FAMILY HEALTH STRATEGY PROFESSIONAL SATISFACTION IN BRAZIL: A QUALITATIVE STUDY

SATISFACCIÓN DE LOS PROFESIONALES DE LA ESTRETEGIA DE SALUD FAMILIAR EN EL BRASIL: UN ESTUDIO CUALITATIVO

ABSTRACT

Objective:

To identify work aspects that generate satisfaction for the professionals who work in the Family Health Strategy.

Method:

This was a qualitative, descriptive study that involved five geographical regions of Brazil, and 27 Family Health Teams from six municipalities. The data were collected from 76 health professionals using semi-structured interviews, and were analyzed articulating the three phases of content analysis using Atlas.ti software resources.

Results:

The findings showed 129 statement excerpts, with 14 codes, grouped into three categories related to satisfaction. The category, Job Identification and Family Health Strategy Principles, represented 40.3%, with the codes: team work, job affinity, health model, completeness of care, and longitudinality of care. The category, Relationship with Family Health Strategy patients, represented 32.6%, with the following codes: bonding with patient, resoluteness of care, patient satisfaction, and patient care. Finally, the category, Professional and Working Aspects related to the Family Health Strategy, represented 27.1%, with the following codes: relationship with professionals, work recognition, enjoying the profession, team organization, and employment relationship.

Conclusion:

Professional satisfaction is associated with the work principles of the Family Health Strategy, and with the relationships that are established between patients, professionals and health management. It also has a subjective dimension, with a strong relationship with characteristics of the work process, how it is organized, and under what conditions and relationships this work occurs.

DESCRIPTORS:
Primary health care; Family health strategy; Working conditions; Job satisfaction; Qualitative research

RESUMEN

Objetivo:

Identificar los aspectos del trabajo, que generan satisfacción en los profesionales de salud que actúan en la estrategia de salud familiar.

Método:

Estudio cualitativo que incluye 5 regiones geográficas del Brasil, 27 equipos de salud familiar de 6 municipios. Los datos fueron obtenidos, a través de 76 profesionales de salud por medio de entrevistas semi estructuradas y analizados, articulando las tres frases de Análisis del Contenido y los recursos del software Atlas ti.

Resultados:

Seleccionaron 129 extractos de conversaciones, 14 códigos agrupados en 3 categorías relacionadas a la satisfacción. La categoría Identificación con el trabajo y principios de la Estrategia salud de la familia, representó 40,3%; tuvo los códigos: trabajo en equipo, afinidad con el trabajo, modelo de salud, integralidad de la asistencia, longitudinalidad del cuidado. La categoría, Relación con los Usuarios en la Estrategia salud de la familia, representó el 32,6% con los siguientes códigos: vinculo con el usuario, resolutividad de la asistencia, satisfacción del usuario y asistencia al usuario. Finalmente, la categoría Aspectos Profesionales y de Trabajo, relacionados con la estrategia salud de la familia, representó 27,1% con los siguientes códigos: Relación con los profesionales, reconocimiento del trabajo, gusto por la profesión, organización del equipo, vinculo del trabajo.

Conclusión:

La satisfacción del profesional está asociada a los principios del trabajo en la Estrategia Salud de la Familia, a las relaciones que se establecen entre usuarios, profesionales y gestión de la salud. También posee una dimensión subjetiva, fuertemente relacionada con las características del proceso de trabajo, como se encuentra organizado, sus condiciones y relaciones.

DESCRIPTORES:
Atención primaria de salud; Estrategia de salud familiar; Condiciones de trabajo; Satisfacción en el trabajo; Investigación Cualitativa

RESUMO

Objetivo:

Identificar os aspectos do trabalho que são geradores de satisfação para os profissionais que atuam na Estratégia Saúde da Família.

Método:

Estudo qualitativo do tipo descritivo que envolveu 5 regiões geográficas do Brasil, 27 equipes de Saúde da Família de 6 municípios. Os dados foram coletados com 76 profissionais de saúde por meio de entrevistas semiestruturadas e analisados articulando as três fases da Análise de Conteúdo e dos recursos do software Atlas.ti.

Resultados:

Indicaram 129 trechos de falas e 14 códigos agrupados em 3 categorias relacionadas à satisfação. A categoria Identificação com o trabalho e princípios da Estratégia Saúde da Família representou 40,3% e teve os códigos: trabalho em equipe, afinidade com o trabalho, modelo de saúde, integralidade da assistência, longitudinalidade do cuidado. A categoria relações com os usuários na Estratégia Saúde da Família representou 32,6% com os seguintes códigos: vínculo com o usuário, resolutividade da assistência, satisfação do usuário, assistência ao usuário. Por fim, a categoria aspectos profissionais e trabalhistas relacionados à Estratégia Saúde da Família, representou 27,1% com os seguintes códigos: relação com os profissionais, reconhecimento do trabalho, gostar da profissão, organização da equipe, vínculo de trabalho.

Conclusão:

A satisfação profissional está associada aos princípios do trabalho na Estratégia Saúde da Família, as conexões que se estabelecem entre usuários, profissionais e gestão em saúde. Possui ainda uma dimensão subjetiva, possuindo forte vínculo com características do processo de trabalho, como esse é organizado e sob que condições e relações o trabalho acontece

DESCRITORES:
Atenção Primária à Saúde; Estratégia Saúde da Família; Condições de trabalho; Satisfação no trabalho; Pesquisa qualitativa

INTRODUCTION

Health work can be conducted in different public or private areas of Brazil, and one of these is the Family Health Strategy (FHS), which is based on the principles of Primary Health Care, and which is a privileged strategy for reordering the Brazilian health care model.1

The achievements from the establishment of the FHS have been significant for the health sector and population, providing: increased access to medications and tests; increased vaccine coverage; a decline in infant mortality; a reduction in hospitalization indicators due to stroke and congestive heart failure, among others.2

Brazil has more than 41,000 Family Health Teams (FHt), which are present in more than 97% of Brazilian cities, covering more than 66% of the population. The impact of the FHS on the health workforce is that it represents more than 14% of all health facilities in the country and, consequently, it is one of the main jobs for health professionals in Brazil.3

The FHS model facilitates a greater bond with patients, by integrating care actions inside and outside the Basic Health Unit (BHU), which requires broader skills and competencies, considering the precepts of the expanded clinic.4

The professionals that compose the FHS are often forced to deal with unsatisfactory working conditions, poor wages, moral harassment, violence, fear, demands for regulatory compliance, among other aspects that negatively interfere with their professional performance. Nevertheless, the FHS can also be a place that promotes satisfaction.

When we receive recognition for the usefulness and quality of care, we have intense satisfaction in our relationship with the work. Therefore, work recognition is indispensable, in the daily practices and in the locus of the worker performance, which can transform suffering into pleasure, because it is "experiencing the work, facing the reality, by suffering and finding solutions, that misery finally turns into pleasure.” 5^:51

The levels of job satisfaction have declined over the decades,6 and a significant number of studies have addressed this topic, in particular those related to job satisfaction in primary health care (PHC).7^-10

However, no study was found that explored a multiprofessional analysis of job satisfaction at FHS, using a macro scope, as in the case of the Brazilian territory. Thus, this study aimed to identify the aspects that generate satisfaction of health professionals who work in the FHS.

METHOD

This was a qualitative,11 descriptive study, based on historical-dialectical materialism for analysis of the work process12 and on Christophe Dejours' theory of work satisfaction.5^,13^-14

The selection of participants was established by convenience sampling, with the sites to perform the research selected following inclusion criteria: presence of collaborating researchers in the FHS of the five geographic regions of Brazil (South, Center-West, North, Southeast and Northeast), including at least one city and state in each region; FHt rated as above average or much above average in the evaluation or the National Program for Access and Quality Improvement in Primary Care; FHt with all components of the minimum team, at least, as recommended by the National Primary Health Care Policy (NPHCP).1

Exclusion criteria were: health centers in which the two models of assistance coexist [traditional model and FHS]; team workers who are not health professionals, which excludes community health agents and administrative, cleaning and support staff.

The data were collected between November of 2010 and April of 2014, using semi-structured interviews containing closed-ended questions about participant characteristics, and open-ended questions regarding professional motivation, and especially the challenges and potential for satisfaction and dissatisfaction in the scope of the FHS.

A total of 76 participants were included: 42 nursing professionals (nurses, technicians, and auxiliaries), 19 dental professionals (dentists, dental technicians, and auxiliaries), 13 physicians, one psychologist, and one pharmacist. This sample was considered sufficient by data saturation criteria. The scenario of participants' performance involved the five geographical regions of the country, 27 FHt of 11 Health Centers, corresponding to six cities: Belém/PA, Natal/RN, Rio de Janeiro/RJ, Brasília/DF [two administrative regions], Coronel Vivida/PR, and Pato Branco/PR. This number of participants was considered sufficient by the data saturation criteria.15 Duplication of findings, and the lack of new data that would expand the object of investigation contributed to sample saturation, and consequently the number of study participants.

The analysis process was supported by the software for qualitative data analysis, Atlas.ti¹⁶, and was based on the precepts of content analysis¹⁷ structured in three phases: pre-analysis, material exploration, and interpretation. The relationship between content analysis and the Atlas.ti software was conducted from the selection of the personnel statements, establishment of codes, and code groupings according to thematic proximity. The selection of the statement excerpts and the naming of codes were guided by the objective of the research, and the theoretical basis on which the study is anchored.

The most significant statement excerpts that could be associated with more than one code were used to compose the results.

The anonymity of participants was guaranteed, using an alphanumeric code combined with the initials of the professional category and the geographical region, followed by a cardinal number.

RESULTS

The results generated 129 statement excerpts and 14 codes, grouped into three categories. Figure 1 shows the relationship of the categories with the codes.

Figure 1 -
List of codes and categories associated with job satisfaction of Family Health Strategy professionals.

Job identification and Family Health Strategy principles

This category represents 40.3% of the statements, and is comprised of five codes: team work, job affinity, health model, completeness of care, and longitudinality of care.

The FHS engenders multiprofessional, team-oriented work. The possibility of professional integration, a union aimed at a specific care purpose, and establishment of partnerships provide satisfaction.

What increases my satisfaction is the team integration. I think it is very important, [...] we are able to work in partnerships, all the professionals, and also with the other services of the health department (NS1).

The identification with the care provided also enables satisfaction of participants, either by means of the required competencies of each professional, or the health care model proposed in the FHS. This job affinity is associated with the health promotion and disease prevention actions that professional practice in this model makes possible.

My satisfaction is working here, being part of the FHS. I like how FHS is proposed, organized, it enables us to provide prevention, something that we don't do in the private office, where we only do the curative part (DPCO2).

The completeness allied to the longitudinality of care was expressed as the possibility of considering the patient as a whole, not only his physical problems, in order to take into account his history, and follow him through the different periods of life, enabling the professional the opportunity of continued care based on the idea of an extended clinic.

You are here and perceive the patient's evolution. When you identify an improvement, you can follow the outcome. In the emergency room you do not follow up with the patient, you do not know what happened to him, and you never see him again; here in FHS you can follow up the patient's evolution, and this makes you satisfied (PhyCO1).

Relationship with Family Health Strategy patients

This category represents 32.6% of the statement excerpts, and combines four codes: bonding with patients, resoluteness of care, patient satisfaction, and patient care.

The possibility of establishing a relationship with the patient and of exercising one’s profession with commitment and appropriate quality standards contribute to the satisfaction of professionals, according to the following statements:

Bonding with the patient satisfies me a lot. I don't see him only as a patient, I can also see him as a community resident, and we can contribute with the community (NSE3).

The ability to solve the problem, with patient satisfaction as a consequence also provides satisfaction to the professional.

A patient arrived with his mouth in a terrible situation, tartar, plaque, and such a situation. He came all sloppy, and we began to talk about the importance of mouth health, which reflects on the body’s health, and on appearance itself, self-esteem. Then we started talking about it and doing the treatment at the same time, in the chair. Suddenly I was so happy, so satisfied when in the second session he came tidier. A lot had to be done in his mouth and the treatment was long. When the treatment was finished he said: Sir, I am thinking about using an orthodontic appliance. I was so happy; for someone who didn't even brush his teeth properly, now he wants to wear braces, which for me was the glory, total satisfaction. I said: Look at how this man has changed. (DPNE4).

Professional and working aspects related to the Family Health Strategy

This category represents 27.1% of the statements, and consists of five codes: relationship with professionals, work recognition, enjoying the profession, team organization, and employment relationship.

The coexistence with other professionals in the care practice, and the relationships that are established among them, have collaborated to increase the levels of satisfaction, as noticed in the following statement:

The friendly relationship between team members is what holds me here the most. I've already thought about leaving, I've already had a proposal to go to another health center, I've even arranged for a transfer to be closer to where I live. This good team relationship holds me here. We are very involved with each other; we share responsibilities. I don't know if this climate will be found in another place (NTCO3).

The recognition from patients, managers, and even the professionals who are part of the team, regarding the care provided at FHS is another aspect that contributes to satisfaction. The following statement demonstrates how work recognition can be a reason for satisfaction.

When you see the recognition of the patient. When you are caring for that patient, and you provide some specific care, even health education, you can perceive the feedback, of him or her really taking the care process seriously, concerning about care; caring, then, this satisfies me (NSE3).

Another conditioning factor for work satisfaction at FHS is enjoying the profession or the work that the professionals do. The following statement expresses the importance of enjoying the profession and the work as a fundamental factor for satisfaction.

I am doing what I like. I am practicing everything I learned at the University, at the graduate level. I am working with people, with people who need my service; I am satisfied (NNE2).

Satisfaction is also expressed when the team, or the actions provided, are organized. The team organization is both in relation to the definition of competencies and roles for professional performance, regarding the possibility of having some space for professionals to discuss aspects related to the organization of work, or even the organization of the flow of care for the patients.

The fact that we can sit down to discuss the teamwork process is a positive point, the team meetings. We work happier when we can decide collectively; the processes here are not imposed. I consider it a very positive point, this movement to discuss and decide strategies with other team professionals in the meetings for the best functioning of the unit (PhyCO2).

The possibility of being employed, combined in some cases with the guarantee of job stability due to having a government-funded position, were other factors of satisfaction that combined into this category, as described in the following statement.

I took the course thinking about the public position; the salary is attractive, the contractual form with the State Health Secretariat is a system that generates tranquility, stability; I think that give us peace of mind and satisfaction (DPTCO1).

DISCUSSION

The results show that professionals’ satisfaction with working in the FHS is related to multiple factors, which are mostly linked to subjective aspects, but are materialized in work practices.

Satisfaction related to one's identification with the work developed in FHS, and the attributes of PHC, implies the adoption of a broader concept of health and understanding of the health-disease process. It proposes the articulation between technical and popular knowledge, and the mobilization of institutional and community resources to face health problems.

The precepts of the FHS provide integral accountability for care of the health needs of the entire population, prescribing a reorganization of the Brazilian health care model, anchored in principles such as universality, equity, completeness of care, and longitudinality.2

In turn, it also requires a multiprofessional performance that is configured in a collective action of reciprocity and interaction among the different professionals. The relationships established in the workplace, and the possibility of developing collective and integrated work with other team members, is one of the central elements of satisfaction among the professionals who work in FHS.

The participants of the study understand completeness to be a daily exercise for achievement of this term in the daily life of the FHS, much more than as a mere concept or principle highlighted in the constitution of the Brazilian Unified Health System. One sense of completeness is the possibility of caring for individuals or collectivities in a manner that transcends traditional care practices.4 Providing professionals with an opportunity to act in a manner that surpasses the practice of focusing on the disease, focusing on the exercise of completeness, contributes to the establishment of elements that provide professional satisfaction.

What allows the principles of the FHS to be understood as aspects that provide satisfaction is precisely the manner in which the work process is constituted. In other words, exercising professional competencies in a FHS perspective necessarily requires a different work performance; the instruments need to be broader, the workforce needs to be more competent, and the product is differentiated depending on some situations.12^,18^-19

However FHS establishes rules and routines that are linked to prescribed work, and guide the thinking and doing of each professional. However, the work is not a mere execution of a prescription,14 because each individual manages his/her own work, considering values and concrete possibilities of practice environments.

At the FHS, professionals do not feel they are mere enforcers of prescribed norms, they act with the possibility of exercising creativity when dealing with multiple and complex demands offered by the assigned population. In this process, the health professionals can reinvent themselves and their own work,13^-14 as the different subjects manage the realities found in a unique way.

The FHS offers this possibility of reinvention, of making actions more flexible in real work. Even guided by a set of prescriptions and routines that are repeated daily, the professional, in the execution of his work, has the opportunity to renew himself, to do it differently, and get satisfaction.

In that sense, the gap between real and prescribed work must be filled, by realizing that the act of work "must be, at every moment, invented or discovered by the working individual”.13^:28 The opportunity of professionals to use their abilities for cooperation and interaction with other colleagues, and the freedom to choose their manner of action at work, are elements which provide satisfaction.

The results of this study also indicate that FHS professionals feel satisfied when they are recognized for their work, whether by patients, team members, or managers. Being recognized also implies being seen, perceived, and felt because of the work they do. When the professional is recognized by his/her peers, by managers, and by the patients, regarding their usefulness and quality of work, he/she demonstrates satisfaction. This finding comes close to the idea that recognition confers belonging to a team, to a collective, to a profession, and enables the one who works to transform difficulties into the development of his/her own identity.14

Work is understood to be a source of satisfaction and creation, when it meets needs, and promotes the transformation of the object and the human being in a pleasant manner, and in this perspective, the professional sees himself in the work he executes.12^,19 Additionally, the professional can invent convenient solutions for confronting prescriptive actions promoted by organizations.

Just as an artist is recognized for his work, whether from the brush marks in a painting, or on stage with his live performance, the FHS professional finds, in professional recognition, the possibility of job satisfaction, as work transforms the professional, and enables him to advance, achieve capability, and become self-fulfilled.

Work is the result of action, it is a product,12 and appreciation of the work as satisfaction is materialized in the recognition of the patient, by a successful performance of health care; by other professionals, when they understand the individual performance of each team member, or the collective performance as essential for the good functioning of health services; and finally, by the managers, when they understand that the work of the professional must be considered in all its aspects, the quantitative technical aspects, but also the subjective dimension.

Another aspect of satisfaction lies in the ability to establish good job relationships, as working is not only about producing, but also about coexisting.14 Establishing good job relationships provides an opportunity for satisfaction, and for this to be accomplished, cooperation is necessary. Employing organizations sometimes do not contribute to the establishment of good working relationships, hindering and even disrupting the possibility of establishing cooperation, i.e., of living together at work.13^-14

The importance of good relationships among professionals is evident when one realizes that the majority of the weekly journey of FHS health professionals is 40 hours, with the exception of physicians who have two more possibilities for contracts (20h or 30h). The result is a dedication of at least one third of the day to the professional role, not counting the time of commuting to the workplace.

Appropriate and positive communication among co-workers enables more satisfaction, and reduces tension, but the effective communication with patients also influences professional satisfaction.20

The interaction with other professionals of the team was found to be a component to promote satisfaction,21^-23 and it enables adequate functioning of the service, helping professionals to have more resolute attitudes, and the population that benefits from the service is also satisfied with the services provided.

This means that professionals spend more time working than with their families or in leisure and rest activities. With this time dedicated to work, relationship between team members is more significant, as are those with patients and managers.

This need for cooperation in a place where a considerable amount of time is spent, is not something easy, it first assumes the worker's willingness to overcome the difficulties of the relational work environment, and the conflicts that can arise from disagreements that occur from different manners of work.13^,14 However, it is something that must be requested everyday in the services to make the work more satisfactory. Therefore, professionals must develop strategies of trust and solidarity, because "the work is inseparably a rule of civility, conviviality, and living together”.14^:370

The guarantee of having a job and a stable employment relationship was also associated with satisfaction, in line with another study.7 In the health sector, especially in the PHC, employability and a secure employment contract have increased in recent years, but there are still a significant number of professionals who are not hired under these contractual rules.24

Salary issues were not highlighted in this study. This aspect is close to what has been exposed in studies on professional valuation, which indicate that remuneration is something very important for the professional, but cannot be treated as the only factor in valuation.

The fact that one earns more does not necessarily lead to workers expressing feeling more valued; however, specifically this aspect differs from a worldwide tendency for APS to associate satisfaction with better wages.25^-26

An aspect not mentioned in this study is the absence of satisfactory elements linked to the physical structure, the guarantee of material, equipment, and work resources. The working conditions related to infrastructure are approached as factors of satisfaction, as they influence the professionals’ health, and also the manner in which they act.22^,-23^,27

The sites of the BHU that were part of the survey did not fully meet the minimum structural requirements for architectural programming of functional health units, as determined by the Brazilian Ministry of Health and NPHCP.1 Thus, increasing the satisfaction of professionals at the FHS, and guaranteeing improvements in physical and structural working conditions are fundamentally important.

The study presents limitations regarding the time used for data collection, nearly three and a half years. Considering the dynamics of reality, data collection, which occurs at different historical moments, may influence results, considering changes in local political issues.

Another aspect that may have interfered in the data collection were the conditions under which some interviews were conducted, because due to certain structural deficiencies of the FHS, and the excess of demand, some interviews were conducted under poor conditions, such as with participants standing, or in the corridor, or even when the professional was eating. This situation implied fragilities of some statements, which could possibly interfere in the results of the study.

CONCLUSION

The analysis of work satisfaction of health professionals within the FHS identified that satisfaction is a complex phenomenon with a subjective dimension, but that it has a strong relationship with work characteristics, how it is organized, and under what conditions and relationships it is developed.

The very model of FHS care can contribute positively to satisfaction, especially in situations where the professionals are allied with the principles that guide this model of care.

The establishment of good relationships within the team, and with the patients themselves, was indicated as a promoter of satisfaction. For this, it is necessary to maintain cooperation among peers in their workplace in order to overcome routine conflicts in care practices.

The recognition resulting from the team, the patients, and the health managers provides satisfaction, and also an opportunity to give the professional a capacity to perceive himself in the work he is doing, to believe that he is the protagonist of health care actions, and to know that professional performance is essential for the good functioning of the health care service.

The findings also contribute to an explanation about satisfaction in health professional work, and can be useful to enhance improvements in institutional relationships with professionals, especially regarding the assessment processes, which mostly happen considering the prescribed work, with little emphasis on the aspects of the real work, and much less on the subjectivity of those who perform it.

ACKNOWLEDGEMENT

To the National Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq, for the PhD fellowship, process number 233152/2014-8, and to the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES, for the PhD fellowship, between the years 2012 - 2015.

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NOTES

• APPROVAL OF ETHICS COMMITTEE IN RESEARCH

  Approved by the Research Ethics Committee of the Universidade Federal de Santa Catarina opinion 723695, Certificate of Presentation for Ethical Appreciation (CAAE) Number 25557614.0.0000.0121

Publication Dates

• Publication in this collection
  01 June 2020
• Date of issue
  2020

History

• Received
  22 Apr 2018
• Accepted
  06 Aug 2018