THE MANAGEMENT OF BASIC HEALTH UNITS FROM THE POINT OF VIEW OF NURSING

Objective: to discuss the difficulties encountered and faced by managers of Basic Health Units. Method: a qualitative, descriptive and exploratory study based on the Basic Health Units. All nurses managers were invited to the research subjects. who held the position for more than a year and excluded those who were not submitted to public selection process. For data production, the focal group was used. The data were then analyzed using the Content Analysis technique, in the Categorical Analysis modality. Results: data analysis resulted in three categories. These are the Difficulties related to working conditions, Difficulties related to the centralization of decisions and Difficulties related to the network of attention. Conclusion: it was verified that vertical management and lack of flows are the main difficulties in the managerial process, since they contribute to reduce the resolution of primary care and undermine the integral care. Descriptors: Primary Health Care; Continuing Education; Professional Competence. RESUMO Objetivo: discutir as dificuldades encontradas e enfrentadas pelos gerentes de Unidades Básicas de Saúde. Método: estudo qualitativo, descritivo e exploratório que teve como cenário as Unidades Básicas de Saúde. Foram convidados, para sujeitos da pesquisa, todos os enfermeiros gerentes, sendo incluídos os que ocupavam o cargo há mais de um ano e excluídos os que não foram submetidos a processo de seleção pública. Para a produção de dados, foi utilizado o grupo focal. Em seguida, os dados foram analisados pela técnica de Análise Conteúdo, na modalidade Análise Categorial. Resultados: A análise dos dados resultou em três categorias. São elas as Dificuldades relacionadas às condições de trabalho, Dificuldades relacionadas à centralização das decisões e Dificuldades relacionadas à rede de atenção. Conclusão: constatou-se que a gestão verticalizada e a falta de fluxos são as dificuldades preponderantes no processo gerencial, pois contribuem para diminuir a resolutividade da atenção básica e minar a integralidade do cuidado. Descritores: Atenção Primária à Saúde; Educação Continuada; Competência Profissional. RESUMEN Objetivo: discutir las dificultades encontradas y enfrentadas por los gerentes de Unidades Básicas de Salud. Método: estudio cualitativo, descriptivo y exploratorio que tuvo como escenario las Unidades Básicas de Salud. Fueron invitados, para sujetos de la investigación, todos los enfermeros gerentes, incluidos los que ocupaban el cargo hace más de un año y excluidos los que no fueron sometidos a proceso de selección pública. Para la producción de datos, fue utilizado el grupo focal. Em continuación, los datos fueron analizados por la técnica de Análisis Contenido, en la modalidad Análisis Categorial. Resultados: resultaron en tres categorias el análisis de datos. Son ellas las dificultades relacionadas con las condiciones de trabajo, dificultades relacionadas a la centralización de las decisiones y dificultades relacionadas con la red de atención. Conclusión: se constató que la gestión verticalizada y acompañada de la falta de flujos son las dificultades preponderantes en el proceso de gestión y que contribuyen a disminuir la resolutividad de la atención básica y minar la integralidad del cuidado. Descriptores: Atención Primaria de Salud; Educación Continua; Competencia Profesional. Masters student, Postgraduate Program in Nursing Education, Fluminense Federal University/UFF. Niterói (RJ), Brazil. E-mail: josielif@hotmail.com ORCID iD: http://orcid.org//0000-0001-7913-9264; PhD, Fluminense Federal University / UFF. Niterói (RJ), Brazil. E-mail: bcordeiro@id.uff.br ORCID iD: http://orcid.org//0000-0001-6387-511X ORIGINAL ARTICLE Fernandes JC, Cordeiro BC. The management of basic health units... English/Portuguese J Nurs UFPE on line., Recife, 12(1):194-202, Jan., 2018 195 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i01a23311p194-202-2018 Management is an important instrument for the implementation of policies, incorporating an articulating and integrative character, that is, the managerial action is determined and determinant of the process of organization of health services and fundamental in the accomplishment of social policies and, in particular, the of health. It can be said that management does not understand a simply rational or technical action, but rather presents scientific, technical and artistic dimensions.1-3 The ability to manage a health team and meet the users' perspectives requires a balanced professional, who can overcome the limitations that the service presents and that, besides providing assistance based on UHS principles, manages to deal with the personnel shortage, materials, resources, as well as the increasing demand of users. Among the professionals who work in the health area, nurses, in their daily practice, show greater interest, vocation and preparation to assume the functions of manager, a fact that does not happen by chance. There are clear investments in this direction, guided by public policies in the areas of health and education, reinforced by professional legislation.4 The management is guaranteed to the nurse, either in the assistance, the Nursing team or the service, as recommended by Law No. 7.498, Art. 11 of June 25, 1986. The National Curricular Guidelines (NCG) for Nursing Graduation management / content between those considered essential to the development of professional skills and competences.6 Even with such preparation, nurses present numerous difficulties in the management exercise and, therefore, it was proposed, in this study, to identify the obstacles that hamper the work of health service management, understanding that it has the potential to transform the health model from its more operational moment, that is, from the production of the service. It is understood that it is a sufficient argument to justify the need for research and construction of theoretical-practical knowledge that bases the realization of managerial processes that reorganize services and health systems, based on their task.7 ● To discuss the difficulties encountered and faced by the managers of Basic Health

Management is an important instrument for the implementation of policies, incorporating an articulating and integrative character, that is, the managerial action is determined and determinant of the process of organization of health services and fundamental in the accomplishment of social policies and, in particular, the of health.][3] The ability to manage a health team and meet the users' perspectives requires a balanced professional, who can overcome the limitations that the service presents and that, besides providing assistance based on UHS principles, manages to deal with the personnel shortage, materials, resources, as well as the increasing demand of users.
Among the professionals who work in the health area, nurses, in their daily practice, show greater interest, vocation and preparation to assume the functions of manager, a fact that does not happen by chance.There are clear investments in this direction, guided by public policies in the areas of health and education, reinforced by professional legislation. 4e management is guaranteed to the nurse, either in the assistance, the Nursing team or the service, as recommended by Law No. 7.498, Art.11 of June 25, 1986.The National Curricular Guidelines (NCG) for Nursing Graduation management / content between those considered essential to the development of professional skills and competences. 6ven with such preparation, nurses present numerous difficulties in the management exercise and, therefore, it was proposed, in this study, to identify the obstacles that hamper the work of health service management, understanding that it has the potential to transform the health model from its more operational moment, that is, from the production of the service.It is understood that it is a sufficient argument to justify the need for research and construction of theoretical-practical knowledge that bases the realization of managerial processes that reorganize services and health systems, based on their task. 7To discuss the difficulties encountered and faced by the managers of Basic Health Units.
Qualitative, descriptive and exploratory study that had as background the Basic Health Units of a municipality of Baia de Ilha Grande do Rio de Janeiro.Focal group was used, for data collection.
This municipality has 47 basic health units and performs wide population coverage.
The basic health care organization is based on the family health strategy and there is no, managerial role in all health units.
All the nurses managers of the municipality were invited to the research subjects.After subjecting them to inclusion criteria (being more than a year in the position of manager) and exclusion (links without public selection process), the total of ten subjects that corresponded to 2.5% of the sample was reached.In order to maintain the confidentiality of their names, the subjects were coded using alphanumeric indices -E.1 to E.10, according to the return of their answers.For the data collection, the focal group was used, which was recorded and transcribed removing the language vices.The recording of the speeches was done so that no information was lost during the focus group, which made possible a better interpretation of the dialogue, ensured the reliability of the information and enriched the data collection.This technique was chosen because it allows the researcher to construct a series of possibilities of information taking into account several opinions on the same subject and also to apprehend the contradictions from arguments.The focus group was guided and problematized by the following question: What are the obstacles / difficulties for the managerial practice of Basic Health Unit?
The data were analyzed based on the Content Analysis following the principles of Bardin8.The analysis of content consists of several techniques where one tries to describe the content emitted in the process of k, be it by means of speeches or texts.In this way, the technique is composed of systematic procedures that allow the collection of indicators (quantitative or not) allowing the accomplishment of inference of knowledge.

INTRODUCTION
The project followed the ethical guidelines of resolution 466/2012 and was approved by the Ethics Committee of the Federal Fluminense University with an opinion issued by the number 1,764,754.
Non-a priori categorization emerged from the Units of Significance (US) grouped and named in a logical-semantic way, following the ideas absorbed by the subjects' speeches and their similarities, starting with the Registration Units (RU) more frequently.Thirty RUs were reorganized into eight US that formed three categories (Difficulties related to working conditions, Difficulties related to the centralization of decisions and Difficulties related to the network of attention:  Category 1-Difficulties related to working conditions.
The difficulties related to infrastructure, physical, material and human resources are included here.In addition to the conflicts in the team, the power dispute, the false autonomy and the overhead of spreadsheets / papers without functionality.
False autonomy was the unit of record that had the highest frequency, being pointed out by six of the ten participants.The lack of autonomy, according to the respondents, correlates with the lack of support for decision making, which greatly hinders the development of activities and the execution of changes for the improvement in health units.They also point out that they are often subjected to political pressures that make it even more difficult to develop their duties in office, as can be seen from the statements below: The manager would have to have a greater autonomy, in everything, mainly in the process of decision and planning.(E.4).

I also have autonomy, but autonomy does not depend on me, I do not have the power to change, autonomy is given to me in parcels [E.9].
Yes, the big problem is the false autonomy.It is because autonomy is a thing that comes from the top of management.(E.10). Thus, it can be said that the delegation of responsibility occurs to the manager without the equivalent delegation of decision-making power, transferring responsibility for the implementation of centralized decisions, but without the prerogative to be able to modify them according to the local need.
It is believed that perhaps false autonomy arises from the absence of legislation for the activity of the management that describes the respective attributions of the manager, since the researched ones describe this nonexistence as a factor difficult of the managerial process.The lack of legislation can also be the source of conflict and power struggle within the team.She was referred to, as a hindrance, by three respondents.
In the municipality studied, there is an imposition of the attribution to the nurse who, according to the respondents, ends up overloading their work and constitutes another obstacle to management, as noted in the following citations:

It is important to consider that this activity is not foreseen in the attributions of a certain professional. The legislation that establishes the PNAB is silent regarding the managerial assignments. (E.5).
In fact, managerial activities in the health area lack a legal foundation that defines their legal attributions and responsibilities.The National Policy of Basic Attention, 11 which determines and defines responsibilities regarding the clinical and family health professionals, does not find similar regarding the subject in question and definition of responsibilities regarding the managers of BHU.On the contrary, it is observed that it is described, as attribution of all professionals, to participate in the management of the inputs needed for the proper functioning of BHU.

RESULTS AND DISCUSSION
Although they are not defined and directed to the person of the manager, in this case, the nurse, the activities that involve the function of interlocutor, mediator of the work process and of decision-making, cause work overload and also anguish for not accounting of all work processes.
In assuming the managerial function of the Unit, what happens, in practical terms, is an accumulation of functions that end up overloading the nurse, harming the development of his work and, consequently, the efficiency of the Unit itself in assisting the population.Excessive misconduct leads to a run-down in the execution of actions.
In the Primary Care Units, nurses develop, daily, multiple activities in the field of assistance in the Family Health Strategy, management and education, expanding the responsibilities that, associated with the existing difficulties and the interest in providing the good progress of the service, overwhelm their daily lives, which causes feelings of overload, stress and dissatisfaction with work. 12n another study, the authors corroborate with the results presented in this category, since the nurses researched by them also pointed out, as a fragility for the exercise of the managerial function, the legal nonformalization of the position of manager and, consequently, the non-receipt of gratification by the exercise of this function, in addition to the relative autonomy for the management of the workers regarding the division of tasks and coordination of the basic unit. 12garding the lack of additional remuneration, the survey by Mesquita and collaborators 13 pointed out that the salary was considered the biggest factor generating managers' dissatisfaction, as it was not consistent with the responsibility and functions performed: Another difficulty is the lack of professional.(E.3).

In addition, low salaries, bond fragility and often situations of moral harassment are stressful conditions of managerial practice. (E.5).
Scarce human resources generate an overload of activity and hamper the quality of care provided to the population, by hindering the achievement of agreed goals.
In one study, a small number of professionals in the service appeared as a tension factor in managerial work. 12Another study reports that the shortage of professionals causes the manager to assume multiple functions inherent to the work process in the UBS and not only those pertinent to the position of Manager. 14hroughout the years of existence of the FHT, work processes have become more complex and new goals are created for Primary Health Care and, in contrast, the number of professionals remains the same. 10ther authors point out that, in our society the worker is exposed to various forms of precarious working conditions, with temporary contracts, low wages, double or triple working hours, pressure for greater production in a shorter period of time, besides organizational models that dispense with the use of creativity and stimulate competition among workers, which may contribute to their devaluation and suffering. 13he management of human resources meets the need for professional training in order to generate changes and desirable results for the exercise of such attribution.Also visible is the idea that the manager obtains his results through the performance of other workers, that is, it depends on the professional performance of certain individuals to benefit and consider their performance as performed.
Combined with the human resources problem is the lack of material resources and infrastructure.According to those surveyed, the evolution of Basic Attention in the city was not accompanied by the improvement and increase of infrastructure of this network of services, of physical space, of equipment, nor the expressive decentralization of activities for the basic units, which has also generated difficulty for management and proper functioning of these services.Fact represented by the manifestations below:

Not enough, routinely, teams face difficulties for their day-to-day (including managerial) practices regarding structure and physical and material resources, with little or no institutional support. (E.5).
This reality of insufficient infrastructure, inputs and materials of Primary Care services, end up compromising the commitment of the Ministry of Health: the constitution of Health Care Networks, articulated and ordered by primary care, which would enable greater qualification and resolubility and, consequently, the integrality of attention.
The lack of a computerized network is another major problem for management in basic care, making it impossible for professionals working in local communities to release data from the reports completed in the e-UHS and to analyze the health conditions of the population of interest, based on data statistical and epidemiological, as well as making it difficult to access other points of the network.As seen below:

Without the computerized network we waste time with rework, [...]. (E.3).
The lack of material resources, inputs and equipment, in many cases, makes the service inadequate, generating user dissatisfaction, overload and stress of the health team, with a fall in income, making the managerial function even more conflicting and exhausting for the professional in their daily lives. 15lthough BHU is constituted as a place of access to health services for millions of citizens, it does not have material and symbolic conditions to function as the center of communication between the various points that make up the complex networks of care, at a time when the Ministry the agenda for the construction of thematic networks. 16nother difficulty pointed out is the excess of spreadsheets and roles that ends up reducing management to bureaucracy and tends to make this dimension of the nurses' work process mechanistic, as seen below: We fill in several spreadsheets without functionality [.

..]. (E.3).
And in relation to the paper you said I understand that it's just more attributions that we have to do without any return, for example, that quarterly map of preventive and mammography I always send the same and no one did not even notice it, nothing at all, it's just another function.(E.1).

And no document returns to you saying the indicator, saying look its coverage is low, there is no return [...]. (E. 10).
The excess of spreadsheets that, according to the respondents, do not have a specific purpose, since they do not generate statistical data that can be evaluated and worked to improve the health conditions of the population, it occupies a great amount of time for the professionals, who would like to apply for assistance.
The quality of information is usually a consequence of the quality of its stages, from registration, collection and processing, to the availability of data produced by Information Systems.The return of the information to those who generated it may trigger the stimulus to the work collaborating to increase the commitment of the workers and incentive to the production of the data, just as the reverse is true, as shown in the speeches.
In this context, it is not enough for feedback to occur, but for it to be used in the decision-making process, the Municipal Health Secretariat needs to create working conditions conducive to the implementation of the actions to be implemented and / or 17 which would make sense to all the worksheets and would disassociate them from the bureaucratization of the service and waste of time.
The E.10 speech highlights the difficulty of access to the indicators, which makes the work even more difficult, since in the work process the manager, in order to establish the programming of health actions, should adopt standards and parameters that will serve basis for the calculation of goals and resources required for the development of actions.In addition, it must use an information system that allows the selection of indicators that will support the monitoring, monitoring and evaluation of the actions developed.The use of health indicators allows the establishment of standards, as well as the monitoring of its evolution over the years.
The use of bureaucracy should only serve to ensure the organization's rationality in order to establish the appropriateness of the means to the ends intended to ensure the maximum possible efficiency in achieving these objectives.However, in the municipality in question, management has been reduced to bureaucracy, which has mechanically made this dimension of the nurses' work process. 10nglish/Portuguese J Nurs UFPE on line., Recife, 12(1):194-202, Jan., 2018 199

The obstacles to my understanding go through the verticality of the process of planning the actions and decisions unrelated to the participation of the professionals who execute them [...]. (E.5).
Through the speeches, we understand that managers sometimes feel they are the depositors of demands from various sectors of the secretariat, passed on in a fragmented way and often without structural conditions in the unit for their development.This is contrary to the management proposal of the National Health Plan, which foresees the strengthening of democratic, participatory, decentralized management that starts from the local reality and plans strategic actions with the participation of health workers.
These facts reinforce that the relations established between the managers and the central instances of the health department indicate that, in the organizational field, decentralization has not yet occurred, since, in practice, what happens is a deconcentration of actions and services thought by a or more instances to be developed at the system tip, the floor of the UHS. 18erarchical and vertical management creates managerial difficulties and fragmentation of the work process in almost all areas.In order for an integrated work, which contributes to increasing the impact of actions, it is important not only to facilitate communication between the various health units, sectors and managerial levels, but to adopt a system that produces a simultaneous sharing of responsibilities by systematic actions with definition of roles.
The lack of participatory management can be a reflection of another obstacle also evidenced by the respondents: the lack of capacity of the central managers also dictates as lack of manager with knowledge.The speeches point out that sometimes the health secretaries are unprepared and many of their interests are at odds with the purpose that the health services should achieve.They report on the populist attitudes of managers (secretaries and mayors) in the health area in order to achieve political return.They reinforce the difficulty of managing when municipal secretaries are not from the health area and do not understand the complexity of this sector.It is also evidenced that, due to political-partisan issues, central managers often lack the preparation and skills expected for the position, which culminates in centralized management and discontinuity of previous processes.
The results of this study corroborate with another one when pointing out that a manager unprepared for such a function is one of the problems found in the public service, as it provides discrepancies regarding the leadership necessary to conduct change processes and execute health policies, leading to the maintenance of projects that must to be overcome. 19It analyzes that in the basic attention, the management faces limitations of several orders: financial, of the municipal legislation and of the exercise of subjectivities permeated by the relations of power coming from the political-partisan dimension.
There  3rd category: Difficulties related to the care network The dismantling of the network and the lack of flows directly interfere in the guarantee of integrality and resolution of the actions, harming UHS principles, and are pointed out as the main obstacles of the managerial process in this category.The speeches below reflect the discontent of the professionals: We need to know streams, we need to have streams in the truth and the municipality does not have.We need to know the network, and we are not aware, every day the municipality works in a way.(E.3)It's a definite flow we've never had, but we had a similar thing once when we came in, and over time it got lost and nowadays we have nothing.We need them, we need to know them, without them we can not continue the process.(E.8) It is evidenced by the statements that there is a communication difficulty between the various levels of the health system, a fact characterized mainly by the lack of information, generating insecurity and conflicts.
Some authors propose a move for investments to be made in BHU, seeking to increase the capacity to intervene actively in regulatory processes and gradually consolidating its legitimacy vis-à-vis users as an effective communication center with other services. 16Direct access of local teams to the marking of consultation, creation of formal and regular mechanisms of communication between physicians in the primary care network and regulatory centers and qualification of microregulatory processes in the units are some feasible measures for the implementation of the care network. 16e proposal made to the nurses to discuss the difficulties encountered in the management of the BHUs made it possible to know the major obstacles of the managerial process and also the factors that contribute to reduce the resolution of primary care and undermine the integrality of care.
The performance of the nurse as a manager suffers interference that may compromise his performance, among which unsatisfactory working conditions stand out; caused by the pressure of excessive demand; lack of resources; unsatisfactory quality and lack of integrality in the health system; precariousness of operational information systems, making it difficult to assess results; lack of integrated human resources development policy; political decisions (political interference); politicalparty interests outside organizational life; lack of technical-scientific knowledge about the health system as well as laws, norms and guidelines that govern health.
The analysis also suggests that vertical management, accompanied by lack of flows, is responsible for the dismantling of the health care network and refers to the urgency of rethinking new forms of management based on participatory, decentralized management, starting from a local reality and the planning of strategic actions, according to the principles established by the UHS, as well as in integrated work processes at all levels of attention that contribute to increase the impact of basic care actions.
It is important not only to facilitate communication between the various health units, sectors and levels of management, but to adopt a system that produces a simultaneous sharing of responsibilities with systematized actions and definition of roles.It is also necessary to structure and financially subsidize basic care so that it is, in fact, the gateway to the health network and becomes resolutive.
Permanent Health Education presents itself as a good alternative for the resolution of technical obstacles.It is presented as a tool to modify the work and the way of producing health within reach of the professional.