Work-related psychosocial risks of the Family Health nurse and management strategies

www.scielo.br/reeusp Rev Esc Enferm USP · 2020;54:e03602 Lázaro Clarindo Celestino1 Laura Andrian Leal2 Olivia Cristina Alves Lopes1 Silvia Helena Henriques3 1 Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Programa de Pós-Graduação Mestrado Profissional em Tecnologia e Inovação em Enfermagem, Ribeirão Preto, SP, Brazil. 2 Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Programa Interunidades de Doutoramento em Enfermagem, Ribeirão Preto, SP, Brazil. 3 Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Departamento de Enfermagem Geral e Especializada, Ribeirão Preto, SP, Brazil. ABSTRACT Objective: To analyze the work-related psychosocial risks of Family Health nurses and the management strategies to minimize them. Method: Exploratory, qualitative study with nurses from teams of the Family Health Strategy (FHS). Data collection took place in July 2018 through semi-structured interviews and subsequently, an inductive thematic analysis was carried out. Results: Participation of 18 nurses. Psychosocial risks related to the work context were identified, namely: insufficient professional training, compromised interpersonal relationships, work-family interface and psychological violence; as well as those related to work content: insufficient work equipment, lack of human resources and heavy workload. In addition, strategies for managing these risks were identified, such as using the family, spirituality, music and reading. Conclusion: The study should provoke the reflection of nurses about the eventual presence of risks in their work and contribute to fill knowledge production gaps in the area. It also provides subsidies for health managers’ knowledge of the psychosocial risks to which these professionals are exposed, with a view to adopting measures.


INTRODUCTION
The restructuring process of primary care in the country through the Family Health Strategy (FHS) had significant impact on the healthcare of the population through adherence to strategies for improvement of basic care and the flow of care and provision of effective treatments more efficiently, thereby generating user satisfaction and increasing the resolution of this service (1) .
Family Health Strategy teams are composed of workers from different categories, among which professional nurses stand out as protagonists and responsible for activities developed by other team members. Several functions are assigned to nursing professionals, namely: planning and execution of actions within the scope of public health; supervision of direct care to the population; health services management; management and coordination of activities developed by Community Health Agents (CHA); coordination and performance of continuing education activities; active participation in the management of necessary inputs for the proper functioning of the FHS, among others (2) . The complexity of activities performed by nurses, added to inadequate working conditions can expose these professionals to occupational risks, including psychosocial risks.
As an example, the workday can be an inappropriate condition that affects FHS nurses. Researchers indicate that excessive working hours significantly increase the workloads of these professionals as a result of problems related to working conditions, excessive demand, inadequate physical structure and dissatisfaction with wages. Workloads are elements present in the daily work process of nurses, interact with each other and with the body of those performing the work, and in most cases, lead individuals to physical and emotional exhaustion (3) .
Psychosocial risks are those related to the work conception, organization and management (4) . They derive from the way work is organized in institutions and from the interaction of its content, considering that workers' exposure to these risks can harm them physically, mentally or socially (4) and represents a major challenge for occupational health and safety (5) .
The literature also demonstrates that among health professionals, FHS nurses are the most affected by psychological problems, because their duties are largely determined by the goals of the Ministry of Health's programs. This is a limitation to professionals in the relation to problems of the population as a whole, interferes with the spontaneous demand and makes them insecure, which generates feelings of helplessness, physical and emotional exhaustion, thereby characterizing exposure to psychosocial risks (6)(7) .
Psychosocial risks related to the work of FHS professionals have already been identified in other studies, such as overload of activities, long work shifts, lack of preparation and training, role overlap, long working hours and insufficient material resources (8)(9) . A brief search in the scientific literature of the five previous years in databases of LILACS (Latin American and Caribbean Literature in Health Sciences) and CINAHL (Cumulative Index to Nursing and Allied Health Literature) using descriptors such as "nurses", " family health" and " occupational risks", and the keyword "psychosocial risks", retrieved no study in which the research object was only the nurse professional of the Family Health.
Exposure to psychosocial risks can have negative physiological and psychological consequences for society, the institution and the health of workers. However, the crucial effects are related to organizational and individual consequences (10) .
Considering nurses' work process in different areas of activity, especially in the FHS, it is relevant to address the aspects interfering with their health, identify their weaknesses, potentialities and possibilities for improvement. The theoretical and empirical knowledge of the reality of the FHS has revealed diverse and often precarious working conditions for nurses. Such conditions, added to the demands of their activities, the complexity of the health reality, and the way their work process is organized, can expose these professionals to psychosocial risks. Thus, this study presents the following guiding questions: What are the psychosocial risks to which FHS nurses are exposed? What strategies can be used to manage the present risks?
The aim of this study is to analyze the psychosocial risks related to the work of FHS nurses and the management strategies to minimize them.

Type of sTudy
This is an exploratory qualitative study.

scenario
The study scenario consisted of 18 FHS units in a city in the inlands of the state of Minas Gerais. The 18 FHS units are distributed in strategic points in the city and cover a defined health territory with approximately 3,000 people for each team. At the time of data collection, the municipality had 18 FHS teams and all agreed to participate in the study.

selecTion criTeria
Nurses from that municipality, who have been performing their activities for more than three months when the data collection occurred. This working time should offer these professionals sufficient experience for the identification of psychosocial risks at work.

daTa collecTion
For data collection, semi-structured interviews were performed with use of scripts validated by specialist nurses in the area, audio recorded and later transcribed. The sample was defined by data saturation, that is, at the moment when the addition of data and information in a research does not change the comprehension of the phenomenon under study, thereby allowing to validate a set of observations (11) . The script contained two parts: the first with questions related to participants' characterization data, such as age, sex, year of graduation and working time in the institution. In the second part, there were open questions related to the object of this study, such as: In the performance of your activities, what conditions are offered by the service? Is there any difficulty? How do you feel after a workday? What do you consider exhausting and harmful to your health? How is it for you to balance the activities and time dedicated to work and your family? Do you use any personal or institutional resources to relieve the effects of difficult situations faced in your daily work?
The contact with nurses to schedule the interviews was made by telephone (numbers provided by the Primary Care coordination). The interviews were conducted by the responsible researcher in order to avoid bias, in the FHS health unit of each nurse, individually, at times established by the professionals, without any interruption and lasted about 20 minutes.

daTa analysis and TreaTmenT
The data were analyzed according to inductive thematic analysis and organized into thematic categories following three steps, namely pre-analysis, exploration of the material and treatment of the results obtained. For the identification of thematic units related to psychosocial risks, the speeches of interviewees were considered in the light of the theoretical framework adopted (12) .

eThical aspecTs
The study was approved by the Research Ethics Committee of the Ribeirão Preto School of Nursing, Universidade de São Paulo, under protocol number 090/2018. All participants signed the Informed Consent form and confidentiality of responses was ensured. In order to preserve participants' anonymity, the letter "I" was used for the interviewee, followed by the numeral, according to the increasing chronological order of interviews, for example, I1 (Interviewee 1), and so on.

characTerizaTion of parTicipanTs
Eighteen nurses participated in the study, with a predominance of females 16 (89%), age range of 36 to 40 years, which corresponded to 12 professionals (67%). The predominant time since graduation was 15 years, as well as the working time in the FHS. There were professionals working in the family health area since the beginning of their professional training.
As for training, 12 (67%) professionals had a postgraduate level, of which, all with a specialization degree (lato sensu) and two (11%) with a master's degree (stricto sensu). There were professionals with up to five specialization titles, which reinforces the profile of nursing workers capable of meeting the diversity of challenges present in the FHS.
The workload of professional nurses was 40 hours per week and eight hours per day. When analyzing the interview data, several psychosocial risks related to the work context of family health nurses were identified, and they were divided into four categories: professional training, interpersonal relationships, work-family interface, psychological violence. There were also psychosocial risks related to the work content of FHS nurses, divided into three categories: work equipment, human resources and workload and work schedule. Besides, strategies were identified to manage such risks.
Psychosocial risks related to the work context of family health nurses

Insufficient professional training
Nurses revealed a lack of investments in professional training and that learning happens in the daily work of family health, which constitutes a work-related psychosocial risk.
I had no preparation. It was all like that, learning during day to day work. I read, studied, because there was no training, no course, nothing (I18).

Interpersonal relationship: relationship difficulties with coworkers and management, interpersonal conflict in teamwork
Difficulties in the relationship between professionals and the population can result in emotional distress of professionals and thus, be perceived as a psychosocial risk: The relationship with the team and the population as a whole is very stressful. (...) And with management too, there are still political issues with a negative effect, so this is very bad. I get really upset. But, as time went by, I learned to filter, otherwise it would be unsustainable (I3).

Psychological violence: excessive exposure of nurses in the media
Nurses perceive that depending on their activities or reactions before users, there may happen a certain repudiation by the media, sometimes misplaced, representing an act of psychological violence, which is considered an important psychosocial risk for workers' mental health. Psychosocial risks related to the work content of family health nurses

Work equipment: insufficient material resources and lack of maintenance
The speeches revealed the presence of great limitations and lack of maintenance in the work environment, where workers need to improvise material resources to perform their tasks.
Our conditions are improvised. Lack of basic use supplies, furniture. There is no sphygmomanometer, stethoscope, sonar, focus, computers. Materials are sent to maintenance, but it takes a long time, then everything is out of date, especially when computers break (I10).
(...) A lot of material is lacking, including the car to travel to the client's home to carry out the home visit. Sometimes, it is a far away place, but even so, there is no car and we have to use our people. (...) There is a lack of topical iodine, drugs, even dipyrone (E6).

Human resources: staff shortage and deviation from agreed role
The insufficient number of professionals and the deviation from agreed role of FHS workers was revealed as a psychosocial risk in nurses' speeches: My team is totally incomplete. It's me [nurse], the doctor and only two health agents in this unit (E17).
The 7 th health agent is a case of deviation from agreed role, he is at the reception. And our cleaning assistant only comes twice a week. I believe a health unit needs a cleaner at least three times a week (I13).

Workload and work schedule: overload and long hours
The reports showed that nurses perform many activities in their daily lives and still take service home, in addition to exceeding their usual workload of the FHS.

Psychosocial risk management strategies
The presence of psychosocial risks reveals the need to develop strategies to combat them. However, the speeches of nurses show the total lack of activities or actions offered by the coordination of FHS teams to eliminate or minimize the risks analyzed: On the part of the institution, no. They do not offer any resource or strategy to manage the risks we are exposed to (I3).
There is no support or action by the institution in this sense, especially this current coordination, they are not concerned, especially with something to help us" (I14).
Nonetheless, professionals have emphasized the use of individual strategies to alleviate risk situations, such as physical activity practice, spiritual help, psychological therapy and meditation:

DISCUSSION
The implementation of the FHS with the focus on health promotion and disease prevention together with the proposal of primary care reorganization in Brazil, corroborated an army of workers in precarious working conditions. Thus, occupational risks have gained a large proportion, especially psychosocial risks (8)(9) .
This study revealed the lack of professional training as a psychosocial risk for workers, corroborating with another study in which this aspect was also considered a risk for nursing workers (9) and showing the relevance of professional training for healthcare. The data found were evidence of the lack of institutional investment for nurses' training and preparation for the FHS work. The complex health reality of this scenario requires updated and prepared professionals with specific skills for meeting the constantly changing demands of service users.
To train is to prepare/enable the worker to perform a certain role. Training must be a real possibility in the scope of health services and happen soon after public servants are hired. In addition, health institutions must have well-defined objectives and workers who feel secure to perform the agreed roles (9) .
In this regard, health institutions must assume their responsibility and invest in training and qualification of their professionals. This preparation should be offered before professionals are inserted in the job market and not after they have worked in the position for years. Nursing training centers have the role of developing teaching strategies during academic training in order to assist the performance of future nurses and clarify the real working conditions, so professionals can act effectively in the various health services of the complex health reality.
Interpersonal relationships are one of the major problems in FHS teams and considered a psychosocial risk factor. In this study, warm discussions were identified in the daily work of team members. Nurses reported conflicts with medical professionals and the main reason was related to non-compliance with the established workload and constant delays. There is also a confrontation between the nursing team itself, community workers and the population in general.
In line with this study, authors state that health is a complex and frail field, where several conflicts occur because of changes in the epidemiological and demographic profile, power relationships between members of the multidisciplinary team and other social determinants (13) . These changes and factors envision the need for a collective work of the FHS, which in most cases is a difficult task, given the tensioned movements guiding Family Health teams. Harmony and interaction between FHS professionals is essential for their integrated action (14) .
The imbalance in the work environment, or lack of harmony between professionals themselves can even generate unnecessary exposure of workers caused by maneuvers and intrigues of a minority. This fact is perceived as an act of psychological violence at work, therefore, a psychosocial risk condition. In this regard, the speeches of nurses revealed www.scielo.br/reeusp Rev Esc Enferm USP · 2020;54:e03602 violence situations experienced by them in their daily work and highlighted nurses' exposure in the media such as radio and social networks as an aggravating factor. Moreover, they also revealed the lack of interest and support from management in relation to proposing solutions for reducing the exposure of professionals on social networks. In line with the above, in a recent study, psychological violence at nurses' work was identified as a psychosocial risk and verbal aggression, moral and sexual harassment were highlighted as forms of this violence. Women and younger professionals were more affected by violence, and patients and family members were the main aggressors of these professionals. In addition, nurses have been victims of physical violence (15) .
Violence against nurses and other health professionals has become a challenge for the Brazilian health system and brought several consequences for these professionals, such as anguish, mental suffering, palpitations, sleep disorder, stress, depression, hearing damage, headaches, anxiety, fear of patients and their families, and even suicide (16) . In view of this reality and considering the rates of nurses attacked in their jobs, managers and authorities must rethink and invest in policies to raise awareness against violence at work in this category.
Another aspect of working conditions related to psychosocial risks and mentioned a lot in this investigation, concerns work equipment and insufficient material resources and/or with maintenance failures, which was also perceived in other studies as a triggering factor of professional stress (9)(10) . In most units, nurses buy and pay the costs of repairing materials and do not yet have a vehicle for transportation during home visits, even when the client is far from the unit area, which leads most professionals to use their own vehicles, without having any financial reimbursement.
The lack of material resources and inadequate physical structure is a reality in the FHS. Researchers have already shown problems such as the lack of resources to provide first aid, and difficulties with accessing the internet and the telephone for performing individual care actions in privacy (17) .
The literature also states that the maintenance of Family Health Programs generates a high cost for the government, where resources transferred to municipalities by the Union and States are insufficient to cover the health service demands in the FHS (18) . However, for performing their functions successfully and effectively, nurses need a physical structure and sufficient resources in order to meet all service demands.
Managers must be aware of and rethink the implementation of policies to guarantee such resources and their maintenance, given the impact of this theme on Brazilian public health. If managers know and understand the purposes and reality of the FHS in each location, there will be a transformation in the allocation of resources, consequently improving the working conditions of the entire team, since the organization of Primary Health Care develops from the political, social and cultural context of each country (19) .
In addition to the proper environment and equipment, a correct number of qualified professionals is needed to perform their functions in a comprehensive manner. The insufficient number of professionals in the FHS and the deviation from agreed role reveal another important psychosocial risk. In this line of thought, other studies have identified incomplete FHS teams and a significant lack of CHAs and doctors. The lack of these professionals can be justified by the need to open new hiring processes, dissatisfaction with salary remuneration and absence from work because of sick leave (20) .
The lack of CHAs is a major problem in all FHS teams in the city surveyed. The few teams that contemplate all the CHAs recommended by the Ministry of Health still find obstacles, as a deviation from the agreed role has always occurred with these professionals, who also worked at the reception. The results obtained also demonstrated teams working with only two CHAs, a doctor and a nurse. This fact can be corroborated by the study that revealed an excess of functions foreseen for the CHA in the FHS, in addition to the lack of clarity of their attributions (21) . These data lead us to reflect on how this strategy was implemented and how professionals were selected, given the known importance and level of responsibility of this sector in the reorganization of Primary Care in Brazil.
Human resources in Family Health, especially in relation to the Nursing team and work overload, constitute a challenge and risk, given the needs of the user population of the care network. The literature points out that the work pace resulting from the various attributions of FHS nurses and the high demand in this sector can easily generate work overload, which is a psychosocial risk demonstrated by scholars on the subject (22) . For the perfect functioning of the FHS, sufficient human resources must be restructured and trained to meet the public health demands (23) .
It is worth highlighting that exceeding the daily workload is a common fact in the routine of participants, and leads to the feeling of physical and mental exhaustion, devaluation and negligence by the system. About this statement, researchers indicate the relationship between long workloads in nursing, associated with poor working conditions, little autonomy, a lot of responsibility and undervaluation that generate high physical and emotional demands (24)(25) . The overload of activities can cause other problems for nurses, for example the imbalance in reconciling work and family.
The lack of balance between home and work demands, and the little time spent with the family were also perceived by nurses as a psychosocial risk. The main factors interfering with the work-family relationship are the accumulation of overtime and tasks and the work taken home.
In line with this study, the psychosocial risk of the work-family interface was found in other evidences with professional nurses. This risk represents an important indicator that can make workers ill (26) . In this regard, the literature shows the importance of a balanced work-family interface and the quality of the work environment as a mediator for the establishment of positive family relationships and children's socio-emotional and school development (27) . Furthermore, it is important to create public policies to eliminate this conflict, in order to ensure dignified and balanced working conditions for nurses, as these professionals are very exposed to this and other psychosocial risks.
In continuity, there is a strong need for the quantity of qualified professionals in FHS teams. The Union, States and Municipalities must guarantee the minimum number of professionals for a decent and safe work context. Managers must rethink the organization of work and offer adequate working conditions and human resources in quantity and quality for the effective care within Primary Care.
One of the forms to reduce psychosocial risks is to design and implement individual and organizational strategies. Nurses' speeches revealed the absence of activities or strategic actions offered by the coordination of FHS teams, while individual strategies such as the practice of physical activity and meditation were reported as aids in stressful everyday situations.
Since organizations are co-responsible for maintaining their workers' health, they must develop strategies to help these professionals alleviate the risks to which they are exposed in their daily work, which consequently, contributes to quality care. When these professionals have support and satisfactory conditions at work, their performance improves because they feel motivated and this is a determining factor for comprehensive quality care to users.
In line with the presented, the literature describes individual and institutional strategies for the management of psychosocial risks at other levels of healthcare, such as physical exercise, cinema, spiritual support, search for therapies, dialogue with family members, music, reading, travel, outings, continuing education programs, an effective internal communication system, job and salary plans, among others (15) .
This study presented the limitation of having been conducted with a small number of professionals in a certain region of the country. Hence the importance of further studies for expanding the quantity and scope to other states in order to assess if there is a divergence in the perception of risks and rethink the management strategies. The study described several essential psychosocial risks for stimulating the reflection of managers, health training centers and nurses towards the creation of strategies to face them in daily work.

CONCLUSION
Nurses' practice in the family health context brings together complex work situations. Depending on how such a practice is organized, professionals end up exposed to psychosocial risks that can lead to their psychological distress. The identification of these risks reinforces the presence of problems in public policies for the management of people and resources in the health area. Attention should be paid to the creation of adequate environments and preparation of professionals for meeting the population's health needs.
There is a worrying scenario in the FHS, where nurses do not have institutional support to face possible problems in working conditions, which is a negative interference. In addition, workers resort to individual strategies for alleviating the presence of occupational risks. The Union, States and Municipalities must rethink their responsibility of guaranteeing the full functioning of the FHS, including the maintenance of adequate working conditions for professionals at this level of care. Training centers must rethink their curricular structures, including active methodologies in the teaching-learning of future professionals and prepare workers with a profile of specific skills for meeting the demands of the labor market, especially the FHS.