Identity of primary health care nurses : perception of “ doing everything ”

Objective: To analyze, in the speeches of nurses, the habitus that conforms their professional identity in the primary health care area. Method: Qualitative study, carried out from March to October 2015, with nurses of primary healthcare units in the cities of Cajazeiras, in the state of Paraíba, and Maracanaú, in the state of Ceará. Data were collected by means of semi-structured interviews, and analyzed through discourse analysis. Results: Nurses, in their practice and perception, perceive that professional identity is linked to the meaning that involves the word “everything”. This situation constitutes a habitus that directs the range of daily actions, often distant from the profession’s core of knowledge. Final considerations: Trying to be and do everything in primary health care involves negative repercussions in the professional identity of nurses. Strategic guidance is necessary in order to achieve and embrace elements that refl ect the essence of this category. Descriptors: Primary Health Care; Primary Care Nursing; Nurse’s Role; Professional Competence; Nursing Care. RESUMO Objetivo: Analisar, na discursividade do enfermeiro, o habitus que conforma sua identidade profi ssional no campo da Atenção Básica. Método: Estudo qualitativo, desenvolvido de março a outubro de 2015, com enfermeiros, em Unidade Básicas de Saúde de Cajazeiras (Paraíba) e Maracanaú (Ceará). Os dados foram coletados por meio de entrevistas semiestruturadas e verifi cados por análise de discurso. Resultados: Enfermeiro associa, em sua prática e percepção, que a identidade profi ssional está atrelada ao sentido que envolve a palavra “tudo”. Essa situação constitui um habitus que direciona a gama de ações cotidianas, muitas vezes distantes do núcleo do saber-fazer da profi ssão. Considerações fi nais: Ao tentar ser e fazer tudo na Atenção Básica, há na verdade repercussões negativas na identidade profi ssional do enfermeiro. Faz-se necessário encaminhamentos estratégicos para alcançar e se apropriar dos elementos que refl etem a essência dessa categoria. Descritores: Atenção Primária à Saúde; Enfermagem de Atenção Primária; Papel do Profi ssional de Enfermagem; Competência Profi ssional; Cuidados de Enfermagem. RESUMEN Objetivo: Analizar, en el discurso del enfermero, el habitus que conforma su identidad profesional en el área de Atención Primaria. Método: Estudio cualitativo, desarrollado entre marzo y octubre de 2015, con enfermeros, en Unidades de Atención Primaria de Cajazeiras (Paraíba) y Maracanaú (Ceará). Datos recolectados por entrevistas semiestructuradas, verifi cadas por análisis de discurso. Resultados: El enfermero asocia, en su práctica y percepción, que su identidad profesional está enlazada al sentido atribuido a la palabra “todo” universalmente. Esta situación constituye un habitus que orienta el espectro de acciones cotidianas, muchas veces alejadas del núcleo saber-hacer propio de la profesión. Consideraciones fi nales: Al intentar ser y Identity of primary health care nurses: perception of “doing everything” Identidade do enfermeiro na Atenção Básica: percepção do “faz de tudo” Identidad del enfermero en la Atención Primaria: percepción del “hacer de todo”


INTRODUCTION
Nursing, as a science in process of consolidation, requires establishing a structure of appropriate knowledge, as well as a specific nomenclature that is able to guide principles of knowledge in its daily practice, and consequently, to guide its working process with elements that specifically represent its professional identity.
This type of identity has a contextual nature with historical changes, from nation to nation and culture to culture; and a systemic nature, where individual, interpersonal, organizational, and social levels interfere in the construction of identities, in a specific and combined way (1) .
In this respect, the professional identity of nurses is intrinsically associated with the context in which this category performs its specific activities, and to whom its actions are directed, as well as what results from these activities.Therefore, professional identity is reconfigured from the awareness of individuals who experience their profession as an agent and applicant of its benefits (2) .
However, there are difficulties in understanding the professional identity of nurses, many times due to the conflicting perception of themselves and their practice.In addition, there are other elements that interfere in this understanding, such as the lack of definition of their spaces and indecision of duties, which hinders the specification of characteristics of nurses' competencies, as well as the definition of their professional identity (3) .
Another characteristic that favors the distortion of this identity are historical and evolution crises, which, in changes of time and even currently, interfere in the essentiality of the practice of care, health, and nurses, weakening the conformation of the professional identity of this category (4) .
The obstacles to define the professional identity of nurses are a phenomenon that may be observed in all healthcare fields and settings; however, in this study, the space of primary health care (PHC) will be approached.
In this healthcare area, there is a lack of definition of duties carried out by nurses.This may be due to the practice of professionals who did not embrace the essence of their work in primary health care and add practice and tasks that are not theirs, as well as due to actions that are not from the interdisciplinary field, such as medical appointments, request of examinations, prescriptions, practice in promotion and prevention of health, which may lead to ambiguities in their identities (5)(6) .
The interdisciplinarity theme is discussed by several researchers of the area, whose definition refers to the combined practice with diverse professionals in their respective areas of specific competencies, interacting in common spaces, where everyone has knowledge, regardless of the specialty of each professional, and aims at the construction of care collectively and, consequently, at comprehensive health care (7) .
The work of nurses in the primary healthcare area is close to this way of seeing the healthcare practice, shared with other professionals and considered common and relevant to any professional category.However, few categories are open for this new way of working in the healthcare area; most of them are restricted to their disciplinary core.Therefore, there is loss for nurses, who, in general, in the primary healthcare setting, present a widespread practice that prioritizes practice in the collective area in detriment of core actions, and distance themselves from their specific tasks that may be an identity referential.

METHOD Ethical aspects
The study initiated after approval of the project by the research ethics committee of the Federal University of Campina Grande/UFCG, in Cajazeiras campus.Ethical and legal aspects were observed in all phases of the study, in compliance with resolution 466/12 of the Brazilian National Health Council.

Theoretical framework
The core concepts of this study are based on concepts of Pierre Bourdieu (8) , according to which the field is understood as a social space of domination and conflicts with some autonomy, as well as with specific rules and social hierarchy.In this study, primary health care has adherence to this concept for representing a space of disputes, sharing of knowledge, and management of conflicts.In addition, it will be also understood that the professional identity of nurses in this healthcare area is linked to their habitus, for involving individual schemes socially made up of structured dispositions (in social) and structuring (in minds), acquired in and by practice, and constantly guiding of tasks and actions of daily practice.
In the face of the considerations presented, the following guiding question emerged: What is the meaning present in the speeches of nurses associated with habitus that conforms their professional identity in their daily practice in primary health care?In this sense, the objective was to analyze, in the speeches of nurses, the habitus that conforms their professional identity in primary health care.

Study design
Descriptive study with a qualitative approach, based on the concepts of Pierre Bourdieu.

Study setting
The present study was carried out with 48 primary health care nurses of two cities: Cajazeiras, small-sized, in the state of Paraíba; and Maracanaú, medium-sized, in the state of Ceará; being 16 nurses from the first city and 32 from the second city.

Data collection and organization
Semi-structured interviews were used as data collection technique, with guiding questions that encouraged speeches concerning the perception of nurses on their professional identity in primary health care.The interviews were carried out from March to October 2015 in a private place in the PHC units.The interviews had an average duration of 20 minutes.The nurses were individually recruited, through invitation letters in the PHC unit where they worked.The participants were ensured right to anonymity and privacy.These were identified by the letter N (Nurse), and arranged according to the order of the interviews, followed by the letters C (Cajazeiras) and M (Maracanaú) for the respective cities (N01C to N48M).

Data analysis
The study data were analyzed by means of discourse analysis (DA), understanding that this is supported for the understanding of meanings interconnected to time and space of practice, mediated by speech, history, and its social context, being this speech still seen as a space of understanding among language, ideology, and meaning for those who speak (9) .
Regarding procedures of analysis, one of the first aspects to consider is the constitution of the corpus.It is understood that the best way of meeting this issue of constitution, is to elaborate discursive assemblies that follow criteria resulting from theoretical of DA based on the objective the analysis, and that enable their understanding.This objective, in line with method and procedures, is not aimed at demonstration, but to show how a speech works producing (effects of) meaning (9) .Therefore, DA is a mechanism used to interpret traces and clues left by individual over corpus.For this purpose, Orlandi (9) directs three stages, which were covered throughout this analysis: transition from language surface to discursive object; transition from discursive object to discursive process, and transition from discursive process to ideological formation.
Only nurses who worked for more than 12 months in the PHC units were included in the study.The exclusion criteria were nurses who were on vacation, medical leave, or other type of leave.

RESULTS
The reports present in this study are directly linked to discursive formations that come from an ideological formation, thus allowing nurses-speakers to elaborate their speeches and report them under a specific social, historical, and cultural context.
Therefore, in the present study, the discursive formations point out to nurses who, in their working process, associate their professional identity with the meaning of the word "everything", as shown in the following reports: In my working experience, nurses often have to do everything.Then, if the nurse is not in the unit, things do not work, right?I think that nurses who work in this unit would be a kind of everything.They would be the foundation of the primary healthcare unit.(N01C) It is an important role, because I think that nurses who work in primary health care have to do everything.Even the users say that when we are here, things get easier, since we do everything to solve problems.This feedback is rewarding.(N36M) It is worth mentioning discursive formations that point out to a negative meaning in the understanding of the participants in this study, regarding nurses who have to do everything in the primary healthcare area: Unfortunately, nurses are always adding, adding, adding tasks and roles […] what I feel is that sometimes, we have to stop being nurses in order to be everything.Then, sometimes, we have to refrain from doing properly what we have to do, in order to handle many things that we are not supposed to do, making it difficult to provide appropriate care.(N47M) There are also discursive formations in which, by doing everything, nurses create their own image according to other professionals, becoming like them, and embracing duties that would belong to other categories.This outlook distorts the professional identity of nurses, as presented below: So*… I end up doing everything.Things that are not of my competence…I had to do things for the social service, understand?I resolved things that physical therapists and doctors were supposed to do.(N07C) Sometimes I say that nurses are psychologists, social workers, nutritionists, they are everything [...] this happens many times here and, sometimes, because we have to resolve so many problems, we do not see ourselves as nurses.(N32M) In addition, there is a discursive formation that points out to practice that demands time of nurses, since they are responsible for everything, including tasks that administrative technicians could do, thus encouraging the absence of these professionals in spaces where they could carry out actions that meet principles and guidelines of the primary health care, aligned with the Brazilian Unified Health System (SUS, as per its acronym in Portuguese).

Everything depends on me in order to work. This is our role. If we do not have gas and I do not look for it, there is no gas. If I do not check the water bill, there is no water. Then, everything depends on us. (N07C)
The service does not work if I am not here.Nurses are the key of primary health care.I see that this is my real role and I can handle everything.From the light that is burst until medicines that did not come to the unit.This ends up overloading us and even making it difficult to provide better care for the population.(N30M) Another aspect that emerged from the discursive formations was the feeling of not belonging to a specific group of professionals.Due to the overload of tasks, sometimes far from the nurses' own core of practice, the feeling of invisibility emerges:

It is like this*… unfortunately, I see myself like a tiny drop in the ocean. There are so many things to do. Nurses of the unit have great responsibility. They have to do everything […] so, unfortunately, I see myself like a drop in the ocean, due to this amount of tasks […] I see that we end up getting lost and becoming invisible*… which is very sad. (N04C)
I was talking to the doctor [doctor of the unit] that some days, it seems that we do and do so many things, and sometimes, it seems that we are not doing anything… This is because we take on everything, the management demands too much.We do so many things that sometimes, we feel like we are invisible due to this feeling that we are not doing anything specific.(N17M)

DISCUSSION
Primary health care may be understood as a field, where there are several permanent agents that seek to aggregate capital, that is, properties that are recognized as values (economic, cultural, social, and symbolic) by agents, and this capital accumulation is the determining factor of their position and place where they will occupy in the area.
It is possible to characterize primary health care as an area of strength and fight, for its maintenance or transformation.Its functioning depends on the existence of objects in dispute and individuals endowed with habitus that enable them to know and recognize the immanent rules of the game, for seizing gains and symbolic rewards resulting from it.In this perspective, primary health care is also understood as a space where knowledge is developed and practice is constructed around objects that are based on its existence; however, concomitantly, it is understood as spaces of dispute for everything that makes it move.
In the present study, the professional identity of nurses in the primary healthcare area may be understood from the interaction of the habitus and accumulated capital.For Bourdieu (10) , habitus is defined as a system of durable and transposable dispositions, that is, ways of perceiving, thinking, feeling, and doing that reflect in the agents' way of acting in a given area.
In primary health care, as an area of position dispute, nurses enter in what Bourdieu calls a "game", trying to aggregate more symbolic capital (recognition) and, as a consequence, a redistribution in this social space.This game, with its own rules, has as object of dispute, more prestige and valuation, making nurses, sometimes consciously or unconsciously, and even by imposition in specific situations, to embrace the practice of doing everything as something "natural" in their daily practice, as shown in the speeches, with the purpose of aggregating more symbolic capital in the primary healthcare area.
The rules of this game, taught by and for the social environment, will influence the objective structures that become the matrix of dispositions, that is, the habitus, making practice and perceptions involved in doing everything to become a behavior condition socially recognized by nurses in this primary healthcare setting.
This behavior and propensity acquired by nurses for a specific way of action in doing everything, in the logic of Bourdieu (10) , are not a product of conscious and calculated choice, but of a basic unfamiliarity with themselves, which forms their social being and identity.
Therefore, in the meaning of the speeches of the participants in this study, nurses emerge as the unit foundation, for embracing in their practice and perception that they must do and be everything, which would provide more symbolic capital in their understanding.However, this situation ends up constituting a habitus that directs to a range of daily actions, many times far from the core of knowledge of these professionals, and consequently, to a professional identity with confusing and inaccurate delimitations.
It is observed in the speeches that, in adding a range of tasks to their daily practice, the participants in this study feel that they stop being nurses in order to be everything in the primary healthcare area, compromising their professional identity, in addition to encouraging the loss of working space and autonomy, and consequently, the devaluation of the profession and social fragility of this category (11) .
It is understood that the indispensability of nurses must not be linked to doing everything, but the fact of undertaking actions that may express the core characteristics of this profession, such as periodic follow-up of the population, organization by means of supervision of the services of primary healthcare units, and encouragement to empowerment of social actors by means of dialogue of educational actions.
According to the speeches, there is the sense that nurses, when assuming a range of tasks, including those that belong to other categories, end up entering the space of competencies of these other professionals, which distances them from their core of knowledge, and consequently, the feeling that professionals in this category, in specific situations, do not see themselves as nurses.
This outlook is strengthened when interdisciplinarity is not understood and carried out, since the same could be an alternative for sharing tasks, with an aim at collective construction of care and comprehensiveness of healthcare actions, which could prevent nurses from undertaking this range of tasks, and consequently, feeling that they do everything in this primary healthcare setting.
This situation of imprecision of nurses' real duties in primary health care is not specific of the Brazilian territory, as it was also pointed out in Canada (12) , Australia (13) , Bahrein (14) , and Ireland (15) , where there is not yet delimitation of the activities of nurses in this area.This weakens this category's social and professional recognition (6) , showing that the problem is the specification of the professional identity of nurses in primary health care, present in the Brazilian and international context.
In addition, according to the speeches, nurses add several actions expressed in their habitus, which could be delegated to other professionals, even to those without higher education, such as issues related to light, cleaning, and gas of the healthcare unit.These duties end up demanding time, making nurses to distance themselves from care actions that should be provided to the community under their responsibility.
In committing themselves to this range of duties, nurses overwork, and this consequently reinforces the idea of a professional always busy, encouraging unavailability for dialogue and causing their distancing from the team and the community (16) .
It is worth mentioning that in several times in this study, it was possible to observe in the discursive corpus, that the participants move the meaning of professional identity to the term "role", thus characterizing the prevalence of a metaphoric slide.
Metaphors are responsible for slides of meanings, drift, and transference.The meaning is always a word, a proposition for another word, and this overlapping metaphor, by which significant elements end up confronting so they cover themselves of a meaning, could not be predetermined by properties of language.Meanings only exist in relations of metaphor of which specific discursive formations become the place more or less provisory (9) .
In this perspective, professional identity linked to habitus cannot be only restricted from the undertaking of specific roles, since it results from the congruence of ideas, roles, historical, social, economic, and cultural aspects, forming elements whose meaning is to attribute nurses with unique characteristics and impressions of themselves, as a specific and comprehensive professional category, crucial to healthcare teams (17) .
Based on the discursive corpus, it is observed that, in the performance of their practice in the primary healthcare area, nurses express feelings of anguish and suffering due to numerous tasks that involve their daily practice.This characteristic of polyvalence, due to the lack of practice limits, as well as institutional demands, generates the sense of devaluation and invisibility of this professional.
In this regard, the achievement of recognition and visibility of nurses is not in doing everything in primary health care, but founded in the construction of specific competencies corresponding to the core of knowledge of the profession, as well as in qualities present in the development of care plans, such as initiative and safety (18) .
Therefore, when nurses clarify their object of work, that is, care, and embrace knowledge, skills, and attitudes inherent to their practice in the primary healthcare area, to the detriment of trying to do everything, they enable a habitus that encourage the visibility of this profession, in addition to contributing to changes in this healthcare setting.

Study limitations
The limitation of the present study is associated with the non-generalization of its results to all primary healthcare settings, since these results represent the speeches of nurses who provide care in primary health care.

Contributions to the nursing area
Nurses' greater visibility and feeling of belonging to a specific category will come with the conformation of their professional identity, which will enable the definition of particular competencies, autonomy, recognition, as well as support in decision making on issues inherent to duties of this profession in the primary healthcare area.

FINAL CONSIDERATIONS
The aim of the present study was to investigate the professional identity projected by the speeches of nurses who work in the primary healthcare area, based on daily practice.In the attempt to unmask habitus of these professionals, it was necessary to immerge into the discursive corpus, in order to disclose the apparent transparency and linearity of the speeches, with the purpose of showing the relation between the nuclear concepts of Pierre Bourdieu and the professional identity of nurses in this practice setting.
In their daily practice, nurses associate their professional identity with the meaning linked to the word "everything", which would apparently grant them more credibility.However, at the same time they seek more recognition when they are responsible for a range of tasks, this generates negative feelings, such as discontentment, disappointment, and invisibility.
This situation also favors the distancing from the essence of the profession, since they assume duties of other professionals, generating the feeling of belonging to these categories and not to nursing, as observed in the discursive corpus.This outlook provides excessive demand of activities for nurses, making them distance themselves from direct care, and consequently, they feel fragility in their professional identity.
Finally, it was observed that trying to do everything in primary health care actually generates negative repercussions in the professional identity of nurses.Therefore, strategic guidance is necessary in order to achieve and embrace elements that reflect the essence of this category, such as clinical practice, semiology, and semiotechnique associated with embracement, bond and listening, expressed for example, by means of nursing consultation and educational actions, which may enable more autonomy, as well as symbolic capital, that is, more recognition, credibility, and visibility to nurses in the primary healthcare area.
To this end, not only the delimitation of professional identity is crucial, but also its internalization in disposals, which will form a habitus that will externalize practice and perceptions according to the essence of nurses in the accomplishment of their working process in the primary healthcare area, thus avoiding the invisibility of their professional identity and tears in the rain.