Introduction

Primary Health Care (PHC) is considered the first and main form of people access to the health system, contributing to universalization of access and strengthening health equity.(¹) The role of nurses, as team members, has had a positive impact on health care within the scope of PHC and encompasses care and clinical management actions. This impact involves a complex set of activities supported by evidence-based practices and the use of management microtechnologies.(²)

The expansion of the clinic and nurses’ care practices in PHC have been associated with better levels of patient satisfaction and continuity of care.(³,⁴) The set of specific duties of nurses within the scope of PHC in Brazil is prescribed by the Brazilian National Primary Care Policy. The duties involve, among other activities, carrying out nursing consultations and procedures, requesting complementary tests and prescribing medications according to protocols.(⁵)

Moreover, all professionals who make up health teams are expected to provide care to patients through integrated and multidisciplinary actions. Collaborative practices, characteristics of interprofessional work, expand the scope of nurses’ professional activity in PHC, being increasingly recognized as an important strategy for improving quality in these services.(⁶)

With a view to offering higher quality care, using innovative technologies in PHC emerges as an optimizer of the work process to maximize its benefits and resources in the provision of health care, in addition to ensuring peoples’ access to safe and effective technologies in an equitable manner.(⁷) For the process of developing and implementing technological innovations to happen, it is necessary to invest in strengthening the care skills of all professional categories working in PHC, emphasizing the use of multidisciplinary protocols based on the best scientific evidence available.(¹)

The Practical Approach to Care Kit (PACK) Adult was developed by the University of Cape Town, in South Africa, and presents guidelines for shared care by nurses and physicians, being structured in flowcharts, which bring together symptoms, diagnosis, management, treatment and assessment of the main diseases treated in PHC.(⁸) Studies show the PACK Adult use as a guiding instrument in the family health team’s work process in the city of Florianópolis, state of Santa Catarina (SC), with emphasis on expanding the scope of nurses’ work in caring for people living with the human immunodeficiency virus (HIV), definition of responsibilities among team professionals and guidance on shared care in the Health Care Network.(²,⁹)

In addition to being used in several countries around the world, PACK Adult is currently available free of charge for use throughout Brazil. However, the greatest experience of implementing and using this technology in the country took place in the capital of Santa Catarina. In this logic, this research aims to analyze the scientific production about the application of PACK Adult in nurses’ work process in PHC.

Methods

The review question was formulated according to the acronym PICOC (Population, Intervention, Comparison, Outcomes, and Context). We chose to use the acronym PICOC due to the interest in delimiting the outcome related to nurses’ work process, in order to select studies that portray experiences and cases of application of the tool, allowing the analysis of its reverberations in care practices. With this, the formulated research question was: How is PACK used in nurses’ work process in PHC?

The inclusion criteria were: to be used by PHC nurses; discuss PACK Adult use; indicate the means/tools used, purpose of use and result of work with PACK Adult; to be an original study, case report, opinion article and review. The exclusion criteria were: to be the PAL GARD Brasil, PAL AIRE, PALSA PLUS, PALM PLUS, Botswana Primary Health Care Guideline versions; do not detail how PACK Adult is used; and studies in the form of editorials, comments, news, conference abstracts, research protocols, theses and dissertations; and to be unavailable in full.

The literature search was carried out in the PubMed^®, Scopus, Web of Science, EMBASE, MEDLINE^® and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases on July 17, 2023. Chart 1 shows the search strategy of the different databases. The first phase established an investigation according to the characteristics and strategies of each electronic database. A time frame of 11 years (2012 to 2023) was chosen to cover the launch period of PACK Adult and its implementation in different countries. The references retrieved from the searches were organized in the Rayyan application.(¹⁰)

Study selection was blinded and independently reviewed by two authors in the Rayyan application. In the first stage, the authors read the title and abstract of retrieved studies. In the second stage, the full text was read by the authors, and discrepancies were jointly removed by them.

The researchers chose not to analyze the quality of evidence in this review because it is an emerging field of research, where a variety of high-quality studies cannot yet be seen. Therefore, the inclusion of all available studies, regardless of quality, was prioritized to provide an overview of the phenomenon.

The data were extracted from the text, figures or tables and inserted into a standardized spreadsheet, and were later validated by the authors. Information was extracted about first author, year of publication, journal/newspaper, country, study design, study objectives, the tools/technologies that are used in conjunction with PACK Adult, the purpose of working with PACK Adult, result/product of work with PACK Adult, conclusions and risks/limitations reported by the authors. A narrative synthesis of the conclusions of included studies was carried out, structured around the objectives and report of PACK Adult use in nurses’ work process.

The risk of bias assessment was carried out by two researchers, using JBI checklists for qualitative research, randomized clinical trials and opinion studies.(¹¹-¹³) There were no discrepancies between the researchers’ assessments.

This systematic review was conducted in accordance with the Preferred Reporting of Systematic Reviews and Meta-Analysis (PRISMA) statement. (¹⁴)

Results

Figure 1 shows the selection flowchart of studies included in the review based on the PRISMA statement.(¹⁴)

Chart 2 presents a brief characterization of studies included in the review.

As can be seen in Chart 2, some authors did not report the study’s methodological design.(¹⁵,¹⁸,¹⁹) In these cases, the authors analyzed study design based on its format, objective and description of results and classified them as essays/opinion articles. The BMJ Global Health stood out with the publication of four of the six articles included in the review, followed by Revista Latino-Americana de Enfermagem and the Southern African Journal of HIV Medicine, with one publication each. A study described PACK Adult use by nurses for clinical purposes to assess symptoms, prescribe medications and offer health care to the population and for training professionals, using the chapters with guidelines from PACK Adult itself. In the training experience reported, 354 health professionals were trained, of which 161 were community health extension workers, 90 were junior community health extension workers, 56 were nurses, 22 were community health officers, 19 were midwives and 6 were physicians. The study showed that the experience with using PACK Adult in training was generally positive in terms of ease of use, usefulness during consultations, better diagnostic capacity, management and referral of users. Health professionals reported using the guide in most consultations and also that PACK Adult use reduced polypharmacy prescriptions and the number of tests requested per patient.(¹⁵)A digital version of the PACK Adult guide (e-PACK) was prepared by the Cape University Knowledge Translation Unit (KTU) design team and made available for use on tablets. Participants preferred the e-PACK version, as they had a better experience using technology and greater adherence to protocols compared to the printed version.(¹⁹)Seventeen nurses were trained to use e-PACK during two day-long workshops, and a KTU-appointed trainer developed clinical case-based training at nurses’ workplace. Nurses reported that they were able to use the digital version successfully, and none felt overwhelmed or stressed at the prospect of incorporating the tool into the clinic, with it being considered a viable practical tool to be integrated into their workflows.(¹⁹)

It was also possible to demonstrate the effects of PACK Adult training in the diagnosis, investigation and treatment of asthma and chronic obstructive pulmonary disease (COPD). Interactive group sessions lasting approximately 90 minutes were held, which were repeated weekly during initial training and biweekly during maintenance training. To achieve this, nurse-physician pairs were appointed to train and support local instructors in delivering training focused on local priorities, including respiratory diseases, diabetes, hypertension, pain and tuberculosis.(¹⁶)

Training in health units took place in 12 sessions over 6 months. After a 3-month break, 14 maintenance sessions were carried out over 12 months. Training was provided to 160 physicians and nurses, whose responsibilities included asthma and COPD care. Research results indicate that educational training of physicians and nurses to use PACK Adult guide in managing respiratory illnesses was associated with increased time to initiation or change of treatment and use of spirometry for adults diagnosed with asthma.(¹⁶)

Another study portrays professional nurses’ and physicians’ training process to use PACK Adult in Florianópolis. Regular 1-2 hour sessions were held, employing interactive small group learning techniques guided by facilitators. In 22 months since the beginning of PACK Adult implementation, 26 training sessions were held for 160 health professionals in 24 health units in Florianópolis between August 2016 and June 2018. The results of the study indicate that local professional legislation, working conditions, support in guideline implementation and local health system organization had a significant impact on the implementation and results of using PACK Adult.(¹⁸)

PACK Adult was also used to train nurses to prescribe antiretroviral agents. All participants were trained with the instrument, completed an HIV management course, and participated in nurse-led antiretroviral therapy training. After training, the mean confidence score in HIV management was 68.7%, with a minimum score of 45% and a maximum of 85%. Participants reported the greatest confidence in using antiretroviral agents (with 51.9% considering themselves experts) and performing a physical exam (with 50.6% considering themselves experts). The mean knowledge score on HIV management was 72.7%, with a minimum score of 38% and a maximum of 100%. Participants had high knowledge scores on treatment of peripheral neuropathy and the side effects of tenofovir as well as high knowledge scores on identifying pneumocystis pneumonia and contraindications to antiretroviral therapy.(¹⁷)

Supporting the South African experience in HIV infection management, a study showed the use of clinical guidelines to guide nursing care for people living with HIV in PHC in Florianópolis. By using PACK Adult, an expansion of nurses’ clinic in this scenario can be seen, which uses technology as a subsidy to guide clinical conduct for diagnosis; assessment of symptoms and health condition of users; counseling; treatment adherence assessment; monitoring of adverse effects, aspects related to mental and sexual health and family planning; exam prescription; medications and immunobiological agents. The authors also highlight the use of technology as a guide for exchanging knowledge and sharing information among PHC team professionals.(⁹)

After applying the risk of bias analysis checklists, it was found that, in qualitative studies, the description of aspects related to researchers’ credentials and their relationship/influence with the research development context was not evident.(⁹,¹⁷) The clinical trial consists of a pragmatic, parallel-group, superiority cluster randomized trial, which is a specific type of clinical trial designed to assess the effectiveness or superiority of medical or health interventions in groups of users, communities, or institutions rather than individuals isolated. Comparing these differences with JBI randomized clinical trials checklist, weaknesses were identified in methodological description, and it was not described whether the blinding technique was performed on health professionals during the intervention application.(¹⁶) Opinion studies did not present a risk of bias after applying the checklist.(¹⁵,¹⁸,¹⁹)

Discussion

The results of the review highlight PACK Adult as a relevant technology to be implemented in different PHC contexts, as its structure is aimed at providing safe, quality and lower-cost care. For nurses, its use helps in clinical decisions and care practices, based on the best evidence. Finally, with implications for patients’ health condition, PACK Adult has the potential to expand access to primary care and guide the appropriate management of respiratory, infectious and chronic diseases.

The experiences of using PACK Adult for training nurses in PHC were successful in different implementation scenarios, which may be related to some aspects. One of them is the process of translating and adapting the material to the realities and guidelines of each country, carried out in a systematic manner, involving different actors. In Nigeria, the instrument was developed through a remote mentoring process by a multidisciplinary team and PACK Adult developers in South Africa. The extensive and ongoing engagement of these groups played a crucial role in ensuring that, despite some gaps in drug availability and testing, the program enjoyed high levels of acceptance and was successfully implemented.(¹⁵)

Another aspect that contributed to PACK Adult implementation was its training model, which focuses on everyday clinical situations in the team’s work, taking place with predetermined frequency and is structured around the formation of different levels of mentoring to disseminate knowledge among health professionals. The training model carried out in South Africa is innovative and moves away from the traditional training model applied in the health sector, which normally occurs far from its context of applicability, and, therefore, is poorly integrated into the care environment.(¹⁹)

The Florianópolis experience also emphasizes the decentralized mentoring model adopted in the tool implementation process. The results of PACK Adult training in Florianópolis, Brazil, support the expansion of nurses’ roles and the strengthening of cooperation between nurses and physicians in care for users affected by asthma and COPD, leading to improvements in treatment within a period of 1 year after completion of training to manage these diseases.(¹⁶,¹⁸)

PACK Adult use in its digital version, e-PACK, proved to be a very accessible and easy tool to be incorporated into nurses’ care workflow, which can improve quality of care and clinical examination in health systems with few resources as well as simplify the process by which new evidence is available to healthcare professionals. The incorporation of cost-effective technologies has been encouraged within the scope of PHC, aiming both at universal health coverage and sustainability of health systems.(¹⁹-²¹)

With positive impacts also on nurses’ clinical practice in primary care, PACK Adult incorporation and use influenced these professionals’ knowledge and confidence in prescribing antiretroviral agents.(¹⁷) The South African experience of prescribing and clinical management of HIV by nurses may have contributed to access to treatment and care for thousands of people living with HIV. A similar result can be observed in the Brazilian experience, which is reflected in the expansion of the clinic and care practices of this professional, which strengthened the collaborative work between physicians and nurses in HIV infection management in Florianópolis, Brazil.(⁹) In this way, it can be understood that the expansion of nurses’ role in PHC tends to contribute to the expansion of access, the provision of more equitable care and the strengthening of decentralized model of care.

The results of this systematic review can contribute to public health management by presenting evidence of PACK Adult use by nurses in PHC, encouraging its implementation in other settings. Furthermore, this research contributes to knowledge construction, especially in the field of health technologies and advanced nursing practices, by portraying cases of use of the tool and its implications for the care provided by nurses. It is suggested that future research be carried out to assess the impact of using this technology on nurses’ clinical performance, seeking to measure the results of its use in the health care provided to patients.

A potential limitation of our systematic review is the relatively small number of included studies, which may have reduced our ability to identify the full nuances and complexities of the topic under review. Another limitation is related to the heterogeneity of the studies, which varied mainly in methodological design, which may have implied the analysis of results and the achievement of general conclusions. A predominance of studies with positive results from PACK Adult use was also identified, which could lead to an overestimation of the real effects of the application of this technology in health professionals’ work practice, which were reported in the study results.

Conclusion

PACK Adult use in nurses’ work process was evident as a support tool for care activities, especially in HIV infection clinical management and respiratory diseases as well as a guiding tool for training carried out with the PHC team. With the use of technology, nurses had their clinical practice expanded and began to act more actively in care management, which characterizes PACK Adult as a technology for instrumentation and support for nurses’ clinical decision-making in PHC.

Acknowledgements

The Brazilian National Council for Scientific and Technological Development (CNPq - Conselho Nacional de Desenvolvimento Científico e Tecnológico) for the research productivity grant for DEPP. The Coordination for the Improvement of Higher Education Personnel (CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) for the doctoral scholarship granted for ICC and MM. The support of the UFSC Graduate Program in Nursing - Financing Code 001.

References

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