

Results

The caring practices produced by nurses in the PHC were organized into two analytical thematic categories that focus on the nurse's role in health education and vaccination in the territory. Regarding the first emerging thematic category, specifically focused on health education, units of records were identified that address the understanding of the territory as the catchment area of the health unit where health education actions are implemented. These actions are guided by group discussions, meetings with priority groups, lectures, and educational campaigns on STIs, mental health, and subtance use. All of this can be evidenced in the illustrative testimonies presented in the following first category:

Discussion

The discussions of the findings pointed to practical dialogues regarding the nurse's role in the territory, understood as a delimited area where caring actions are carried out with the community under the responsibility of the BHU. There is a problematization of the emphasis on the territorialization process of care in its strictly interventional terms, supported by two central dimensions: health education and vaccination. This consideration is brought to light because the Brazilian Public Health System (Sistema Único de Saúde - SUS), by valuing social processes and the diverse ways in which the population conceives the health-disease process, establishes a kind of distancing from strictly biophysiological and interventionist dimensions to be performed in the territory.

The challenge, therefore, of identifying care practices in the territory, especially from the perspective of nurses, remains, without disagreeing, of course, that the educate-vaccinate dyad is an important strategy from the public health point of view for the people and the territories in which they reside. Specifically regarding health education, it is emphasized that nurses must be attentive to quality communication during consultations, ensuring that the user understands the necessary care and can follow it at home. For this, it is necessary to use clear and understandable language.¹⁴

From the perspective of health education implemented by nurses in the PHC setting within the territory, the identified practices and thematic contents included lectures, educational campaigns, and group discussions focusing on the control of STIs, mental health, and substance abuse. Expanding the analysis of the first category provides a detailed discussion of how the educational actions led by nurses in the territory largely reproduce an outdated representation of health education, based on traditional, technicist methods, and reduced to simply conveying information through lectures and campaigns.¹⁵

It is noteworthy that educational lectures were frequently utilized in the PHC setting. This practice provides relevant information about healthcare, requiring advance planning, script preparation, and material development, as well as in-depth exploration of the topics.¹⁶⁾ Another aspect concerns the campaigns promoted by the Ministry of Health, which are very common practices. These campaigns utilize various communication channels for health education, aiming to encourage and raise awareness about self-care among the population within the territory.¹⁷

In contrast to these findings, there is an emphasis on the nurse's educational role in the territory facilitated by group discussions, understood as an expanded approach to improving healthcare-seeking behavior, especially among women.¹⁸ This practice conceives interactive (popular) health education as having transformative potential, enabling individuals to critically and reflectively take care of their health. In this modality, the educational practices adopted by nurses are based on the construction of individual and collective knowledge, taking into account the work territory and the health situation of individuals. This encourages users to reflect, emphasizing that they also have responsibility for their health.^9,19

Group discussions are understood as integrative educational methods that allow for powerful dialogical encounters and the reframing of meaning, knowledge, and the exploration of participants' experiences. This methodology is based on the horizontalization of power relations, transforming individuals into critical and reflective historical and social actors.¹⁹

In summary, it is crucial to recognize the need to go beyond traditional health education strategies in PHC, as represented in the findings by the preference for lectures, towards educational approaches with sociopolitical adherence to the peculiarities of each territory. Although the adoption of lectures by nurses is important, it is necessary to expand the range of possibilities and explore innovative, dialogical, collaborative, integrative, and participatory methods, such as group discussions, as evidenced in two testimonials.

Health education is enriched by the incorporation of discussion groups, practical workshops, and activities of popular health education; such that these practices pave the way for debates in the field of public health about sustainable and healthy territories. Thus, the incorporation of themes into popular health education practices, as well as the increase in activities capable of strengthening health promotion in the territory, must be considered.

Another aspect identified in this investigation concerns immunization as a caring practice carried out by nurses in the territory circumscribed to the BHU. Immunization in the context of PHC is considered the main strategy for preventing diseases, promoting, and protecting the health of the population. In BHU and in the territory, routine vaccination should be performed following the guidelines of the National Immunization Program (Programa Nacional de Imunização - PNI) and the schedule established by the Ministry of Health. It is crucial that health professionals, municipal and state managers in the areas of PHC and Health Surveillance, are integrated and develop strategies appropriate to the needs of the territory.²⁰

According to a situational assessment based on data from the National Immunization Program Information System (SI-PNI), low adherence to vaccines was observed, especially those included in the childhood vaccination schedule, despite their widespread availability in BHU.^21,22,23)

In Brazil, 15 vaccines are available free of charge to be administered before the age of ten. However, many mothers have doubts, resist vaccination, are influenced by myths regarding vaccination, and lack of knowledge hinders the adherence to some vaccines. It is crucial to ensure that children are up to date with their vaccination schedule, which depends entirely on parents and guardians. Therefore, it is essential to keep them informed and aware of the importance and benefits of childhood immunization. To achieve this, the interviewed nurses provide vaccine guidance to families, analyze vaccination cards, actively search for unvaccinated or overdue individuals, and conduct periodic vaccination campaigns in the territory.

Given this situation, it was necessary to implement proven strategies in PHC services, such as active search, vaccination campaigns in schools within the territory, immunization guidance, and home vaccination, in order to increase vaccine coverage and ensure immunization for all, in accordance with the guidelines of the Ministry of Health.^21,22,23) Based on this, the role of the PHC nurse is recognized within homes and schools, where they provide guidance on the benefits of immunization and health promotion through vaccination actions.

Finally, it is crucial to highlight the role of nursing in the COVID-19 pandemic, especially emphasizing the involvement of nurses, nursing technicians, and nursing assistants in the large-scale implementation of immunization across various territories in Boa Vista, Roraima. This team has been and continues to be responsible for driving the vaccination mechanisms of PHC, contributing to establishing a strong connection between users and COVID-19 immunization in the territories.²⁵

Indeed, immunization plays an extremely important role in PHC, especially in a post-COVID-19 context. By ensuring high vaccination coverage rates and equitable access to vaccines, collective protection is strengthened, mortality is reduced, and a wide range of infectious diseases are prevented. Yes, vaccination is a powerful caring strategy that contributes to the promotion of public health and the creation of healthy territories.

Conclusion

With the certainty that there are many other inquiries about the practices carried out by primary care nurses in the territory that deserve to be investigated, here we take a brief scientific pause with two central findings: educating and vaccinating are part of the daily caregiving routine in the far north of Brazil. Health education as a caregiving practice has been decoded from actions with priority groups present in the territory, guided by group discussions, educational lectures, and educational campaigns on the following topics: STIs, mental health, and drug use. From the vaccination perspective, vaccination actions in the territory for COVID-19 have been identified, along with vaccination campaigns in schools and active search for children for vaccination.

The search for foundations to investigate caregiving in the territory led by primary care nurses alongside individuals, families, social groups, and communities; lacked in this study an expansion to existential, subjective, singular, ecological, and multidimensional dimensions that permeate the process of illness. The territory was objectively identified as a programmatic area of professional action and execution of interventionist actions, calling for emerging reflections and more open and expanded studies from a social perspective.

This study contributes to the field of Nursing by delving into the territory of Primary Care as a place for nurses to showcase their expertise. Thus, the qualitative evidence presented here intertwines health education and vaccination as fundamental practices to be considered in the territory and in the process of territorialization. Therefore, it is expected that this study will assist nurses, managers, and health advisors involved in modes and models of health care and management in improving the quality of actions carried out in the territories. Additionally, the findings on the caregiving practices performed by nurses in the territory indirectly touch on political elements of health, especially by mobilizing actions in primary services, in the basic network itself, and in guiding documents of practices that occur in the social reality of the extreme north of Brazil.

Based on these understandings, the identifications presented pave the way for emerging research on territory, territorialization, and caregiving practices led by nurses that consider theoretical, philosophical, and epistemological dimensions of social sciences. Thus, it is expected that this study will raise emerging possibilities regarding caregiving practices and the daily activities of assisting, managing, educating, and investigating the territory in Primary Care.