Workloads of Nurses in the Family Health in Brazil: What the Literature Says

Introduction: Workload (WL) is expressed in the working process elements which when interacting with each other and with the worker’s body can materialize themselves into distress, many times as an attempt of adaptation to the work demands. The nurse’s work in the Family Health Strategy (FHS) exposes him to different types of WL and they can be divided into: Psychical, physiological, biological, mechanical and chemical.


Methods:
Integrative revision of the oriented literature through previous protocol, with data collected by two independent collaborators in the following data basis: PUBMED, LILACs, SCIELO and CAPES Bank of Theses in the languages described in Portuguese, English and Spanish in the period from 1994 to 2014. The study inclusion and exclusion descriptions obeyed requirements established by Ganong (1987) and Whittemore (2005). The Atlas.ti ® software was used as a resource for storage and analysis of the studies.

Results:
No research work specifically approached the WL of nurses in the FHS. There are seven research works that approach the workloads of family health teams, which include the nurses. A total of eight research works approach the health of the FHS teams topic in which it was possible to identify generator elements of WL. From the set of the studies it was identified the presence of psychical, physical, physiological, mechanical and biological loads with predominance of the first ones. There were not found chemical loads.

Introduction
The Family Health Strategy (FHS) consists of an innovative care model in relation to the biomedicine's model and integrates the National Basic Attention Policy (NBAP) [Soratto et al., 2015;Fertonani et al., 2015], formulated as a priority strategy to approximate the health activities to the precepts of the SUS [Brasil, 2012]. The FHS intends to assist the population according to its needs and the reality in which it is inserted, aiming at a best resolution of health actions, favoring a positive impact in the individual and/or collective health of the population [Brasil, 2012]. In this attention model it is estimated assistance made by the Family Health Strategy (FHS) multi-professional teams from which the nurse takes part and plays a fundamental role. Nurses are responsible for multiple activities in interaction with other teams' members.
In the context of their profession they carry out actions of the assistance, managerial and in the education field types [Pires, 2009]. Also according with the referred author, the nurse´s working process in the FHS aims at the production, maintenance, recovery and/or the promotion of individuals, families and/or communities attached to the FHS covered area. In addition to this purpose, it focuses the carried activity, which is developed with the purpose of contributing to the improvement of the population's health condition. It also can be mentioned, in this operation area, the execution of actions such as: direct care to the users and families in the Basic Units and homes; the nursing consultation; those related to the work organization and supervision of the team; the monitoring of health indica-tors; educative action in groups among many others [Bertoncini;Pires;Scherer, 2011;Paula et al., 2014].
The working conditions that those professionals face in the FHS, aspects of the professional formation itself, issues related to the team work, population characteristics or the way of organizing works in the FHS itself cause to happen not usually appropriated conditions to the proper execution of their work [Bertoncini;Pires;Scherer, 2011]. The working reality in the FHS also involves: environment precariousness in the Basic Unit; lack of inputs, equipment and human resources; difficulty to implement interdisciplinarity, unequal distribution of work, excessive managerial bureaucracy and assistance demands; pressure to the achievement of targets, and sometimes not in line with the reality in which the nurse is inserted; lack of support and lack of knowledge of the administrator regarding the FHS model; low pay not compatible with the excess of professional responsibilities; precarious employment relationship and little professional valorization from users, work mates and administrators are some of the demotivation elements to the professional nurse in his daily work [David et al., 2009;Trindade et al., 2014a;Trindade et al., 2014b]. Such elements, present in the nurse's working process in the FHS exert important influence over the working loads reflecting in his health and in the assistance quality spent to the user [Schmoeller et al., 2011].
The understanding of Workload (WL) in this study is based on the concept of Laurell and Noriega (1989). The authors conceive them as working process elements which interact with each other and with the worker's body causing stress. Since being stress a result of the worker's attempt of adaptation to the negative conditions in his work environment, what can cause loss of potential and/or effective, corporal and psychic capacity of those who carry out the work [Kirchhof et al., 2011]. Depending on the nurse's area of operation he can be exposed to different types of loads. Such areas can be divided into: psychical (prolonged tension, monotony, lack of autonomy); physiological (physical effort, break of the circadian rhythm, inadequate positions); physical (exposition to ionizing radiation, noise, humidity); biological (infectious and contagious diseases exposure, fluids and secretions, manipulation of contaminated materials); mechanical (working tools and materials in the work environment without appropriated conditions), and chemical (antiseptics, disinfectants, sterilizing agents, medicine manipulation) [Laurrel;Noriega, 1989;Kirchhof et al., 2011]. It is considered that the first two types of WL show their symptoms in the worker's body; the other ones are susceptible to be noticed in the work environment [Laurrel;Noriega, 1989].
Thus, to describe what the workload presented on the FHS nurses' work are that can cause fatigue, stress and damage to their health, is a promising way that can contribute with the search of actions to be taken in order to minimize them. The studies of the WL to which nurses are submitted can also contribute to the protection of those professional and for the improvement of the services provided. In this sense the present study has as its goal to analyze what has been published in literature regarding work loads of nurses in the Family Health Strategy in Brazil, identifying generator elements and relating them to the load types.

Methods
The literature integrative review was undertaken by two independent revisors based on the criteria established by Ganong (1987) and Whittemore (2005) aiming the reliability and the rigor of the findings. A protocol was elaborated (Appendix 1), according to Forte (2013) and validated by an external validator. The protocol served as a guide to the researchers during the searches. The process was organized in five steps: the definition of the research question, definition of the inclusion/exclusion criteria, selection of the corpus, inclusion of the selected studies and analysis of the results found in the studies. The guiding question of this revision was: what does the literature say regarding workloads of nurses who work in the Family Health Strategy in Brazil?
The search took place in the Public/PublishMedline (PubMed), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scientific Electronic Library Online (SCIELO) and CAPES Bank of Theses and Essays. The search terms were used based on the Health Science Descriptors (HSD): nursing, Family Health Strategy, working conditions, workload, job satisfaction, occupational health, resources management, health services administration and management. It was based on the form Medical Subject Headings (MESH): nursing, nurse, nurses, family health, workload, job satisfaction, occupational health, health services administration, organization e administration. The Boolean terms, e/ and, were used in order to make combination between the descriptors.
The publications were limited to include only: original complete scientific articles, theses and dissertations; to contain the descriptor in its title and/ or summary, to be published in the English, Spanish and Portuguese idioms between years 2004 to 2014 in its complete form with access via the Universidade Federal de Santa Catarina.
In the first search 15,343 works were found in the databases. After the reading of the title and the provided data cross-checking were excluded: studies in form of letters, essays, written reviews and editorials, books, book chapters, newsletters, official documents, publications not available in its entirety for analysis in the bases chosen via UFSC, texts out of the required interest or subject, dupli-cated works (in those cases in which theses and articles related to the theses were found only the articles were kept), publications in idioms other than those stipulated in the inclusion criteria, systematic reviews, experience reports, tests and theoretical reflections. From this first selection 156 studies remained. After reading the summaries and identifying the relevancy to the theme of this review, 10 of them were selected in the LILACS (06 articles and 04 theses); 14 SCIELO (14 articles); 08 PUBMED (08 articles); 09 CAPES (07 dissertations and 02 theses). In other words, in this second step 116 studies were excluded for not being appropriated to this investigation's object, remaining 41 as a total result. In the third step the collaborators gathered to carry out the final selection, discussing the doubts about the adequacy or not to the theme, what resulted in a corpus of 24 studies. (Figure 1) The selected works were organized and analyzed with the help of the Atlas.ti 7.0 ® software. The 24 publication included in the study were inserted in the software as primary documents. Thereafter each document was read selecting the quotations associated with the codes that made the organization of the studies in a characterization Table possible (Table 1) and yet another that organized the types of workloads (Table 2).

Eligibility
Inclusion 15343 studies found in the databases when using the terms below combined Enfermagem "Nursing" "Enfermería"; Nurse "Enfermeiro/a"; Nurses "Enfermeiros/as"; Estratégia Saúde da Família "Family Health Strategy" "Estrategia de Salud Familiar"; Condições de Trabalho "Working Conditions" "Condiciones de Trabajo"; Carga de Trabalho "Workload" "Carga de Trabajo";S atisfação no emprego"Job Satisfaction" "Satisfacción en el Trabajo "; Saúde do Trabalhador "Occupational Health" "Salud Laboral"; Gestão de recursos "Resources Management" "Gestión de Recursos"; Administração de Serviços de Saúde "Health Services Administration" "Administración de los Servicios de Salud"; Gerência "Management" "Gerencia"; Organization & administration "Organização e Administração" Excluded studies in form of letters, essays, written reviews and editorials, books, book chapters, newsletters, official documents, publications not available in its entirety for analysis in the bases chosen via UFSC, texts out of the required interest or subject, duplicated works (in those cases in which theses and articles related to the theses were found only the articles were kept), publications in idioms other than those stipulated in the inclusion criteria, systematic reviews, experience reports, tests and theoretical reflections 326 studies excluded for being duplicated or for locating the originated articles of the dissertation or theses.

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To characterize the studies the following codes were used: study title, author, year, database, origin and type of publication, study method and place where the study happened.
To the organization of the workload types were selected quotations in which the elements that brought workloads on the FHS' nurses, to those quotations were attributed five codes in accordance with the chosen theory. The results from this organization are described on Table 2.

Results
Those works which fulfilled all the established requirements for their inclusion in this review were the following ones: theses (03), dissertations (07) and articles (14). Regarding the characterization of the studies 08 of them were found in the LILACS' base, (10) in SCIELO and (07) in the CAPES Bank of Theses and Dissertations. In the PUBMED database were not found studies in accordance with the approached issue. All the works with relevancy with the issue were found in national databases and it happened because of the limitation of the subject, in other words, focusing the Family Heath Strategy in Brazil.
Regarding the place in Brazil where the researches took place, it was identified that in the southern region there was a greater number of incidence (10), in the southeastern region (07), northeastern region (04) and in the center-west region (03), having no researches about the subject in the northern region. It was observed that in the period from 2010 to 2013 there was the prevalence of scientific productions with proximity with the theme, with significant amount of works in year 2012 (6). As to the type of study researches of the qualitative type with descriptive focus become evident. No study approached the WL of the FHS nurses. There were found 08 works approaching workloads of the Family health teams in which its nurses were included. A total of 07 works approach the health of the FHS's team issue in which it was possible to identify generator elements of WL.
The Table 1 describes the characterization of the studies.
From the elements that increased the workload of nurses many factors that increase their psychical loads were found in all the studies. Some of such factors that are associated with the psychical loads may also generate other ones as physiological and mechanical. Among them are pressures caused by work overload and many other deficits in the working conditions.
The third group of WL generator elements increase consists of: precariousness of the environ-

Biological Loads
Exposure to body fluids and sharp/cutting materials (07).
Source: Review data, 2015 ment and materials including inappropriate physical plant, absence or insufficient sizes of spaces and unhealthy structures (01; 03,05,07,09,10,11,13,16,18,20,22,23); exposure to humidity, noise and air conditioning (03 e 11). These elements are related with physical loads. Elements as the exposure to body fluids and sharp/cutting materials were also found (07), which are related with the biological WL. In no one of the works the presence of chemical loads was mentioned.
The Table 2 describes the WL generator elements associating them to the types of loads.

Discussion
In the selected studies five other types of workload described by Laurell and Noriega (1989) were identified. Only chemical loads related elements were not quoted. From the 24 studies included in this revision none of them specifically approached the workloads on nurses who work in the FHS in Brazil.
From the workload types described before, the psychical ones predominated and can be observed in elements like: excess of demands; relationship fragility between team mates, managers and users; pressure to achieve goals; disagreement in relation with the assistance model of the FHS work mates and users who still defend a medical centered practice; lack of autonomy and of professional recognition of nurses.
Such loads can only be detected after a log time of exposure. The psychical loads can be divided into two groups, the one related with psychical overload, when the worker remains under long periods of tension at work. And another group referred to the psychical underload, being this one formed by elements that hinder the development and use of psychical capacity of the professional at work. [Laurell;Noriega, 1989;Kirchhof, 2011]. The psychical underload was not identified in the studies to this review.
Studies have shown that the emotionally based problems are the most important in the Family Health Strategy. The intensive and increasing amount of assisted demand (spontaneous and programmed) in the Health Unit seems to be beyond the nurse's possible reach. This problem may either reflect the attached population density bigger than that foreboded by the Health Ministry [Brasil, 2012] or it may be the result of the lack of professional staff or qualification to carry out the prescribed activities. This excess may yet be generated by situations in which the professional nurse, in addition to his activities, carries out those of responsibility of other work team members, aiming at the attempt to cover the workforce deficits in the Health Care Units.
There is a considerable appeal when we think about the psychical workloads of the FHS nurses in Brazil, besides causing important psychical distress to the worker it brings other problems which directly influence in the quality of the provided assistance. Deficient communication also directly affects the actions hampering their accomplishment. These difficulties interfere in the quality of the user's attendance causing dissatisfaction in the professionals and users.
Thereafter the physiological and mechanical loads were pointed out. The physiological loads are related with several situations which demand physical efforts, organization and accomplishment of the job which may alter the working balance of the body and also the exposure to improper position [Laurell;Noriega, 1989;Kirchhof et al., 2011;Trindade, 2011;Pires, 2014]. The excess demand to be accomplished inside and outside the FHS by the nurse was the main element that besides generating psychical loads may also generate physiological and mechanical loads. The studies highlight the professional nurse's activity accumulation that performs tasks alone as he could and/or should share them with other staff members. Many times, in order to accomplish his tasks the worker ends up working beyond the scheduled working hour to the Health Unit. Nurses indicate that the number of working hours (40 hours a week or more) in the same place and under work pressure results in a significant WL elements increase. From the activities carried out by nurses we can point out: bureaucratic-administrative activities and individual or collective care. It was also observed the accelerated rhythm of work and work organization, many times fragmented similar to the parceled or detailed division of the work as described by Marx in "The Capital" (1983).
The mechanical loads have strong relation with the quality and functionality of the working tools as well as the exposure to situation that demand the use of physical strength or repetitive effort that may cause lesion like contusion and fracture. The mechanical loads are derived from the interaction of the worker's body with the workplace materials which do not received appropriated maintenance for their use or by movements that demand from the worker's body efforts that may cause injuries [Laurell;Noriega, 1989;Kirchhof et al., 2011;Amestoy;. From the studies that integrate this review were mentioned equipment precarious conditions which presented rust or lack of maintenance, and also problems in the vehicles used for dislocation in action out of the Health Basic Unit.
The physical loads have direct relation with the work environment that exposes the worker to physical agents as for example radiation, noise, heat, cold, [Laurell;Noriega, 1989;Kirchhof, 2011;Martins et al., 2013]. In the studies that integrated this review were detected problems related with physical environment of the services like insufficient spaces, unhealthy structures and exposure to humidity, noise and heat.
The biological loads are those resulting from the contact with the object of work or the exposition to organic products as fungi and microorganisms [Laurell;Noriega, 1989;Schmoeller, 2011]. The constant exposition to body fluids and contact with sharp/ cutting material were elements of biological loads of nurses in the FHS, mentioned in the studies.
Chemical loads were not identified in this review. Such loads are derived from chemical substances which may be present in the working environment, like dust, powder, smoke, gas and/or vapor, fluids or liquids with which the worker could be exposed [Laurell;Noriega, 1989;Kirchhof, 2011].

Conclusion
The reviewed studies showed, with wider evidence, elements that might configure psychical loads in the work of the FHS nurse, followed by physiological and mechanical loads. It is noticed the difficulty to analyze the types of workloads in a dissociated form, since the elements that form them interact among themselves, what increases and reinforce determined types of loads. The studies also relate loads to the production of distress, and possibly, to illness.
The workloads influence the occupational health and the quality of the attendance offered to the population. When the worker faces loss of his psychical and psychical capacity the result is the impact on the achievement of his job.
The results from this review showed that the WL of nurses in the FHS must be studied and that knowing them may guide managerial decisions in the sense of organizing and reorganizing the nurse's work in the FHS, aiming at making possible the working quality improvement of this professional. Modifications in the elements that trigger the increase of workload also contribute to the satisfaction and health of the nurses, as well as they influence the improvement in the services provided to the users in the field of health care.