Abstract

This study was multicenter with a qualitative approach, which sought to identify the elements that can increase or reduce the workloads of the Family Health nurse. Forty nurses were interviewed, from 36 teams from five regions of Brazil, considered successful according to the requirements of the National Policy of Primary Care and with good evaluation in the National Program for Improvement in Primary Care Access and Quality. Data collection was performed by instrument triangulation, using a semi-structured interview, observation and documentary study, from 2013 to September 2016. The findings were analyzed based on the Thematic Content Analysis and categorized with the help of Atlas.ti software. It was identified that the elements that most influence the increase of the workloads are the precariousness and deficits in the work environment, materials and equipment, added to the numerical deficit of the workforce and the excess of health care demand. However, teamwork, recognition for the performed work, bonding with users and good interpersonal relationships, all contribute to reduce the workloads. We highlight the dialectic present in the elements of the work process. They can increase or decrease workloads influenced by objective conditions, the moment and way they are handled.

Key words
Nurses; Work conditions; Work; Primary Health Care; Family Health Strategy

Introduction

Health is a priority in people's lives and is part of the international agenda for sustainable development formulated by the United Nations¹1 Buss PM, Fonseca LE, Galvão LAC, Fortune K, Cook C. Health in all policies in the partnership for sustainable development. Rev Panam Salud Publica 2016; 40(3):186-191., but its guarantee as a universal right is a major challenge²2 Giovanella L, Mendoza-Ruiz A, Pilar ACA, Rosa MC, Martins GB, Santos IS, Silva DB, Vieira JML, Castro VCG, Silva PO, Machado CV. Sistema universal de saúde e cobertura universal: desvendando pressupostos e estratégias. Cien Saude Colet 2018; 23(6):1763-1776..

In this scenario, the debate on health systems becomes relevant, especially regarding the access and improvement of quality of care, with emphasis on public funding³3 Viacava F, Oliveira RAD, Carvalho CC, Laguardia J, Bellido JG. SUS: oferta, acesso e utilização de serviços de saúde nos últimos 30 anos. Cien Saude Colet 2018; 23(6):1751-1762. and the role played by the workforce in the effectiveness of the health care provided to the population. The World Health Organization (WHO) recognizes that “there is no health without the workforce”⁴4 World Health Organization (WHO). Global Health Workforce Alliance [página na Internet]. 2013 [acessado 2019 Fev 18]. Disponível em: http://www.who.int/workforcealliance/en/
http://www.who.int/workforcealliance/en/... .

With regard to who performs the health work, there is a recognition of the role played by nursing, both due to the number of workers, as well as by their presence in almost all health institutions and the responsibilities assumed at the institutional level, including care, management and administrative actions and education, with a strong impact on the quality of the provided services⁴4 World Health Organization (WHO). Global Health Workforce Alliance [página na Internet]. 2013 [acessado 2019 Fev 18]. Disponível em: http://www.who.int/workforcealliance/en/
http://www.who.int/workforcealliance/en/... ^,55 Pires DEP. A enfermagem enquanto disciplina, profissão e trabalho. Rev Bras Enferm 2009; 62(5):739-744..

Currently the profession includes 19.3 million nurses worldwide⁶6 Mendes IAC, Ventura CAA. Nursing Protagonism in the UN Goals for the people's health. Rev Lat Am Enfermagem [periódico na Internet]. 2017 [acessado 2019 Fev 21]; 25:e2864. Disponível em: http://www.scielo.br/pdf/rlae/v25/pt_0104-1169-rlae-25-02864.pdf
http://www.scielo.br/pdf/rlae/v25/pt_010... . In Brazil, nursing represents half of the health workforce and has more than 2 million professionals, 24% of which are nurses, 56% technicians and 20% nursing aides ⁷7 Machado MH, Aguiar Filho W, Lacerda WF, Oliveira E, Lemos W, Wermelinger M, Vieira M, Santos MR, Souza Junior PB, Justino E, Barbosa C. Características gerais da enfermagem: o perfil sócio demográfico. Enferm Foco 2016; 7(n. esp.):9-14.^,88 Conselho Federal de Enfermagem (COFEN). Enfermagem em números [página na Internet]. 2019 [acessado 2019 Fev 21]. Disponível em: http://www.cofen.gov.br/enfermagem-em-numeros
http://www.cofen.gov.br/enfermagem-em-nu... . Regarding the health work market, nurses constitute the second most significant category working in higher-level jobs. Regarding the middle level, nursing technicians and aides represent more than 70% of the positions in the health care system⁹9 Instituto Brasileiro de Geografia e Estatística (IBGE). Estatísticas da Saúde: assistência médico-sanitária 2009 [documento na Internet]. Rio de Janeiro: IBGE; 2010. [acessado 2019 Fev 15]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv46754.pdf
https://biblioteca.ibge.gov.br/visualiza... .

Since the Alma-Ata International Conference of 1978, Primary Health Care (PHC) has been reaffirmed as a promising strategy to face the serious health problems that affect the planet's population. In Brazil, PHC was created as a government policy integrating the National Primary Care Policy (PNAB, Política Nacional de Atenção Básica), specially concerning the Family Health Strategy (FHS). Nursing is part of the minimum team recommended by the Ministry of Health and its presence has potential to influence the quality of care provided to the population¹⁰10 Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 set..

The FHS proposes to expand the access to health services, based on the principles of the Brazilian Unified Health System (SUS, Sistema Único de Saúde). However, even in the presence of the promising proposal and the several investments, many challenges stills remain. These are regarding the system effectiveness, the public-private association in the provision of health services, the underfunding of SUS, the magnitude of the country and the intense regional inequalities.

Just like other jobs found in today's society, nursing is influenced by the conditions and concrete working relationships established in the daily practice settings¹¹11 Marx K. O capital: crítica da economia política. Livro I. 3ª ed. Rio de Janeiro: Civilização Brasileira; 2012.^,1212 Pires DEP, Machado RR, Soratto J, Scherer MA, Gonçalves ASR, Trindade LL. Cargas de trabalho da enfermagem na saúde da família: implicações no acesso universal. Rev Lat Am Enfermagem [periódico na Internet]. 2016 [acessado 2019 Fev 15]; 24:e2682. Disponível em: 10.1590/1518-8345.0992.2682.
https://doi.org/10.1590/1518-8345.0992.2... . This scenario has implications in the workloads (WL) to which nurses are exposed daily. A study by Trindade & Pires¹³13 Trindade LL, Pires DEP. Implicações dos modelos assistenciais da atenção básica nas cargas de trabalho dos profissionais de saúde. Texto Contexto Enferm 2013; 22(1):36-42. shows that working conditions and relationships can negatively affect FHS professionals and also the care outcome.

The WL are constituted by elements found in the work process that interact with each other and with the body of the worker, which can cause burnouts or illness¹⁴14 Laurel AC, Noriega M. Processo de produção e saúde: trabalho e desgaste operário. São Paulo: Hucitec; 1989.. These elements are determined by factors that are often not clearly identified by the professionals themselves. To know the elements that contribute to the increase and reduction of workloads contributes to the strengthening of the positive aspects of work and to minimize the negative aspects.

Therefore, this study aims to identify the elements that contribute to the reduction and increase of workloads of nurses working in Brazilian PHC.

Method

This is a qualitative study, with data collection carried out through triangulation techniques (interview, observation and documentary study).

Participants were included according to the intentionality criterion: nurses in full exercise of their function and who had been working for at least one year in the FHS; nurses that were part of Family Health Teams (FHT) considered as reference (through indications of managers and the results of the evaluation of the first cycle of the National Program for Improvement in Primary Care Access and Quality – Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção básica – PMAQ-AB, published in 2013); nurses working in at least one city in each of the geographic regions of Brazil (Florianópolis-SC, South region; Rio de Janeiro-RJ, Southeast region; Natal-RN, Northeast region; Belém-PA, North region and Brasília-DF, Midwest region); and nurses who were available at the Health Unit (HU) to be interviewed at the time of data collection.

Forty nurses from 22 HU who provide care in the FHS modality participated in the study, from five Regions of Brazil: nine in the South, nine in the Southeast, seven in the Northeast, six in the North and nine in the Midwest.

Figure 1 shows the profile of the research participants according to sociodemographic characteristics.

Figure 2 shows the characterization of the participants regarding employment bond and working hours.

Data collection took place from March 2013 to September 2016. For the interviews, a semi-structured script was constructed based on Karl Marx¹¹11 Marx K. O capital: crítica da economia política. Livro I. 3ª ed. Rio de Janeiro: Civilização Brasileira; 2012. work process theories and Laurel and Noriega¹⁴14 Laurel AC, Noriega M. Processo de produção e saúde: trabalho e desgaste operário. São Paulo: Hucitec; 1989. theories on workloads. In addition to the interview script, scripts were used for the documentary and observational study, aiming a better understanding of the studied work environment.

Observations were recorded in a field diary. The analyzed documents included: worksheets and information system data, production sheets, minutes, record books, panels, and posters. At the end there were approximately 40 hours of interviews, 196 hours of observation and more than 300 assessed documents.

The data were analyzed following the principles of content analysis, considering pre-analysis, material examination and interpretation and by associating resources of the Atlas.ti software¹⁵15 Friese S, Soratto J, Pires DEP. Carrying out a computer-aided thematic content analysis with ATLAS.ti. Max-Planck-Institut zur Erforschung multireligiöser und multiethnischer Gesellschaften 2018; 2:1-30.. The text files were inserted into the software, selecting significant quotations and assigning codes. The codes with thematic convergence to the research object were aggregated in code groups and associated in analysis categories, presented in visualization networks.

The research project followed the requirements of Resolutions 466/2012 and 510/2016 of the National Health Council¹⁶16 Brasil. Resolução nº 446, de 12 de dezembro de 2012. Normas regulamentadoras de pesquisas envolvendo seres humanos. Diário Oficial da União 2013; 13 jun.^,1717 Brasil. Resolução nº 510, de 07 de abril de 2016. Normas aplicáveis a pesquisas em Ciências Humanas e Sociais. Diário Oficial da União 2016; 24 maio., and was approved by the Ethics Committee on Research with Human Beings of the Federal University of Santa Catarina (UFSC) and by the Ethics Committee on Research with Human Beings of Universidade do Estado de Santa Catarina (UDESC).

The participants agreed to be part of the data collection and signed the Free and Informed Consent Form (FICF). To guarantee the anonymity of the participants, they are coded according to the region where they worked, being named by the letter N for nurse, region where they worked (S-South; N-North, SE-Southeast; NE-Northeast and MW-Midwest) and ordinal number of the sequence of the performed interviews. In turn, to preserve the identification of the observed HUs, the acronym OBS was used, followed by the identification.

Results

The results were structured into two macro categories: elements present in the work process that contribute to the increase and reduction of workloads.

Elements present in the work process in the FHS that contribute to the increase of nurses' WL

The main elements that generate WLs for nurses working in the FHS are summarized in Figure 3.

Among all the elements present in the work process that contribute to increase the WL, the precariousness of the work environment stood out.

The lack or precariousness of materials and instruments can negatively influence care, generate rework, as well as affect the worker-user relationship.

Another important element causing the increase in WL is the excessive demand in the HU, together with the complexity of health needs and the significant number of users living in socially vulnerable situations. Moreover, acting not only within the physical space of the HU, but also in the community, in order to meet one of the FHS prerogatives, also increases the WL. This scenario is associated with the existence of territories with underestimated populations.

The nurses report the numerical staff deficit as a generator of their WL increase. This is aggravated by the lack of commitment of some professionals who fail to perform their assigned work activities due to absence, neglect or demotivation, which leads some nurses to end up doing the work of coworkers and those tasks that are “nobody's work”.

The excess of duties, including those that are not the nurse's responsibility, such as, for example, bureaucratic activities in a BHU, even though the unit has a manager hired for this function, combined with care and educational activities, have an impact on both the work and health of nurses.

In this context, professionals consider that the working hours are very high, due to the intensity of the workday, as explained by the participant:

Management failures, both at municipal and higher level of health system, are among the relevant reasons for the increase in WL. The failures are related to the lack of professionals in the teams, the work demands by managers, which are often considered unnecessary, but also the absent of decision making by managers.

The nurses reported feeling anxious while trying to perform all the necessary tasks and having difficulties in performing the requested ones and those they consider important.

Elements present in the work process in the FHS that contribute to reduce nurses' WL

The work in the FHS can be a generator of stress and illness; however, there are elements that contribute to make this work less difficult, or even more pleasant, with a positive impact on WL. The synthesis of these findings is shown in Figure 4.

The nurses mentioned, with greater emphasis, teamwork as the main responsible for reducing WL. Collaborative teamwork, with the joint commitment of all participants and action planning, contributes to the adequate function of the work in the FHS, making it more effective and enjoyable.

In this context, it is also clear that only the minimum staff prescribed by the National Policy of Primary Care (PNAB) is not sufficient to conciliate all prescribed tasks.

For all workers to be able to work in a health care team and perform their tasks adequately are necessary good interpersonal relationships and good communication.

Positive bonding with the users contributes for them to feel part of the process, facilitating the therapeutic action and responding better to treatments and guidelines.

The adequate function of care networks and the resolutivity in the actions positively influence the quality of care provided and the satisfaction of users and professionals, contributing to the reduction of WL.

When nurses feel part of the work process and “like what they do”, daily work becomes “lighter” and, apparently, simpler.

In order to nurses perform a good quality work, the support from colleagues, users and managers from all governmental levels is necessary, and these types of support are important to reduce the WL. The manager should be the one who facilitates the process and contributes to the planning and organization of work.

In addition to the elements associated with the workforce, the work object and the relationships that permeate the work process, there are elements related to the instruments. These, when present at adequate amounts and of good quality, become allies and contribute to facilitate the care and management process.

I think the structure of the unit, although we have increased the number of teams and do not have enough offices for everyone, I think we can handle it. And regarding the material, we have enough as much as possible, so we have not gone without something that we needed to work, and so it is important to have material to work with (NS7).

Discussion

Currently in Brazil, the FHS is an important labor market for nurses¹⁸18 Oliveira JSA, Pires DEP, Alvarez AM, Sena RR, Medeiros SM, Andrade SR. Tendências do mercado de trabalho de enfermeiros/as na visão de gestores. Rev Bras Enferm 2018; 71(1):148-155., and the study of the work of these professionals, especially the aspects/elements present in their work process that can positively or negatively influence their workloads, assumes significant relevance.

Regarding the sociodemographic profile of the nurses participating in this study, there was a predominance of women, young adults, with significant experience (82.5% over 5 years) and good qualification, with 82.5% having completed residency or specialization courses.

The findings are close to those of the Brazilian Nursing Profile⁷7 Machado MH, Aguiar Filho W, Lacerda WF, Oliveira E, Lemos W, Wermelinger M, Vieira M, Santos MR, Souza Junior PB, Justino E, Barbosa C. Características gerais da enfermagem: o perfil sócio demográfico. Enferm Foco 2016; 7(n. esp.):9-14., regarding female hegemony and the predominance of young individuals in the profession⁷7 Machado MH, Aguiar Filho W, Lacerda WF, Oliveira E, Lemos W, Wermelinger M, Vieira M, Santos MR, Souza Junior PB, Justino E, Barbosa C. Características gerais da enfermagem: o perfil sócio demográfico. Enferm Foco 2016; 7(n. esp.):9-14.^,88 Conselho Federal de Enfermagem (COFEN). Enfermagem em números [página na Internet]. 2019 [acessado 2019 Fev 21]. Disponível em: http://www.cofen.gov.br/enfermagem-em-numeros
http://www.cofen.gov.br/enfermagem-em-nu... . Similarly, regarding qualification, previous studies conducted in the Midwest, North and Southeast regions of Brazil obtained the percentages of 53.1%, 80% and 93.8%, respectively, of nurses working in the FHS with postgraduate studies¹⁹19 Santana FR, Santana FR, Anjos GV, Campos TV, Lima PCT, Lopes MM, Lima RP, Oliveira NS, Weirich CF, Fortuna CM. Ações de saúde na estratégia saúde da família no município goiano na perspectiva da integralidade. Rev Eletr Enf 2013; 15:422-429.

20 Rocha ACD, Sousa CPC, Queiroz D, Pedraza DF. Atenção básica à saúde: avaliação de estrutura e processo. Rev Adm Saude 2012; 14(54):71-79.^-2121 Lima EFA, Primo CC, Leite FMC, Souza MHN, Maciel EEN. Perfil socioprofissional de trabalhadores de equipes saúde da família. Rev Enferm UERJ [periódico na Internet]. 2016 [acessado 2019 Fev 02]; 24(1):e9405. Disponível em: https://doi.org/10.12957/reuerj.2016.9405
https://doi.org/10.12957/reuerj.2016.940... .

FHS teams that have nurses with more experience and higher level of schooling have more satisfactory results in relation to the requirements of the care model, such as accessibility, longitudinality, coordination capacity and comprehensive care to families and communities²¹21 Lima EFA, Primo CC, Leite FMC, Souza MHN, Maciel EEN. Perfil socioprofissional de trabalhadores de equipes saúde da família. Rev Enferm UERJ [periódico na Internet]. 2016 [acessado 2019 Fev 02]; 24(1):e9405. Disponível em: https://doi.org/10.12957/reuerj.2016.9405
https://doi.org/10.12957/reuerj.2016.940... ^,2222 Silva LMS, Fernandes MC, Mendes EP, Evangelista NC, Torres RAM. Trabalho interdisciplinar na Estratégia Saúde da Família: enfoque nas ações de cuidado e gerência. Rev Enferm UERJ 2012; 20(2):784-788.. Based on what is prescribed in the PNAB¹⁰10 Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 set., the professional nurse is required to perform comprehensive care, which includes health promotion and protection, disease prevention, treatment, rehabilitation and health maintenance of individuals and families. Better training contributes to achieving the desired efficiency and effectiveness in attaining comprehensive care.

Among the elements that increase the workloads in the FHS, the precariousness of the work environment stands out, related to deficiencies in the physical structure and lack of materials, that means deficits and deficiencies in the work instruments. The literature also shows that the lack of equipment and inputs is present in most HU in Brazil, restricting the scope and resolutivity of actions and limiting the capacity to meet the population's health problems²³23 Bousquat A, Giovanella L, Fausto MCR, Fusaro ER, Mendonça MHM, Gagno J, d'Ávila Viana AL. Tipologia da estrutura das unidades básicas de saúde brasileiras: os 5 R. Cad Saude Publica [periódico na Internet]. 2017 [acessado 2019 Fev 23]; 33(8):e00037316. Disponível em: http://dx.doi.org/10.1590/0102-311x00037316
http://dx.doi.org/10.1590/0102-311x00037... . Instruments of work, in a broader sense¹¹11 Marx K. O capital: crítica da economia política. Livro I. 3ª ed. Rio de Janeiro: Civilização Brasileira; 2012., include what is placed between the worker and what will be transformed by them, and also the environment where the work takes place. Deficits and precariousness of these instruments make difficult to perform one's work and generate increased loads. This is a problem of which resolution is beyond the scope of professional governance, and when the performance is limited, it brings feelings of sadness and powerlessness, generating discouragement and dissatisfaction, as disclosed by the nurses in this study.

The excess of demand associated with quantitative labor force deficits have emerged as key elements in increasing workloads. These two aspects result in: the accumulation of functions that nurses perform in addition to care, often being a reference for the operation of the HU; the overestimated territory and the workforce deficit, related to having to take on the work of coworkers; the complexity of the population's health demands and the difficulties in meeting users' expectations. All of them are included in the macro concept of work conditions, highlighting that the “how” to perform a certain activity is fundamental in the analysis of any work process¹¹11 Marx K. O capital: crítica da economia política. Livro I. 3ª ed. Rio de Janeiro: Civilização Brasileira; 2012..

The nurse assumes the coordination of the nursing work and, often, the coordination of the HU. Thus, they expand their performance by adding attributions beyond their professional core. Despite the relevance of HU management to health care²⁴24 Melo RC, Machado ME. Coordenação de unidades de saúde da família por enfermeiros: desafios e potencialidades. Rev Gauch Enferm 2013; 34(4):61-67., the duplication of activities generates increased workloads. The excessive number of activities performed by nurses can trigger a series of processes involving frustration and stress, and stressed workers are more susceptible to work-related accidents and occupational diseases related to psychological disorders, such as depression, anxiety and altered sleep patterns, which result in reduced productivity and high absenteeism rates²⁵25 Rosario CAR, Lopes AM, Pereira FFA, Costa FM. Avaliação do estresse entre enfermeiros que atuam na Estratégia Saúde da Família de Montes Claros, MG. Renome 2015; 4(1):3-14.. Excessive demands constitute a stressor factor that makes workers more demotivated²⁵25 Rosario CAR, Lopes AM, Pereira FFA, Costa FM. Avaliação do estresse entre enfermeiros que atuam na Estratégia Saúde da Família de Montes Claros, MG. Renome 2015; 4(1):3-14.. In addition to this picture, there are possible consequences for the quality of care provided to users, including patient safety²⁶26 Magalhães AMM, Dall'Agnol CM, Marck PB. Carga de trabalho da equipe de enfermagem e segurança do paciente - estudo com método misto na abordagem ecológica restaurativa. Rev Lat Am Enfermagem 2013; 21(n. esp.):146-154..

Management problems also generated increased workloads. These problems interfere in the resolutivity of care, in the organization modes and work management and in aspects of working conditions, such as excessive working hours. The PNAB¹⁰10 Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 set. establishes a mandatory 40-hours work week for nurses and other members of the FHT, which corresponded to what was found in the survey: a significant majority of the nurses participating in the study work 40 hours per week or more.

In the recent health care scenario in Brazil, there are other “shadows”, with possible consequences on the market and working conditions of nurses and other workers and a negative impact on PHC/FHS. Noteworthy is the Constitutional Amendment N. 95, approved in 2016²⁷27 Brasil. Emenda Constitucional nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União 2016; 15 dez., which froze public spending for 20 years, greatly affecting the historically underfunded SUS. The consequence of this normative may be cutbacks in employment contracts, and professionals will have to treat a growing population with the same resources. In this scenario, the demands for increased productivity grow, leading to the imposition of rhythms and ruptures that deviate from the time of human life, requiring adaptability and flexibility²⁸28 Gaulejac V. Gestão como doença social. São Paulo: Ideias & Letras; 2007.. The context of scarcity of resources can lead to the intensification of demands by managers, contributing to the increase in the WL.

Another “shadow” against the effectiveness of PHC lies in the constant changes in the PNAB as the change approved in 2017¹⁰10 Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2017; 22 set., which alter fundamental aspects in PHC attributes, such as the longitudinality of care.

On the other hand, elements in the nurses' work process that reduce workloads were identified, with teamwork being one of the most significant. The cooperation, collaboration and division of responsibilities in teamwork contribute considerably to the improvement of the work process and stimulate professionals to face their difficulties based on the specificities of each one, while respecting the different ways of dealing with challenges. This finding refers to the recognition that the organization and relationship modes have an impact on the workforce¹¹11 Marx K. O capital: crítica da economia política. Livro I. 3ª ed. Rio de Janeiro: Civilização Brasileira; 2012., especially on the workers' health¹⁴14 Laurel AC, Noriega M. Processo de produção e saúde: trabalho e desgaste operário. São Paulo: Hucitec; 1989..

In the teamwork, the obtained results are greater than the sum of individual results, increasing the effectiveness and efficiency of care provided to the population²⁹29 Pereira RCA, Rivera FJU, Artmann E. The multidisciplinar work in the family health strategy: a study on ways of teams. Interface (Botucatu) 2013; 17(45):327-340.. Teamwork does not always mean working in a harmonious way; the differential lies in transforming conflicts into growth, knowing how to work with differences of ideas or behaviors and, therefore, acting professionally in the presence of conflicts³⁰30 Fernandes HN, Thofehrn MB, Porto AR, Amestoy SC, Jacondino MB, Soares MR. Relacionamento interpessoal no trabalho da equipe multiprofissional de uma unidade de saúde da família. Rev Pesqui Cuid Fundam 2015; 7(1):1915-1926.. Thus, a good relationship emerged as a workload reducer and a mediator of the participants' work difficulties.

The NASF proposal strengthens teamwork, as it also involves co-responsibility and integrated care management with the Family Health Team (FHT) professionals. Care and therapeutic projects are shared and contribute to improve the actions' resolutivity. This matrix support was also mentioned as a positive aspect in another study³¹31 Santana JS, Azevedo TL, Reichert APS, Medeiros AL, Soares MJGO. Núcleo de Apoio à Saúde da Família: atuação da equipe junto à Estratégia Saúde da Família. Rev Pesqui Cuid Fundam 2015; 7(2):2362-2371., considering it as a support for teams to solve problems, assisting users and minimizing the demand for specialized care.

Work affinity and bonding contribute to reducing workloads. Affinity makes it possible to look at the work and see oneself as an integral and important part of result achievement, which contributes to the reduction of WL. The importance of bonding in Family Health has been recorded in recent literature³²32 Santos ROM, Romano VF, Engstrom EM. Vínculo longitudinal na Saúde da Família: construção fundamentada no modelo de atenção, práticas interpessoais e organização dos serviços. Physis [periódico na Internet]. 2018 [acessado 2019 Fev 25]; 28(2):e280206. Disponível em: http://dx.doi.org/10.1590/s0103-73312018280206
http://dx.doi.org/10.1590/s0103-73312018... . This enables nurses to become a reference in user assistance, creating bonds of complicity between the professional and the user, and it has been considered as a facilitator of FHS practices, contributing to the production of more effective care³³33 Souza MG, Mandu ENT, Elias AN. Percepções de enfermeiros sobre seu trabalho na Estratégia Saúde da Família. Texto Contexto Enferm 2013; 22(3):772-779..

Good working conditions, including the adequate function of the care network, the resolutivity of care and managerial support, have also been mentioned as significant for the reduction of nurses' WL. Working conditions, organization and relations, as mentioned in the theory of work process¹¹11 Marx K. O capital: crítica da economia política. Livro I. 3ª ed. Rio de Janeiro: Civilização Brasileira; 2012. and of workloads¹⁴14 Laurel AC, Noriega M. Processo de produção e saúde: trabalho e desgaste operário. São Paulo: Hucitec; 1989., dialectically, generate an increase in WL when deficient and a reduction when satisfactory.

Besides being facilitators of the work, the adequate function of the care networks and provide resolutive care positively influence the bonding with the users. To rely with other health care services and know that they will perform their role effectively and safely, contributes to the consolidation of trust between professionals and users and ensures the quality and continuity of care.

In summary, the findings of this study are similar to those found by other researchers on this subject¹²12 Pires DEP, Machado RR, Soratto J, Scherer MA, Gonçalves ASR, Trindade LL. Cargas de trabalho da enfermagem na saúde da família: implicações no acesso universal. Rev Lat Am Enfermagem [periódico na Internet]. 2016 [acessado 2019 Fev 15]; 24:e2682. Disponível em: 10.1590/1518-8345.0992.2682.
https://doi.org/10.1590/1518-8345.0992.2... ^,1313 Trindade LL, Pires DEP. Implicações dos modelos assistenciais da atenção básica nas cargas de trabalho dos profissionais de saúde. Texto Contexto Enferm 2013; 22(1):36-42., when studying the group of professionals working in PHC/FHS. These studies describe that the main elements that generate WL increase in the FHS multidisciplinary teams are associated with working conditions, such as: work overload; excess demand; deficits in physical structure; insufficient workforce availability; insufficient wages and excessive working hours. All of these elements have a strong relationship with service management. The authors¹²12 Pires DEP, Machado RR, Soratto J, Scherer MA, Gonçalves ASR, Trindade LL. Cargas de trabalho da enfermagem na saúde da família: implicações no acesso universal. Rev Lat Am Enfermagem [periódico na Internet]. 2016 [acessado 2019 Fev 15]; 24:e2682. Disponível em: 10.1590/1518-8345.0992.2682.
https://doi.org/10.1590/1518-8345.0992.2... ^,1313 Trindade LL, Pires DEP. Implicações dos modelos assistenciais da atenção básica nas cargas de trabalho dos profissionais de saúde. Texto Contexto Enferm 2013; 22(1):36-42. also report that teamwork, bonding with users and affinity with the work performed, are factors that reduce the loads, constituting protective aspects for the work.

Final considerations

The study identified the elements of the work process of FHS nurses that contribute to decrease and increase workloads. Regarding the work process, the elements related to working conditions and relationships, work management and the work object of PHC nurses (service users) stands out. The study identified problems in working conditions in the FHS in the five Brazilian regions, interfering with the nurses' professional practice.

The workloads are intensified by the still existing deficits in physical structure and human and material resources, by the high work demand and the problems related to the management of units and municipalities. The increase in WL can lead to the professionals' dissatisfaction, burnout and even illness.

If there are shadows, there are also lights, and in this sense, nurses take shelter in the light of teamwork, in enjoying what they do, getting support from the NASF teams, and living good relationships with users and co-workers. Thus, they are motivated to perform their daily functions, aiming at attaining continuity and quality of care.

This study emphasizes the dialectic present in the elements of the work process that can increase or decrease workloads. The positive or negative influence of this relationship depends on concrete, objective conditions, but also on the moment and the way these elements manifest themselves and how they are managed by nurses.

The study results provide insights to understand how workloads are currently expressed in this important nursing work market in Brazil. However, it is noteworthy that the research involved only Family Health teams considered as reference for local managers and that, in the majority, had a good evaluation in the PMAQ-AB. Therefore, further investigations in different scenarios should be carried out, contributing to the increase in knowledge about the workloads present in PHC, as well as providing subsidies to public policy makers, aiming to rethink the work process in this context, to the benefit of SUS guidelines and principles and universal access.

Acknowledgments

To the support and funding received from Conselho Nacional de Desenvolvimento Científico e Tecnológico – CNPq (National Council for Scientific and Technological Development).

References

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