Nursing workloads in family health: implications for universal access1

Objective to identify the workloads of nursing professionals of the Family Health Strategy, considering its implications for the effectiveness of universal access. Method qualitative study with nursing professionals of the Family Health Strategy of the South, Central West and North regions of Brazil, using methodological triangulation. For the analysis, resources of the Atlas.ti software and Thematic Content Analysis were associated; and the data were interpreted based on the labor process and workloads as theorical approaches. Results the way of working in the Family Health Strategy has predominantly resulted in an increase in the workloads of the nursing professionals, with emphasis on the work overload, excess of demand, problems in the physical infrastructure of the units and failures in the care network, which hinders its effectiveness as a preferred strategy to achieve universal access to health. On the other hand, teamwork, affinity for the work performed, bond with the user, and effectiveness of the assistance contributed to reduce their workloads. Conclusions investments on elements that reduce the nursing workloads, such as changes in working conditions and management, can contribute to the effectiveness of the Family Health Strategy and achieving the goal of universal access to health.


Introduction
Universal access has been one of the main challenges for health systems worldwide. Currently, it has assumed so significant role that it is under discussion its inclusion as one of post-2015 millennium development goals (1)(2)(3)(4) .
Ensuring universal access is extremely relevant for human life and it means a great challenge for the countries and professionals of this field (2)(3)5) .
The meaning of access to the health actions and services that people need involves values such as justice and equity, which could not be incorporated into the concept of coverage. The universal coverage concept often refers to the amount of the population covered by health services, which does not mean that this number of people use the service or that the health service is able to meet the multiple and complex health needs (6) .
The work of health professionals lies in the service sector, involves a relationship between subjects of the same nature (human beings), and the work outcomes depends on collaboration between those who care and those who are cared. Furthermore, like the work of other sectors of the economy, it is heavily influenced by specific conditions under which it is performed; the manner in which it's done and under what work conditions and labor relations (7) .
The special characteristics of work in health care and the importance of workforce for its development are recognized by the Global Health Workforce Alliance and World Health Organization (WHO). In the debate on coverage and universal access, these organizations prepared a report in which they state "A universal truth: no health without a workforce" (1) . Therefore, to achieve the goal of universal access to health it is necessary to focus on who does the work, how it is performed and under what conditions, in different historical and social scenarios. In this sense, the analysis of the workloads present in the way of working is a promising way to guide the provision of care to users/patients, and thus improve the quality of access to health services.
Workloads are elements found in the work process that synthesize the mediation between work and wear of the worker. Workloads interact with each other and with the body of who does the work. They do not act individually, but in combination with each other and determine the condition in which the worker faces the global logic of the labor process (8) . as strategic for universal access to health services (9) .
The FHS has been growing significantly in Brazil and, in March 2015, 37,944 family health teams had been deployed in 5,319 municipalities, with a national population coverage of 60.56%, which represents almost 118 million people (10) .
The FHS has expanded the access to health services and strengthened the principle of universality.
Nonetheless, the country is still facing serious problems to ensure universal access, equitable and comprehensive to all individuals (11) .
The way of doing the work, as well as the complexity of the work environments and conditions available for its completion, interferes with the quality and safety of the health care results at all levels of care (12)(13)(14) . The nursing team represents the largest category among healthcare professionals and plays a central role in health services and in the assurance of users' safety (15)(16)(17) .
In the FHS, nursing professionals are present in all teams and their work has an impact on the quality of care. Thus, to identify the workloads present in their routine helps to guide managers in the strengthening of positive factors and in the search for actions to reduce them, contributing to the viability of universal access.
Although nursing is essential for access and operation of health services, there are still major imbalances and gaps in the availability, distribution, composition, qualification and productivity of nursing professionals, which has implications in terms of quality and safety of services provided. Excessive workloads in the daily routine of the services, worsened by poor working conditions negatively affect the results, satisfaction and health of these professionals (14) .
Literature points out complex internal and external challenges to the profession as well as challenges at other levels such as historical, cultural, gender and field knowledge and fighting for appreciation of the important role that nursing plays in the health system (4) .
This study was based on the observation that health workforce is critical to achieving universal access and that the FHS is the preferred policy to achieve this www.eerp.usp.br/rlae Pires DEP, Machado RR, Soratto J, Scherer MA, Gonçalves ASR, Trindade LL.
goal and, in this context, nursing plays a relevant role in the healthcare sector and in the FHS. Consequently, the aim of this study was to identify the workloads of nursing professionals of the Family Health Strategy, analyzing their implications for the effectiveness of universal access.
For the analysis of the research results, theoretical approaches of labor process (7) and workloads (8) were associated.

Method
This is a qualitative study, in which it was Regarding the data collection, the description of the quantity and distribution of the interviews, observation notes and documents examined are shown in Table 1.   by a serial number. The observation note was identified followed by the first letter of the region.

Results
The results were sorted into two analytical categories: way of working in the FHS and increase in the workloads and way of working in the FHS and reduction of the workloads.

Way of working in the FHS and increase in the workloads of the nursing professionals
With regard to the increase in the workloads, in all three regions of the country, the major components identified are shown in Figure 1, created by using the Atlas.ti software. In the three regions of the country, the workload associated with excess of demand and territory overestimated were the most significant elements for the increase in the workloads of the nursing professionals, as illustrated by the following report.

Way of working in the FHS and reduction of the workloads
With regard to the way of working in the FHS, considering the reduction of the workloads, teamwork has been found as the most significant, as shown in

Discussion
In this study, the results showed a predominance of situations that increase the workloads of the nursing professionals. Among the elements that contributed to the increase of the workloads, are several elements related to the working conditions and management of the health system, of which the FHS is part.
The problem of working conditions has been repeatedly recognized as a serious problem in the health field in Brazil and, particularly in nursing, including deficits in the quantity and quality of the workforce, excessive working hours, deficits in the salary and problems in the work environment (14)(15) . Deficits in working conditions negatively influence the health of the nursing professionals and results of the assistance provided by these professionals (13)(14)(15)(16)(17)(18) .
With regard to the work overload, even considering the involvement of subjective aspects, it was identified that there is a discrepancy between demand and team's ability. Other aspects related to working conditions, Universal access is related to providing assistance to the entire population at all levels of the system (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) , considering the complexity of the needs in health. It includes the environment where the work is carried out, method of organizing work and how care is provided, as well as the relationship established between professionals and users. It is worth mentioning that health work is highly dependent on labor force (1) , therefore any initiative in this field requires focusing on who performs the work.  (20) .
The identity with the work and search for recognition and appreciation of the work, reinforce the capacity to act of the collective, offering prospects of coping of the adverse side of the work contexts. To believe that work has been carried out in the "right way" promotes satisfaction and, even in inappropriate situations, helps in the reduction of the workloads.
In Brazil, the definition of universal right to health It is worth mentioning that this study was carried out with an intentional sample, which limits its generalization.
However, it is important to note that even intentionally including teams considered as of good quality, deficits in the working conditions and in aspects related to the system management were significant. These findings suggest that more studies in this same perspective might be promising for further investments in health and advancement of knowledge in nursing and health.