Difficulties faced by the nurse manager in the primary health care unit

Objective: to present, from the scientific literature, the main difficulties faced by nurses in the management of the primary health care unit. Methodology: this is a narrative literature review carried out in SCIELO and LILACS data sources. The search took place in September 2021. The keywords used were “Nursing”, “Primary Health Care” and “Health Management”. The total of studies revealed in both data sources was 139 studies. After reading and analyzing the researched theoretical framework, 42 selected manuscripts were reached. However, after exhaustive reading of these articles, only nine (21.5%) manuscripts were included in the sample of the present research because they answered the guiding question of the study. Results: the sample of articles in the present study consisted of nine scientific articles. The difficulties most present in the routine and that make the work of this professional more difficult are lack of incentive and qualification and training courses, reduced professional staff, scarce human resources, work overload, lack of financial resources, lack of support from part of public management, and inadequate physical structures. Final Considerations: the difficulties faced by these professionals become a major challenge in the exercise of this profession, culminating directly in a precarious and unsafe quality of care for the patient.


Introduction
With the emergence of Brazilian nursing, its important role in the provision of care, in the supervision of health services, and the formation of health education in the country was noted. Years later, the regulatory and supervisory body of the profession in Brazil, the Federal Nursing Council (COFEN), standardized its exercise, ensuring the quality of the services provided and compliance with the Law of Professional Nursing Practice (Araújo et al., 2020;Brasil, 2001a;Brasil, 2001b).
The profession in Brazil started to consist of nurses, technicians, and assistants (Brasil, 2001a;Brasil, 2001b). Nurses, therefore, have always had the responsibility of leader within the nursing team, and this has been increasingly noticeable at the level of primary health care.
In the field of public and primary health, nurses stand out in the role of health manager due to their capacity and capacity for functional leadership Carvalho et al., 2019). The nurse, as a manager of the most diverse sectors and health services, plans and outlines, together with his team, strategies capable of alleviating, solving, and/or overcoming any difficulties that exist or that may arise over time in his service, whether punctual or transversal Araújo et al., 2021;Góis et al., 2018). This is because a health manager, especially at the primary health care level, has as one of the main objectives to structure quality and resolute care in different contexts of care, which guarantees the autonomy and effectiveness of their actions .
Within the scope of his work in the basic health unit, the nurse manager is fundamental, mainly because he is concerned with the quality of services provided to the community. This professional can plan, prepare and perform his/her functions based on available management technologies and adequate to the needs of the population (Carnelutti, 2012).
According to Amthauer (2018), your role as a manager and your role in the management of nursing care in the community must always be focused on the planning and execution, based on available resources, of high-resolution actions and services.
However, challenges arise when faced with the role of leading a health and nursing team, especially when the nurse is forced to lead the care and management team within the basic health units. The stress caused by problems that occur among team members, where nurses cannot reconcile management with the care function, is one of the important challenges pointed out and discussed in the literature (Azevedo et al., 2021;Lentine et al., 2020;Amaral et al., 2019). Other challenges have also been discussed but they lack better investigations, reflections, and publications on the subject.
The nurse manager, as is known, also acts dynamically and mainly uses his leadership skills to organize health units and plan the best actions and strategies to face the difficulties that arise in the community. In addition to these demands, this professional within the scope of basic health units still acts as a mediator of conflicts and operational difficulties in the work process. One of the factors that make this process difficult is the lack of trained and specialized professionals to work in primary health care and the lack of investment and government attention for the first level of health care (Machado, 2018).
The professional manager responsible for managing the health service is often faced with a complex environment, full of limitations. This happens because several social actors participate in this scenario, including managers, health professionals, and the community itself (Rodrigues et al., 2019). Therefore, for the proper functioning of basic health units, aiming to improve service to the population through the provision of high-resolution services, it is essential to investigate and point out the main factors that have hampered the role of nurses in the management of primary health care units.
Considering the context, relevance, and justification mentioned above, the present study aims to present, from the scientific literature, the main difficulties faced by nurses in the management of primary health care units.

Methodology
This is a narrative review of the literature. This scientific method does not impose on researchers the obligation to present a specific research question, so it allows a broader search without in-depth research on a particular topic (Cordeiro et al. 2018). Cordeiro et al. (2018) also point out that the selection of articles and bibliographic materials is conditioned to the subjectivity of the researchers, considering that the literature data sources are not necessarily exhausted. Although it is not a requirement of the method, in this narrative review study it was decided to previously determine the data sources, as well as to In the SCIELO database, 117 articles were found (single search strategy). In the LILACS database, 22 articles were revealed based on the described strategy (single search strategy). Thus, the total number of studies revealed in both data sources was 139 studies. All articles and materials found had their titles and abstracts read. The materials that possibly responded to the objective of this research were read in full by the researchers of the present study.
The researchers of the present study were strategically organized to read the materials found in both data sources, given the collection of works found, as did Ferreira et al. (2020). Due to a large amount of material found from the search strategies used, it was not possible to control and describe, through a PRISMA flowchart, the entire process of selection, eligibility, and inclusion of studies. However, as this process is not a requirement for this review method, the methodological aspects of the present study were not compromised, therefore, a brief flowchart of how the process of selecting studies for analysis took place ( Figure 1).
The inclusion criteria adopted were: being a scientific manuscript, having been published in the last 10 years, being freely available on the internet, and having been published in Portuguese, Spanish, and/or English. Duplicate and repeated studies in the data source itself or both were excluded. As can be seen in Figure 1, after reading and analyzing the researched theoretical framework, 42 manuscripts were selected. However, after exhaustive reading of these articles, only nine (21.5%) manuscripts were included in the sample of the present research because they answered the guiding question of the study.

Results and Discussion
The sample of articles in the present study, based on the methodological aspects used, consisted of nine scientific articles. The articles were exhaustively analyzed to obtain an answer to the guiding question of this scientific work. The main results evidenced from the reading of these articles, which highlight the challenges that nurses in the role of managers face in the basic health unit, were synthesized for discussion.
In Table 1, below, the characterization of the articles selected to compose the study sample was described based on the title of the article, authors and year of publication of the work, objectives, and main results of the study. To analyze the difficulties and facilities of the work process of nurses in the Basic Units of the Family Health Strategy.
The main difficulty revealed was the lack of incentive for qualification courses and reduced staff, overloading the other team members, and inadequate physical structures.
Importance of the nurse manager in health institutions.

RODRIGUES et al., 2019
Highlight the importance of the professional nurse in management services in health institutions, as well as reflect on the weaknesses found in health services and the necessary instruments.
The nurse carries with him the spirit of leadership, at least those who are in charge of a family health unit should, as he will be responsible for the entire course of the services.
The difficulties listed in this study are related to this leadership ability in the context of primary health care, which has many weaknesses.
The management of basic health units in the view of nurse managers.

FERNANDES & CORDEIRO, 2018
Discuss the difficulties encountered and faced by managers of Basic Health Units.
The difficulties encountered were related to working conditions, team organization, and inadequate infrastructure, making the health actions offered in the unit to the population difficult. Many of the difficulties are still related to the centralization of decisions.
Being a nurse in the family health strategy: challenges and possibilities.

CAÇADOR et al., 2015
To analyze the challenges and possibilities of the nurse's work in the Family Health Strategy.
The results show that the daily routine of nurses as managers in primary health care units has a different organizational scenario. Their main difficulties are the daily work overload, which prevents the dedication of these professionals, causing conflicts of responsibility for the care of the population and the functioning of the team.
Restructuring of the basic unit of the Nossa Senhora das Graças Family Health Strategy.

GUEDES, 2014
Build interventions that facilitate access for the population in the area covered by the family health strategy.
Difficulties in care as a result of inadequate physical structures, making it impossible to carry out health activities in a place that presents insecurity for the professional and the community. It is necessary to improve the service space, making it accessible to the population.
Management conflicts: difficulties for the nurse manager.

LAMPERT et al., 2013
Check what is being researched about managerial conflicts experienced by nurses and how they are dealing with them to guarantee the quality of care provided to patients.
The lack of cooperation among employees when faced with different opinions, the lack of motivation, and the devaluation of work, causing damage to the work that should be offered to the population, are the main challenges faced by nurse managers.
Nursing supervision in the vaccine room: the nurse's perception.

OLIVEIRA et al., 2013
To understand the perception of the vaccine of nursing units on the supervision of activities carried out in the primary health care room.
The results showed the absence of a supervision process by nurses, which may have occurred due to the number of actions taken by them in the study. Nurses need to be proactive with educational actions and effectively monitor activities in the vaccine room.
The nurse manager in the Basic Health Unit.

CARNELUTTI, 2012
Knowing the work of the nurse manager who works in the Basic Health Unit and the difficulties faced inherent to the execution of their work.
Faced with the role of leading a team, difficulties arise such as stress caused by problems that occur among team members. The inability of nurses to reconcile their care work with the management of the health establishment is a challenge to be overcome.
The role of nurses as managers in basic health units.

SILVA, 2012
To analyze the role of nurses as managers in Basic Health Units (BHU).
The trained professional has the domain of specific knowledge, from their education, training, experience so that they can perform a certain function and the better the professional's training, the better the quality of the work developed.
As shown in Table 1, the conditions that determine the difficulties faced by the nurse manager in the primary health care units highlighted were: the lack of vaccines, human resources hampered by the absence of professionals, the lack of dialogue between the members of the nursing team and health of the unit, and the absence of qualification and training courses for professionals to be able to perform their function.
From the analysis of the selected articles, it was observed that in the public service the role of the nurse manager is still a challenging task. Studies indicate that the difficulties faced by these subjects in the public sector, regardless of their place of work, are similar or the same. The difficulties most present in the routine and that make the work of this professional more difficult are: lack of incentive and qualification and training courses, reduced staff, scarce human resources, work overload, lack of financial resources, and lack of support from part of public management and inadequate physical structures.
The lack of professionals in the team overloads the other members, resulting in work inefficiency (Mendes et al., 2020). This, in turn, becomes a problem for the manager, who finds himself unable to organize his practices and care processes aimed at the community. The absence of training and updating courses for these professionals also interferes with the quality of care offered to the population. These courses are essential for the professional training of these workers so that they can obtain knowledge about existing updates and the best available scientific evidence. Public management, therefore, must consolidate partnerships with managers of health units, so that they can make decisions safely and articulate with current local policies (Braghetto, 2019).
Studies also show the difficulty in providing care due to inadequate physical structure, which makes it impossible to carry out health activities (Melo et al., 2021;Rossetto & Grahl, 2021). The place that presents insecurity for the professional and community are factors that make it difficult for the manager to act. In Brazil, although there are principles that govern the Unified Health System (SUS), such as universal, egalitarian, and equitable care, reception and care are not effective because the structure of many basic health units is not adequate for the size of the population demand it receives (PINHO et al., 2020).
For Fernandes & Cordeiro (2018), the main difficulties related to working conditions in basic health units are related to inadequate infrastructure, making health actions carried out daily difficult. Therefore, public managers must propose a review and expansion of the physical structure of many of these units across the country. In this way, they must have adequate lighting and environments, airy and well-distributed areas, with access ramps and other details, to provide a greater stimulus to the care and management team to offer a service that solves the demands of the community (Guedes, 2014).
Conflicts in the team due to the dispute for leadership, where there is already a leader, is also a present and worrying difficulty, according to Lanzoni et al. (2016), as this results in a decrease in the number of professionals. This current problem is mainly due to the professional devaluation of nursing workers. These professionals compete for leadership positions due to salary and additional benefits and reduced working hours. If government sectors do not recognize the importance of nursing and do nothing to institute a salary floor linked to a fair workload (up to 30 hours per week) for these workers, this challenge will certainly not be overcome quickly. This difficulty prevents the unit manager from succeeding in his decisions.
Another important difficulty to be considered is turnover and the decrease in the number of workers in this first level of health care. This difficulty is aggravated especially in the face of high absences and sick leaves, which in turn overwhelms other professionals in the unit, especially care nurses and managers, generating stress and ineffective service delivery.
Consequently, this overload leads to an increase in the number of professional nurses diagnosed with mental syndromes, such as Burnout (Lourenção, 2018;Silva et al., 2020;Frota et al., 2021). It is, therefore, necessary to implement effective strategies that can minimize this factor, which considerably affects the work offered in primary care units.
In the context of primary health care, in addition to the risks faced by nursing workers, the manager faces many difficulties arising from the organization of the work process in basic health units. The difficulties related to work overload are mainly due to the procedural organization of work in these primary care health units. Such difficulties interfere in the professional's dedication to the performance of his/her function, which generates conflicts of responsibilities in serving the population and in the functioning of the team. These problems culminate in others, generating excessive charges for everything that cannot be resolved promptly (Caçador et al., 2015).
The work environment is formed by different professionals, where although each one exercises their profession, they need to interact to carry out an integral, singular, and interdisciplinary therapeutic prescription. Without a good manager with well-developed leadership skills, there is a tendency for continuous conflicts, which can make coexistence and work processes difficult. The main factors related to the difficulties arising from the non-interdisciplinary of the health team of the basic health unit are the lack of cooperation between the employees, the divergent opinions, the lack of motivation, and the devaluation of the working class, which causes damages in the resolution of the problems population demands (Lampert et al., 2013). In this context, the nurse manager must have the competence to propose strategies that can solve these and other difficulties within the scope of the multidisciplinary health team, so that they can continue the care provided to the community.
For Rodrigues et al. (2019), the nurse manager has the autonomy to decide on the work of his team. However, some professionals hinder the interpersonal relationship with the team and do not accept to follow the work rules and requests from the management team, making the work process of the entire basic health unit difficult. This difficulty about work processes was highly emphasized in the articles selected to compose the sample of this study. In this scenario, the nurse manager is capable of planning meetings and meetings with members of the healthcare and managerial team so that they can strengthen fraternal relationships and thus discuss the best ways to overcome these limitations.
For all these reasons, it is important to emphasize the importance of this professional being trained to perform well in his role as a manager. This training can be achieved through training and professional qualification courses. Every manager must be properly trained for this role because, given the weaknesses, challenges, and limitations in the training of professionals related to management, their decision-making must be directed and effective (Silva, 2012).
Another common challenge experienced by the nurse manager of basic health units is the difficulty in controlling the population's demand for vaccines, from the routine in the vaccine room to the implementation of vaccination campaigns. This difficulty generates greater wear and tear for children and their mothers, resulting in distancing and even evasion of this vaccine group. Basic health units do not have defined population control, which makes the logistics of total doses to be requested from the cold chain difficult. These situations end up leading to community stress, which creates a challenge for management to resolve. Thus, the main challenges faced by the manager in this sector require the planning of strategies based on the guidelines of the unified health system, such as mapping the areas covered by the basic health unit to know its registered population and to know the number of people who need vaccination assistance (Oliveira et al., 2013).
The limitations of the present study are linked to the impossibility of exhausting all existing databases, mainly because it is a narrative review of the literature and the low level of evidence of the selected studies. However, the results of this study are essential to guide care and management practices, especially for nurses in the context of health services that manage primary health care units, to overcome the main difficulties faced by these professionals in the management of these establishments. It is therefore recommended that further research be carried out to map, present, and discuss the strategies that these professionals can use to overcome the challenges of managing basic health units.

Final Considerations
The main difficulties faced by nurses in management in basic health units are lack of incentive and qualification and training courses, reduced staff, scarce human resources, work overload, lack of financial resources, lack of management support public, and inadequate physical structures. The research presents important information for knowledge in the area of managerial and active nursing in primary health care, in this way it can be useful to guide research that measures the impact of these difficulties on community assistance, as well as the impact of these damages on public health and for professionals and the community. The difficulties faced by these professionals become a major challenge in the exercise of this profession, culminating directly in precarious and unsafe quality care for the patient. It is necessary to plan and implement strategies that Research, Society andDevelopment, v. 11, n. 4, e18911427248, 2022 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v11i4.27248 8 can overcome these listed difficulties so that the health system user has their demands resolved promptly.