Adversities experienced by professionals in the Primary Healh Care: implications for the meanings of the work

Objective: To understand the experiences of adversity in the Primary Health Care and their implications for the meanings of the participant professionals' work. Methods: Single case study, of qualitative nature, with 62 professionals active in the Family Health Strategy, whose data were collected by means of semi-structured interview and comics technique and analyzed by the thematic content analysis, with aid of Atlas ti, version 7 software. Results: There emerged the categories: Experiences of adversities in the Family Health Strategy and Implications of the adversities for the meaning of the professionals’ work. In these categories were pointed aspects related to inadequate conditions of work, to wage question, to excessive demands and interpersonal conflicts that provided negative implications for the meanings of the team's work, for satisfaction and usefulness of the work. Conclusion: it was possible to apprehend the experiences of adversities in the work environment and its implications on the meanings of the work that can impair the professionals' actions. Implications for practice: the study may subsidize the reflection on the strategies that enable the reduction of the adversities in the work environment, contributing to benefiting the worker's health and care of quality for the population.


INTRODUCTION
The Primary Health Care (PHC) is considered by the international literature as an axis organizer of the health services organization, based on the universal access to services. The principles of the PHC, formulated in the Health World Organization Conference, held in Alma Ata, include the attention at the first contact, the longitudinality, the completeness and coordination of care, the family and community orientation, the recognition of people's needs according to the physical, economic and cultural context. [1][2][3] In Brazil, the Family Health Strategy (FHS) integrates the National Policy of the Primary Health Care, being recognized as a axis priority for reorganization, strengthening and consolidation of the Primary Health Care (APS), for enabling the reorientation of the work process with higher potential for enhancing the resolutivity and impact in the health situation of persons and collectivities. 4,5 The FHS includes a set of actions, which constitutes the basis for the organization of the attention networks, prioritizing the promotion, the protection and the recovery of health, in an integral and continuous way, developed on the basis of the recognition of the population's needs and link formed between users and professionals. 6,7 The changes proposed by the FHS, with a view to restructuring the PHC and consolidation of the Single Health System, bring new and constant challenges to workers. 8 The complexity of the work environments and the conditions available to carry out this can interfere with the security and quality of care. 9,10 Moreover, at the same time in that it is required preparation and capacitation, many times, the professionals do not meet, in the work environment, favorable conditions for performance of the humanized, competent and resolute work, factors that expose them to physical and mental damages, 11 in addition to promoting implications for the meanings attributed to work and care given to the community.
About this problem, national and international publications have mentioned the importance of understanding the events, factors or adverse situations that can cause damages and bring risks to physical, mental and social health of the worker and to the performance of its activities. 12,13 It is considered the adversity as an experience of events and life circumstances can threaten the healthy development. 14 Therefore, researches have pointed out the relevance of valorizing the subjective perception and the meaning attributed to experiences of adversity present in the different contexts, having in view that the professionals' interpretation about the own experiences can bring implications for the meanings attributed to the work, as well as the way they deal with the adversities. 11, 12,15 The scientific production about the concept of the meanings of work includes several theoretical and methodological approaches. The definition of a work with meaning consists of a challenge, since it contemplates subjectivities, interpretation, besides involving social, cultural, psychic and identity factors. 16 For the purposes of this study, it is assumed Morin 17,18 as the theoretical reference about the meanings of the work, who postulates necessary characteristics for a work to make sense, namely: be done in an efficient way and lead to an useful result; to enable satisfaction in the carrying out of the tasks; to allow the worker to use its own talent and potential with autonomy; to be morally acceptable; to be source of satisfactory human relationships; to make possible financial security, linked to a wage that allow for guaranteeing the survival and keep the persons occupied, avoiding the anxiety. This way, when the work has a meaning, it starts being developed with satisfaction and commitment.
When considering the importance of the Primary Health Care and its potential significant of expansion, by means of the Family Health Strategy, this study is justified by the need of reflection on the situations of adversity in the work environments and the implications to the professionals' work meanings, that could lead to repercussions on the care provided to the population. Thereby, it may be possible to provide subsidies on the reality of the work in the labor environment of the Primary Health Care and reflect on improvements in the organization and in the professionals' work conditions, besides actions directed toward the well-being and the mental health of the workers. Based on the above considerations, when thinking about the relevance of discussing the thematic, the study aimed to understand the adversity experiences of professionals of the Primary Health Care and their implications for the meanings of work.

METHOD
This is a single case study, of qualitative nature. The option for the case study as a methodological reference is justified when one wants to study in depth some contemporary, social and complex phenomenon, inserted in a real-life context, by allowing the researcher to understand the significant characteristics of the events, individual, group, organizational, social, and political among others. 19 The carrying out of the case study requires the utilization of different sources of evidence, which may include documents, records in archives, interviews, observations, films, photographs, projective techniques, among others. The different sources of evidence allow the data triangulation and the possibility of convergent lines of investigation, providing more refined and reliable discoveries, meeting, therefore, the criteria regarding the construct validity. 19 The study was developed in all units of the Family Health Strategy that compose the Network of Services of the Primary Health Care of the municipality in the high backland of the State of Paraiba, Brazil, which has 23 units of the Family Strategy, being 17 located in urban area and six in rural area.

Meanings of the work in health care
Costa IP, Pimenta CJL, Brito MJM We decided to interview one participant of each professional category that composed the basic team in each unit of the FHS. The basic team of the FHS, according to Decree no 2436, of 11 September 2017, should be composed of one physician, one nurse, one nursing technician and community agents, depending on the population contingent of the territory. 5 When treating about CHA, it was realized a raffle of one participant per unit of the FHS.
For including the participants, it was adopted the criterion of working time greater than or equal to six months, time required so that the professionals could experience the dynamics of the services and establish a greater proximity to the community. Professionals on leave, on vacations or removed during the data collection period were excluded.
The data collection occurred from February to August 2017, being used two sources of evidence: the interview and comics technique. As the first source of evidence, it was carried out an interview guided by semi-structured script that included the characterization of the socio-demographic profile of the participants, open questions about the object of study, focusing on organizational aspects, work environment, interpersonal relationships and experiences of adversity that bring implications to the meanings and the carrying out of the work. The interviews were carried out by the researcher, individually, in private room, in the own unit of the FHS, according to the professionals' availability, lasting between 30 and 90 minutes.
The comic technique, used as a second source of evidence, consists of a playful strategy, in which the subjects have the opportunity to express about a true problematic situation that experiences in the daily, by means of analogies among figures of comic books of comic type. 20 Comics Books (CB) are narrative forms, essentially contextual, which due to the playful character, have the potential of reaching sentiments and emotions, enabling a better approach and reflections about the object in study, allowing the participants to express, in a more spontaneous way, subjective aspects that could not to be addressed in the traditional ways. 21 Qualitative researches used the Comics technique as a strategy of data collection, being established as a choice criterion of the magazine the current edition of the Turma da Monica (Monica's Group), available in newsstands during the collection period. [22][23][24] The comics of the Turma da Mônica (Monica's Group) offer the participants the link of research themes with situations of the daily, in a spontaneous and informal way, facilitating the capture of subjective aspects of the reality.
It should be noted that for the purposes of the current study, the Comics technique was used considering the criteria used in other researches 25 both in that refers to the application, and to the methodological option. [22][23][24] Study describes the steps for the technical realization of the Comics technique and emphasizes the successful experiences with the utilization in the care practice in nursing, in the teaching and as data collection strategy, in qualitative researches. 25 Another study conducted by Albuquerque et al. 26 reports the experience about the use of the technique during a course linked to the Post-Graduation Program in Nursing of the UFMG.
To carry out the technique, the participants were initially guided about the stages. Next, the Comics were made available upon request of that they would be represented, by means of one or more figures of the magazine, including the cover and back cover, aspects about the following guiding phrase: "The work does not make sense when.". Subsequently, the participants talking about the figures choice, considering their relation with the guiding phrase.
The empirical data coming from the two sources of evidence were recorded and transcribed in full and the testimonies identified with the initials of each category, Nurses -E; Nursing Technicians-TE; Physicians -M; Health Community Agents-ACS, followed by a number of identification of each participant.
To analyze the data that emerged from the sources of evidence, we used the thematic content analysis, 27 with the steps of pre-analysis, material exploitation, treatment of the results, inference and interpretation. As the operational tool, we used the Atlas ti, version 7 software. The use of this tool allows to organize the material coming from the data collection, favoring the indexing, search, theorization and qualification of the findings. 28 The study complied with the formal requirements of the Resolution no 466/2012 of the National Health Council, regulatory of researches involving human beings, being approved by the ethical committee of the Federal University of Minas Gerais, according to the opinion 1.886.483.

RESULTS
Sixty-two professionals active in the units of the FHS participated in the research. With regard to participants by professional category, 14 were physicians (22.6%), 16 nurses (25.8%), 16 nursing technicians (25.8%) and 16 HCA (25.8%). Thirty professionals were not included in the research: 17 did not agreed to participate (56.3%), nine had less than six months of professional actuation in the service (30.0%), three were on vacations (20.0%) and one was on medical license (3.3%). Regarding the non-acceptance of participating in the research, the professionals attributed to the fear of retaliations in case the testimonies were identified, even after explanations detailed about the study objectives and ethical principles that orient the research, ensured by the Free and Informed Consent Form. Another aspect cited was the little availability of time, as a result of the work requests.
Among the physicians category, the majority were female (8; 57.2%), aged 20 -29 (7; 50.0%), single (11; 78.5%), between six and 11 months of actuation in the unit (2; 14.2%), with link of Meanings of the work in health care Costa IP, Pimenta CJL, Brito MJM employment by contract (10; 71.5%). With regard to the nurses, the female has prevailed (14; 87.5%), with age range 30 -39, single, with employment bond with an equal percentage for hired and effective and time of actuation in the FHS unit between six and 11 months (12; 75.0%).
From empirical data analysis, the following categories emerged: Experiences of adversities in the Family Health Strategy and Implications of the adversities for the senses of the professionals' work.
In the category Experiences of adversities in the Family Health Strategy, among the situations referred by the professionals, there were observed aspects related to: inadequate work conditions, lack of support of the management, wage question, excessive demands and interpersonal conflicts at the work.
The inadequate work conditions, regarding the infrastructure, shortages of materials, supplies and transport were pointed out by the professionals as adversities presents in the experiences of work, by making impossible for them to develop what they want at work:   In the testimonies, the excessive care and administrative request, emerged in the reports of the participants such as adversities that imply an overload and have repercussions on the work developed: Then, sometimes, I would like to have a time to think, to digest that problem, and see the best possible solution. The excessive requests for the nurse, the excess of charges is one of the biggest adversities (E9).
Here, there are many charges, much demand for immunization and many procedures. I do during the whole morning until midday and a half, at one p.m. I get

Meanings of the work in health care
Costa IP, Pimenta CJL, Brito MJM The meaning, thus, is of usefulness, unproductivity, because when you know how to do a certain procedure, you have the will to do, but you do not have resources in order to that procedure can be done, you feel impotent. As you did not serve much (T3).
Unfortunately, we try to be able to give an answer to these patients, because we do not go to the rural are to care. But, up till now, we do not have this answer from the management and, thus, the team, in a way ends up also getting that some feeling of impotence (M13).
The wage question, for some participants, compromise any of the participants, compromise the meaning of work related to the personal valorization and satisfaction, since, according to these, the insufficient remuneration for activities that they play result in discouragement, in addition to the possibility of abandonment of employment: Then, for you to work well, you have to be satisfied, be valorized and receive a wage according to the work you do. Then, how are you going to want to be in a profession like this, how are you going to work with so much will? (T15).

I like it here, but I'm going to leave, we work so much in the Family Health Strategy, but it's low paid, do you understand? (T2).
In the testimonies, the excessive requests, have a negative impact on the meaning of work related to the personal satisfaction, compromising the adequate care and approach to the population's problematics. This context was pointed out mainly by physicians and nurses: (...) the fulfillment of those production sheets, then, this makes me unsatisfied because it disturbs me a lot. Because I have to deal with the patient, talking, carrying out the consultation and, also, I have to look for the "blessed" codes to put on the sheet, and after putting all this, you still have to type at home, in a system and this disturbs a lot, the care of the people (M1).

But, we end up also unfortunately administrative questions and of human resources in general that, according to the regulation of the Ministry of Health, it was only for us to worry only about the nursing technician and the CHA (E9).
The conflicting situations related to the relationship among the professionals in the labor environment affect the meaning of the teamwork: The interpersonal conflicts among the team members were mentioned by some of the participants as factors that interfere with the work: There are conflicts, many conflicts, thus, with some professionals and this in any way interfere with the carried out, not only with my work, but with the team and in the care to the user who is needing at that moment (T5).
The inter-personal relationship interpersonal within the own team is the one that brings many conflicts, these conflicts, many times, were seen by the patients (E13).
In the category Implications of the adversities for the work meanings of the professionals, it was possible to apprehend how the experiences of the adversities can compromise the meanings attributed to the work by the professionals to their performance alongside the community.
The inadequate work conditions make the resolutivity of the actions difficult and may influence the care, in so far as it compromises the meaning to the work related with usefulness, being associated with the feeling of impotence:

Meanings of the work in health care
Costa IP, Pimenta CJL, Brito MJM The findings are in accord with the theoretical reference of Morin,17,18 adopted in this study, in that, for the work have meaning, the characteristics of the work should be associated with the motives that stimulate the professionals to the own development, such as: satisfactory conditions of work, acceptable wage, preservation of the health, stimulating and variate work, and opportunity to carry out the tasks in an adequate way.
The adversities mentioned by the participants in this study provided negative meanings to the work, being associated with dissatisfaction, uselessness, impotence and frustration, factors that compromise the mental health and, consequently, the care provided to the community.
These aspects are also pointed out by Morin,17,18 when affirming that a work with meaning must be useful and developed with satisfaction, but, when the work loose such meanings, it may have negative repercussions on the compromising of the workers with the activities that they develop.
For the confirmation of the results of this study, the researches carried out with multi-professional teams of the FHS, in different regions of the country, pointed that the labor conditions can be configured as a source of dissatisfaction of the individual with the work, for not being able to provide the care of quality to the population, resulting in suffering for the professional. 29,30 Regarding the wage question, the participants mentioned that, although remuneration do not be the only important aspect for working in the FHS, an insufficient wage compromises the meaning of personal and professional realization and make them think about leaving work. This problem was pointed by some physicians and nursing technicians. The participants evidenced the need for a career action plan that guarantee them recognizing and valorization, by means of remuneration compatible with the function, beyond the incentive to training.
Similar to the results pointed in this study, a research emphasizes the dissatisfaction of physicians, nurses and technicians professionals of the FHS with regard to the remuneration and inexistence of a Career Action Plan, promoting the lack of perspective and the discouragement with regard to the investment in professional training. Such factors, according to the study cited, can cause a demotivation and little involvement of the worker with the work, having a negative impact on the care of the users and in the implementation of institutional and communitarian bonds. 31 Still with regard to the remuneration in the FHS, any of the participants reported that they need to search more than one work that provide them an adequate income to meet the particular needs. Such problematic, added to the excessive requests in the own FHS, can bring consequences for the worker's health and the care provided. With regard to the excessive requests in the daily of the FHS work, it was possible to apprehend in the participants' discourse that there are specificities among the professional categories. When everyone thinks only of you, then it comes the difficulty, the disagreement, then there is a heavy environment to work, it loose the meaning of the teamwork, I've just had experiences like this, it's terrible (T10).
Conflicting situations among the team that disturb the integration among members and interfere with the dynamics of the labor environment and in the care of the users were referred by the participant M13, by means of the Comics technique ( Figure 3): When in a team, where everybody works disunited and one is angry or has some problem with the other, this disturb all the progress of the works, furthermore, the entire progress of the work of the unit. Besides bringing sadness personally, it also will bring damages to our users, in the sense of each one working separately, no one will be able to give a final answer to a patient in an adequate way (M13).

DISCUSSION
In the experiences of the FHS, many times, the worker is faced with complex situations that, in majority, are related to the confrontation among the principles established for reorganizing the service and adversities inherent to the true context of the work, be they structural, organizational, financial, managerial or relational.
Among the adversities referred by the professionals, the inadequate work conditions, regarding the sufficient financial, material or human resources are circumstances that compromise the resolutivity of the actions directed toward the promotion of the population's health, making it difficult to reach the results with excellence. The situations of adversity revealed, provided negative implications to the meanings attributed to the work, which affects the care given to the users.

Meanings of the work in health care
Costa IP, Pimenta CJL, Brito MJM While for the health community agents, the excessive requests come from insufficient human resources for coverage of the included areas, for the nursing technicians, this is linked to the accumulation of procedures and activities, for physicians and nurses, this is referred to the excessive bureaucratic and care problematic activities. However, the aspects cited, present in common the possibility of causing a negative impact on the performance and in the quality of the care provided to the population.
Faced with the reality mentioned, the accumulation of employment bonds, of work hours and tasks with different complexities can cause the work overload, by requiring physical and psychological demands that go beyond the supported by the worker. 31,32 This difficults was also revealed by means of the Comics technique, being possible to apprehend in the discourse of the participants the possible psychological and cognitive grievances came from the excessive demands in the daily, which interferes, consequently, in actions alongside the community.
In this perspective, a research reveals the implications arisen from the work overload for the professionals of the FHS team and points that the high demand of work, associated with pressure for compliance with deadlines, to collection for results, to the insufficient number of persons to carry out the activities, repetitive tasks, quickened pace of work among others, are aspects that make it difficult to carry out the care with quality. 33 Regarding the interpersonal relationships in the work environment, the testimonies revealed that the conflicts existing among the professionals cause their distance and implications for the meaning of the teamwork. This aspect emerged in the Comics technique, being mentioned by one of the physicians, who reaffirmed how much the conflicts and distances between the professionals disturb the dynamics of the teamwork and the resolutivity of the actions, interfering with the care of the users.
Similar results were described in a study carried out with 13 professionals of the FHS of the municipality of the South Region of Brazil, about the perceptions regarding the teamwork. In the referred study, the participants reported that the difficulty of collaboration among the team members arose from the existence of conflicting and far relationships, problems related to personality, excessive work and scarcity of resources, as well as the devaluation and demotivation of the professionals. 34 Therefore, it is understood that the teamwork emerges as a result of a complex work, in that there is a necessity of overcoming the fragmentation of the work and of the relationships among the professionals of the FHS from different areas and levels of formation, so that it can allow the cohesion and integration of the team, which will favor the actions directed toward the effective care and to a healthy labor environment.

FINAL CONSIDERATIONS
This study enabled to apprehend the experiences of adversities in the Primary Health Care and their implications for the meanings of the professionals participants' work. Among the experiences of adversities, there emerged aspects related to inadequate conditions of work, to wage question, to excessive demands and to interpersonal conflicts at work.
It was concluded that the adverse events experienced by the professionals triggered feeling of impotence and discouragement, which had a negative impact on the meanings of work associated to usefulness, personal valorization, teamwork and of satisfaction with the activities performed. These aspects, many times, lead to suffering, by preventing the development of effective actions in the problems solutions related to the population's needs.
With regard to the potentialities of the method used, it is denoted the importance of the case study as the methodological reference of this research, by enabling to add two sources of evidence that enabled wider and more significant findings. In addition, the carrying out of the case study in all units of the FHS that composed the Primary Health Care Network of the municipality that included workers of different professional categories provided a more comprehensive vision about the thematic.
It should also be emphasized, as a potentiality of this study the utilization of the Comics technique as an innovator strategy for the data collection in qualitative researches and significant source of evidence for the case study developed, allowing the participants to reflect and express in a more spontaneous way about the complex adversities experienced and their implications for the meanings of works that can interfere with the care provided.
It is hoped that the reflections presented in this study can bring contributions to the professionals' practice in the FHS, with a view to make possible discussions and reflections between managers and professionals about the true needs in the work daily, with a view to implement strategies that allows for the reduction of adversities in the work environment and can have effects on the meanings and in the development of the work in a positive way. Such actions may enable the professionals to have healthy work environments, with democratic space, which reflects as benefits on the worker's health and care of quality to the population.
It is emphasized that the context in that the study participants are inserted can influence in their perceptions, making impossible that the results presented be generalized for other scenarios, aspect that constitute the limitation of this research. It is suggested, thus, that the study be carried out in other spaces, in a way to subsidize new discussions and investigations about the thematic, in different contexts of the work in health, enabling to enlarge the results about the phenomenon investigated.