Students' perceptions of the nurse's work in the family health strategy

Objective: to understand the perceptions of nursing students about the work of nurses in the Family Health Strategy. Methods: qualitative research developed with 19 students from different periods of the undergraduate nursing course. Semi-structured interviews were carried out, proceeding, after being organized, to thematic analysis and confrontation with some concepts of Institutional Analysis. Results: the data analysis gave rise to three themes: 1) Students’ perceptions of the nurse’s work process, 2) The bond in the nurse’s work and 3) Structural and relational limits of the nurse’s work. Conclusion: the nurse’s work in the Family Health Strategy is something in constant institutionalization process, requiring a range of theoretical and scientific knowledge and skills that are expressed through autonomy and bond with users. However, it faces some crossings such as the scarcity of infrastructure, human and material resources and the difficulty in teamwork. Descriptors: Nursing; Primary Care Nursing; Students, Nursing; Primary Health Care; Family Health Strategy. RESUMO Objetivo: compreender as percepções de estudantes de enfermagem sobre o trabalho do enfermeiro na Estratégia Saúde da Família. Métodos: pesquisa qualitativa desenvolvida com 19 estudantes de diferentes períodos do curso de graduação em enfermagem. Foram realizadas entrevistas semiestruturadas, procedendo-se, depois de organizadas, à análise temática e confrontação com alguns conceitos da Análise Institucional. Resultados: a análise dos dados deu origem a três temas: 1) Percepções dos estudantes sobre o processo de trabalho do enfermeiro, 2) O vínculo no trabalho do enfermeiro e 3) Limites estruturais e relacionais do trabalho do enfermeiro. Conclusão: o trabalho do enfermeiro na Estratégia Saúde da Família é algo em constante processo de institucionalização, requerendo uma gama de conhecimento teórico-científico e habilidades que se expressam pela autonomia e vínculo com os usuários. Contudo, enfrenta alguns atravessamentos como a escassez de infraestrutura, recursos humanos, materiais e a dificuldade no trabalho em equipe. Descritores: Enfermagem; Enfermagem de Atenção Primária; Estudantes de Enfermagem; Atenção Primária à Saúde; Estratégia Saúde da Família. 1Universidade Federal de São Carlos. São Carlos, SP, Brazil. 2Universidade Federal do Mato Grosso. Cuiabá, MT, Brazil. Corresponding author: Flávio Adriano Borges Rod. Washington Luiz, Km 235, Jardim Guanabara, CEP: 13562-150. São Carlos, SP, Brazil. E-mail: flavioborges@ufscar.br EDITOR IN CHIEF: Viviane Martins da Silva ASSOCIATE EDITOR: Francisca Diana da Silva Negreiros Pablo Ramon Carloni1 Flávio Adriano Borges1 Natália Sevilha Stofel1 Márcia Niituma Ogata1 Larissa de Almeida Rézio2 Ariane Tufaile de Paiva1 How to cite this article: Carloni PR, Borges FA, Stofel NS, Ogata MN, Rézio LA, Paiva AT. Students' perceptions of the nurse's work in the family health strategy. Rev Rene. 2021;22:e61209. DOI: https://doi.org/10.15253/2175-6783.20212261209 Carloni PR, Borges FA, Stofel NS, Ogata MN, Rézio LA, Paiva AT Rev Rene. 2021;22:e61209. 2 Introduction Primary Health Care corresponds to the expected gateway to the health system. It is characterized by the set of health actions at the individual and collective level, in the context and territory of the subjects and their families, with the aim of promoting, preventing, diagnosing, treating, rehabilitating, reducing damage, exercising palliative care and surveillance strategies in Cheers. Brazil has adopted the Family Health Strategy as a model of Primary Health Care and it has a multiprofessional team composed of nurses, doctors, dentists, dental assistants, nursing technicians, community health agents and endemic control agents(1). The national curricular guidelines for courses in the health area provide for a graduate professional profile, which is generalist, assuming the development of skills to act at different levels of health care(2). Among the courses in the health area, Nursing has historically been playing a leading role in the management of health care, being seen as a reference profession at different levels of care, especially in the Family Health Strategy(3). It is known that the construction of the professional identity of nursing students is closely linked to their life history and limited to the material and historical conditions that are circumscribed to them. Their perceptions about the nurses’ work are being woven from the training process acquired during graduation, mainly with their insertion in the practice scenarios(4). This fact is in line with the degree of satisfaction presented by these in relation to the course and, also, the possibility of a process of reframing the profession during its trajectory, understanding that this learning can influence other fields of life(5). There are few scientific productions that deal with the perceptions of nursing students about the role of nurses in Primary Health Care. Primary studies developed in Australia and Mexico on the subject point out the insufficient training of nurses to work in this instance of health care and the benefits of a university education directed to the specificities required by this level of care, and students perceive Nursing, still, as a work more focused on the hospital area(6-8). Thus, in view of this scenario and seeking to contribute to scientific knowledge in the field of Primary Care Nursing, the question was asked: how do nursing students perceive the work of nurses in the Family Health Strategy, aiming to understand the perceptions of nursing students about the nurses’ work in the Family Health Strategy?


Introduction
Primary Health Care corresponds to the expected gateway to the health system. It is characterized by the set of health actions at the individual and collective level, in the context and territory of the subjects and their families, with the aim of promoting, preventing, diagnosing, treating, rehabilitating, reducing damage, exercising palliative care and surveillance strategies in Cheers. Brazil has adopted the Family Health Strategy as a model of Primary Health Care and it has a multiprofessional team composed of nurses, doctors, dentists, dental assistants, nursing technicians, community health agents and endemic control agents (1) .
The national curricular guidelines for courses in the health area provide for a graduate professional profile, which is generalist, assuming the development of skills to act at different levels of health care (2) . Among the courses in the health area, Nursing has historically been playing a leading role in the management of health care, being seen as a reference profession at different levels of care, especially in the Family Health Strategy (3) .
It is known that the construction of the professional identity of nursing students is closely linked to their life history and limited to the material and historical conditions that are circumscribed to them. Their perceptions about the nurses' work are being woven from the training process acquired during graduation, mainly with their insertion in the practice scenarios (4) . This fact is in line with the degree of satisfaction presented by these in relation to the course and, also, the possibility of a process of reframing the profession during its trajectory, understanding that this learning can influence other fields of life (5) .
There are few scientific productions that deal with the perceptions of nursing students about the role of nurses in Primary Health Care. Primary studies developed in Australia and Mexico on the subject point out the insufficient training of nurses to work in this instance of health care and the benefits of a university education directed to the specificities required by this level of care, and students perceive Nursing, still, as a work more focused on the hospital area (6)(7)(8) .
Thus, in view of this scenario and seeking to contribute to scientific knowledge in the field of Primary Care Nursing, the question was asked: how do nursing students perceive the work of nurses in the Family Health Strategy, aiming to understand the perceptions of nursing students about the nurses' work in the Family Health Strategy?

Methods
Qualitative approach study, which used some concepts of Institutional Analysis for its analysis process, such as institution (immaterial dimension related to rules and norms constructed and socially established), instituted (what is visible and apparent from the institution), instituting (what causes, moves and displaces the instituted), institutionalization (the dialectical relationship between the instituted and the instituting) and analyzer (what reveals the institution, making it speak) (9) . The data are the result of a scientific initiation project developed with undergraduate nursing students at a public university.
The nursing course in question has 30 places, with an annual entry flow via the Unified Selection System and has 4,000 hours of curricular activities divided into: 1,785 theoretical hours, 1,035 practical hours, 810 hours of internship and 370 hours for complementary activities. This course was formatted to be completed in nine semesters. The contact with professional practice in Primary Health Care takes place from the third semester, especially on the subject of Collective Health, which has almost 35.0% of its total workload directed to practical activities. Since then, all subsequent semesters have disciplines with practical immersions in Primary Health Care, leading to a percentage of about 15.0% of the course (555 hours) developed with practical activities that go through this instance of health care.
The inclusion criteria of the subjects were: being a student regularly enrolled in the course in 3 question and in relation to the exclusion criteria: not attending the interview schedule after the third attempt made by the researchers.
At the time of development of the research, the course had 176 students regularly enrolled. These were recruited by the non-probabilistic snowball technique (snowball) until the sample reached its saturation, that is, when the students' statements did not bring new information to the analysis board (10) . Of the total, 25 students were invited to participate in the research, of which six were excluded after the third unsuccessful attempt to schedule the interview. Thus, the last interviewee was asked for a new indication. Therefore, 19 nursing students participated.
Data collection was performed in September 2019 through individual semi-structured interviews, in the Study Group laboratory registered in the research group directory of the National Council for Scientific and Technological Development, of which the authors of this production belong. They were previously scheduled through telephone contact.
The interviews had variables of characterization of the participants, such as gender and period of the course in which they were and guiding questions, which were presented to the members of the Study Group, aiming to qualify them before being put into practice. These had an average duration of 30 minutes and were recorded in MP4 format and later transcribed for the analysis procedure.
The guiding questions of the research were: a) Tell me what you understand as the nurse's work in the Family Health Strategy. b) Tell me what you feel about the nurse's work in the Family Health Strategy. c) Tell me what easiness and/or difficulties you identify about the nurse's work in the Family Health Strategy.
The data were analyzed by thematic analysis, respecting the steps: 1) floating reading that consisted of an exhaustive reading of the interview transcripts; 2) definition of provisional hypotheses about the content read; 3) determination of the text comprehension nuclei that were phrases, text fragments or paragra-phs; 4) definition of themes based on the agglomeration of understanding nuclei with similar meanings; 5) analysis of the themes in comparison with the proposed theoretical framework (11) .
From the analysis of the interviews, three themes were constructed, which will be presented to the research subjects, aiming to develop an intervention, problematizing the findings and building new paths from a collective construction: 1) Students' perceptions about the work process of the nurse; 2) The nurse's job link; and 3) Structural and relational limits of the nurse's work.
The research that gave rise to this work was approved by the Research Ethics Committee of the University in question with a Certificate of Presentation of Ethical Appreciation: 17355619.7.0000.5504 and opinion No. 3,526,611/2019 and, in order to guarantee privacy, anonymity and all ethical precepts in the development of research with human beings, according to the ethical resolutions in force in the country, the speech fragments were identified by means of the letter E followed by a cardinal number.

Results
The research had the participation of 19 nursing students, 11 of whom were female and eight were male. Of the total number of individuals, four were in the first year (which does not have a timetable for practicing in Primary Care), six in the second (which has 105 practical hours in Primary Care), six in the third (which has about 195 practical hours in Primary Care) Primary Care) and three the fourth year of the course (which includes a practical workload of about 255 hours in Primary Care). The development of this work made it possible to identify that the closer to the end of the course, the greater the richness of details in the statements and the clarity with which the perceptions were made explicit by the students.
The first theme, Students' perceptions of the nurse's work process, addressed aspects related to the complexity of the work, permeated by the diversi- A report was also identified explaining the possibility of sharing some of these functions with the other members of the team that make up the Family Health Strategy: He can share this burden with other people in the Family Health Strategy, I have an example that I saw that it was the nurse and the dentist who shared the unit's tasks (E15).
The statements also pointed out the relevance of the work itself and professional autonomy as a power in this instance of health care: I think that a nurse from And the third theme -Structural and relational limits of the nurse's work -pointed out the students' perception regarding the difficulties that nurses face with regard to the lack of adequate infrastructure, equipment and materials, in addition to the insufficient number of professionals, revealing that nursing performs its activities in precarious conditions: Perhaps difficulty in relation to the infrastructure that is working, the equipment, some rules that limit us (E5). The greatest difficulty I think is the lack of resources, both human and material (E12). I think that personal resources are also lacking in many places. This happens a lot within the units (E4). Lack of professionals on the team, making it impossible to perform all the necessary actions and provide comprehensive care, leading to overload of professionals (E7).
In addition to the structural limits, the difficulties in professional interrelationships and in the development of interprofessional and collaborative teamwork were also made explicit: It is difficult to keep a team together. Team management, dealing with the team itself (E1).

One difficulty would be dealing with the multiprofessional team (E3).
Difficulty is relating to the team, as it is a smaller team, if you don't have affinity, you can't talk, the work becomes more difficult (E14).

Discussion
The difficulty faced in recruiting students in the last year of the course is a limitation of this study, since they were in a supervised internship period, preparing for the course completion process. It is assumed that their participation could enrich the content presented in the speeches and themes due to the greater contact with the nurse's work in this instance of health care. However, it is believed that the data produced and analyzed consist of a product that will enable the development of research-interventions from then on, functioning as a possible trigger for this process in different realities.
The present production contributes to problematize the university education of future nurses, meeting the national (2,12) and international (6)(7)(8) perspectives, which point out the need for nurses to be able to deal with the existing complexities in the scope of Attention Primary to Health. In addition to this, the research shows the possibility of resonances in other realities, awakening the eyes of students, health professionals and especially teachers so that they can analyze Pedagogical Projects of Nursing Courses with regard to the perspective of training future nurses capable of acting with quality and efficiency in this instance of health care (2) .
The findings reveal that professional training takes place gradually, where the student learns from the experiences acquired throughout life, added to previous knowledge, which must be considered and questioned continuously, in order to build new knowledge (13) . Thus, it is relevant that students experience the fields of practice gradually and as early as possible, so that knowledge is built along the formative trajectory, promoting reflections and construction of new concrete possibilities based on scientific evidence, as pointed out by the National Curriculum Guidelines for health courses (2) .
Observing the theoretical and technical skills of the nursing profession in the Family Health Strategy, it is noticeable the diversity of fronts in which this pro-fessional works in his daily practice. Having nursing as an institution, it is known that it encounters, on a daily basis, with instituting forces that provoke, move and displace what is established and consolidated in professional practice, characterizing or evidencing the profession as it is (14) . This dialectic process means that Primary Health Care Nursing is in a constant process of institutionalization, that is, in a continuous process of decomposition and recomposition.
There is an overload of work experienced by nurses in the Family Health Strategy and the accumulation of administrative and assistance functions established has repercussions on the lack of time for care, on the great demand of service users and on the scarcity of human and material resources, generating physical and psychological suffering to them (15) . That is, this burden corresponds to an analyzer of the nurse's work process, reflecting the precarious conditions experienced by this professional and the technical and social division of work in the Family Health Strategy.
Walking in the perspective of the development of teamwork, it has been found that interprofessional education and collaborative practices in health education have been identified as powerful strategies for meeting the population's health needs and enhancing the quality of care provided (16) . Interprofessional education corresponds to a proposal where people from different professions or backgrounds integrate in a participatory way, aiming at joint and collaborative learning (16)(17) . In this way, what is established as the exclusive responsibility of nurses in the Family Health Strategy can be shared in favor of developing collaborative practices, aiming at strengthening teamwork. An example of this is the management and management of health work, whose activities could be decentralized and worked from a shared perspective.
The National Humanization Policy brings shared management as a guiding principle of health work. Thus, it becomes necessary to have a certain balance between the professional autonomy of nurses in the Family Health Strategy (explained in the proposition of advanced practice nurses, which differentiates them in the degree of autonomy in decision-making and in the diagnosis and treatment of diseases, attributing a higher degree of resolution in users' health care) (3) and the sharing of roles and responsibilities among team members (17) .
This sharing also consists of one of the challenges experienced by courses in the health area in implementing curriculum changes. These should take place through collective discussions with teachers, students and workers (2) as in an instituting movement. Something that would move towards the incorporation of interprofessional education and the development of collaborative health practices, meeting the needs of both the nucleus and the field of professional activity and, consequently, in guaranteeing comprehensive and quality care to users of Primary Health Care services (16)(17) .
When it comes to precarious work in health, it is known that it goes from guaranteeing good remuneration to the existence of minimum possible conditions for the development of quality work, consisting of a recurring agenda worldwide (18) . It corresponds to something institutionalized, which moves little (or is perceived) in the sense of changes caused by instituting forces, such as: public policies and a plan of positions and careers for effective professionals. Thus, they end up disregarding the fact that job satisfaction is associated with the characteristics of the work process in the Family Health Strategy, its organization and the conditions for its development (18) .
Another factor associated with job satisfaction developed by professionals in the Family Health Strategy is the connections established between professional users and vice versa, that is, the bond. This is closely related to demands and competencies within the scope of the extended clinic, which, in turn, requires an integral, shared and interdisciplinary approach to the subject, expanding the focus of the intervention beyond the symptoms, procedure and disease, in order to contemplate the family configuration and the social territory (19) .
It consists of a paradigm shift in what is esta-blished, being considered one of the great challenges faced by interprofessional education in the establishment of interpersonal communication flows. Therefore, they must occur in a way that favors a horizontal construction of the care process, contributing to the freedom and participation of the people involved in the decision-making process of everyday problems (16)(17) . However, such evidence falls again on the limit of the training process of students from the different periods of the undergraduate nursing course in this study, in which their perceptions about the professional practice of nurses in the Family Health Strategy reveal how close they are to the reality of nursing professional practice developed by them.
This finding differs from the integrative review of primary studies carried out on the subject, whose results pointed out the lack of knowledge of nursing students in relation to the role of nurses in Primary Health Care (20) . For professional training to be carried out with quality, it is necessary for the student to experience the socio-cultural context and the work process of the health services (2) , understanding the process of this approach as a strategy capable of generating a narrowing between theory and practice, where learning takes place in and through work, envisioning critical and reflective teaching and learning.

Conclusion
The students perceived the nurse's work in the Family Health Strategy as something in constant institutionalization process, requiring a wide range of theoretical-scientific and practical knowledge to deal with the complexity experienced in daily work. They also understand the need for some skills to work in Primary Health Care, such as forming bonds with users, the (re) knowledge of the territory, as well as Primary Health Care as a promoter of a differentiated techno-assistance model and in line with the principles and guidelines of the Unified Health System. However, it faces some crossings, such as the scarcity of material, human and infrastructure resources, in addition to the difficulty in developing teamwork.

Acknowledgments
To the Fundação de Amparo à Pesquisa do Estado de São Paulo, Brazil, for the financial support, process No. 2019/20060-4.

Collaborations
Carloni PR and Borges FA contributed to the conception and design, analysis and interpretation of data, writing of the article and approval of the final version to be published. Stofel NS, Ogata MN, Rézio LA and Paiva AT contributed to the analysis and interpretation of data, writing and relevant critical review of the intellectual content and approval of the final version to be published.