The Work Environment of Primary Health Care Nurses: An Integrative Review

El entorno laboral de los enfermeros de la atención primaria en salud: una revisión integradora

Ambiente de trabalho dos enfermeiros da Atenção Primária à Saúde: revisão integrativa

Lucas Lorran Costa de Andrade lucaslorrancosta@gmail.com

Universidade Federal de Santa Catarina, Brazil

Laura Cavalcanti de Farias Brehmer laura.brehmer@ufsc.br

Universidade Federal de Santa Catarina, Brazil

Bruna Alves Machado Amazonas brunaalvesmachado37@gmail.com

Universidade Federal de Santa Catarina, Brazil

Wagner Ferreira Monteiro wfmonteiro@uea.edu.br

Universidade do Estado do Amazonas, Brazil

Amélia Nunes Sicsú asicsu@uea.edu.br

Universidade do Estado do Amazonas, Brazil

Flávia Regina Souza Ramos flareginaramos@gmail.com

Universidade Federal de Santa Catarina, Brazil

Primary health care (PHC) is the first level of contact individuals have with the healthcare system. It is the gateway to most services and interventions required, and it encompasses a set of actions to promote, protect, diagnose, treat, rehabilitate, and monitor health needs ¹. To provide these health actions and services, a deeper understanding of PHC is key, with emphasis on understanding and analyzing the work environment of the healthcare professionals who work in this field ².

The PHC environment is not limited to meeting the population's health needs, as it becomes a continuous space for reflection and improvement. Improving work conditions for professionals emerges as an essential component in ensuring the quality and effectiveness of the services provided. This assigns PHC an important role not only in the clinical approach but also in promoting a work environment conducive to the well-being of professionals that contributes to optimizing care for the community ^2,3.

Work activities include physical, social, emotional, and technical elements that influence the professional experience. In healthcare, this environment transcends physical facilities, encompassing human interactions, clinical protocols, and interdependence between professionals ⁴.

Furthermore, nurses' work environment in PHC is determined by its challenging nature, with their work being strongly related to disease prevention, health promotion, and the creation of innovative strategies to meet the specific needs of each community. They face a dynamic environment and often have limited resources and varied demands, which requires management and decision-making skills ⁵.

Achieving excellence in nursing care requires addressing the factors that mold this type of care, and the work environment is a core element in this process ⁶. The interaction between the work environment and the quality of care in PHC is unquestionable. A favorable work environment not only has a positive impact on the health and well-being of nurses but also directly influences the quality and efficiency of the care provided to the population ^2,7.

In this sense, the urgency of improving the work environment becomes clear, highlighting the need for positive changes and understanding the dynamics of the work environment of nurses in PHC. This emphasizes the importance of strategies aimed not only at valuing these professionals but also at improving their work conditions as a whole ⁸. In a scenario of constant transformation in the healthcare sector, it is imperative to understand the current state of science on the structure and work conditions of PHC nurses. Therefore, the aim of this study is to identify, in the scientific literature, the aspects related to the work environment that influence the work of nurses in PHC.

This is an integrative literature review registered on the Open Science Framework platform, developed in six stages, as follows: defining the research question based on the problem, searching the literature, applying the inclusion criteria, evaluating the studies, analyzing the data, and synthesizing the knowledge with the presentation of the review ⁹. The selection process for the publications followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Prisma ¹⁰.

In the first stage, the research question was devised using the PICo strategy ¹¹, where "P" stands for population (nurses); "I" for the phenomenon of interest (work environments), and "Co" for the context (PHC). The research question that guided the review was regarding which factors related to the work environment influence the performance of PHC nurses.

In the second stage, the data was searched in August 2023. Six databases were searched: Lilacs (Latin American and Caribbean Health Sciences Literature), Cinahl (Cumulative Index to Nursing and Allied Health Literature), Web of Science, Medline (Medical Literature Analysis and Retrieval System Online), Scopus, and Embase. The search used the controlled descriptors of the Medical Subject Headings (MeSH) and the Descriptors in Health Sciences (DEcS): work conditions (condições de trabalho/ambiente de trabajo); primary health care (atenção primária à saúde/ atención primaria de salud); nursing (enfermagem/'enfermería), combined by the OR and AND Boolean operators. As this is an underexplored topic, keywords (non-controlled vocabularies) were added to direct the search strategy (Table 1).

Table 1
Database Search Strategy. Florianópolis, Santa Catarina, Brazil, 2023

Source: Prepared by the authors.

To expand the search possibilities, the journal website of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior -Capes (Coordination for the Improvement of Higher Education Personnel) in Brazil was accessed via an Internet Protocol (IP) service provided by the Universidade Federal de Santa Catarina.

In the third stage, the following inclusion criteria were set: complete articles available electronically, in Portuguese, English, or Spanish, published between 2019-2023. Reviews, abstracts in event annals, experience reports, dissertations, theses, and studies not related to the objective were excluded. Following the search in the databases, the results were entered into EndNote, where duplicate studies were removed. The articles were then uploaded to the Rayyan web platform ¹² to facilitate the organization and evaluation process of the previously defined inclusion criteria. The studies were selected by two researchers independently and simultaneously, in line with the established criteria. In the event of disagreement between the evaluators, a third reviewer in the field was consulted to settle the disagreement.

To extract and categorize the data, an instrument adapted from an integrative review ¹³ was used with the following items: Author/year; title of the publication; sample and location of the study; objective; methodological aspects, main results, and conclusions; and influencing factors in the work environment that affect nurses' professional practice (positive and negative).

In the critical evaluation step, the studies considered to be of high quality were those with consistent results, an adequate sample, appropriate control, and pertinent conclusions, based on a comprehensive literature review with full references to scientific evidence. Moderate quality studies were those with reasonably consistent results, a sufficient sample, some control, and fair conclusions, based on a comprehensive literature review with some reference to scientific evidence. Low-quality studies have limited evidence, inconsistent results, an insufficient sample, and conclusions that lack a firm foundation ¹⁴.

Given the importance of combining methodological quality and evidence strength, the researchers decided to evaluate the studies' level of evidence according to the Johns Hopkins Nursing ¡ Evidence-Based Practice ¹⁴, which has the following classification: level 1 - 1.a) experimental study, randomized controlled trial (RCT); 1.b) explanatory mixed methods project that includes only one level 1 quantitative study; 1.c) systematic review of ran- | domized clinical trials (RCTs), with or without meta-analysis; level 2 - 2.a) quasi-experimental study; 2.b) explanatory mixed methods project that includes only one level 2 quantitative study; 2.c) systematic review of a combination of RCTs and quasi-experimental studies, or only quasi-experimental studies, with or without meta-analysis; level 3 - 3.a) systematic review of a combination of RCTs, quasi-experimental and non-experimental studies, or only non-experimental studies, with or without meta-analysis; 3.b) exploratory, convergent, or multiphase mixed methods studies; 3.c) explanatory mixed methods project that includes only one level 3 quantitative study; 3.d) qualitative study; 3.e) systematic review of qualitative studies with or without metasynthesis. Evidence of non-research: level 4 - opinion of respected authorities and/or nationally recognized specialist committees or consensus panels based on scientific evidence, which includes clinical practice guidelines and consensus panels/ position statements, and level 5 - based on experimental and non-research evidence, which include scoping reviews; integrative reviews; literature reviews; quality improvement, program or financial evaluation; case reports; nationally recognized specialist opinion based on experimental evidence.

The data were analyzed qualitatively and the evidence from the primary study was synthesized descriptively. In addition, the evidence was carefully grouped into thematic categories, which provided a structured and coherent organization of the content, facilitating interpretation and understanding of the relationships and patterns identified in the study.

This review used the ROBIS instrument ¹⁵ to assess the risk of bias. In step 3, "Assessing the general risk of bias," all domains showed low risk: study eligibility criteria (low risk, considerable effort), study identification and selection (low risk, considerable effort), data collection and study assessment (low risk, with suitable criteria, data extraction, and assessment of risk of bias performed by two reviewers, and extraction of relevant study characteristics and results), and synthesis and results (low risk, unlikely to produce biased results).

Initially, 1,417 records were found in the databases, of which 55 were selected for full analysis, following the established criteria. After rigorous evaluation, 20 primary studies were considered eligible and included in the final sample of this review. Figure 1 shows the steps in the selection process for the primary studies in this integrative review.

Figure 1
Identification and Selection of Publications Based on the Prisma Statement, Florianópolis, Santa Catarina, Brazil, 2023 Flowchart
Source: Adapted from Prisma.

The final sample consisted of 20 articles, published between 2019 and 2023, with most of them in 2020 (30 %; n = 6), in languages including Portuguese, English, and Spanish with 55 % (n = 11), 40 % (n = 8), and 5 % (n = 1) publications, respectively. These studies were conducted in several countries, such as Saudi Arabia, South Africa, Australia, Brazil, the United States, Spain, Colombia, and Portugal.

Notably, Brazil was the country with the highest number of publications, representing 55 % (n = 11) of the studies. Regarding the methodological approach, it can be noted that qualitative studies comprised 55 % (n = 11) of the sample, quantitative studies comprised 40 % (n = 8) of the contributions, and a mixed-method study represented 5 % (Table 2).

Table 2
Descriptive Synthesis of the Selected Primary Studies, Florianópolis, Santa Catarina, 2023

Source: Prepared by the authors.

Regarding the assessment of the level of evidence, it was noted that most publications, i.e., 55 % (n = 11), were classified as level 3.d. For a more comprehensive overview of the characteristics of the studies that composed the final sample, Table 3 shows the main results and the methodological quality of the selected studies.

Table 3
Information Regarding the Main Results and Conclusions, Level of Evidence, and Methodological Quality of the Studies, Florianópolis, Santa Catarina, 2023

*LE: Level of evidence. Source: Prepared by the authors.

Based on the studies analyzed, the thematic categories that emerged were "psychological and emotional elements," "human resources, materials, and infrastructure," "interpersonal relationships," "dissatisfaction," "violence in the workplace," and "overload." These thematic categories are key to understanding the triggering factors that influence nurses' performance in the workplace (Table 4).

Table 4
Thematic Categories and Triggering Factors that Impact Nurses’ Professional Practice

Source: Prepared by the authors.

The methodological process integrated data that enabled the identification of aspects related to the work environment that have an impact on nurses' practice in PHC. Considerable research was found in this field, especially in the Brazilian context. The evidence found reflects that several elements of the work environment influence and correlate with the work of PHC nurses and have an impact on productivity, organization, planning, and healthcare measures directed to the population. One of the main factors is related to the psychological and emotional elements faced by workers when performing their duties. Among these factors, stress stands out as a key point, triggering adverse effects on the daily work routine ^24,27,29.

Studies show that constant interaction with patients and their families is a significant source of stress, resulting in frustrations that have an impact on the professional experience ^27,36. Closeness and empathy in the relationship with patients are essential characteristics for providing effective healthcare, but this level of closeness can also trigger emotional challenges, highlighting the complex and diverse nature of the demands presented by patients in PHC. When faced with a range of health conditions and social and emotional needs, nurses can feel overwhelmed and stressed, especially when the expectations of patients and their families are high ³⁷. Similar to these findings, a study with 295 nurses found that the stress resulting from this continuous interaction can have a significant impact on nurses' mental health, contributing to emotional exhaustion, anxiety, and even burnout symptoms ³⁸.

In addition, it was found that the pressure to avoid errors and the increased work hours can also contribute to increased psychological stress, affecting the quality of life in the workplace. It is worth noting that these problems have become even more evident in recent years, particularly due to the COVID-19 pandemic. The global health crisis has intensified stress levels, heightening the pressure already present in nurses' work environments ^22,39. This not only affects the emotional well-being of professionals but can also result in physical consequences such as chronic fatigue, sleep disturbances, and other stress-related health problems ⁴⁰.

Studies show that the constant pressure to avoid errors is an intrinsic aspect of the healthcare field, especially for professions such as nurses ^25,41. The critical nature of the decisions made in patient care amplifies this pressure. The permanent pursuit of precision and excellence, although essential, can create a stressful workplace, where professionals face a significant burden of responsibility for every decision and action taken ⁴⁰.

Regarding the work environment, several elements contribute to the complexity of nurses' work, and the conditions associated with human, material, and infrastructure resources have a significant role in determining the performance of professionals and the efficiency of the healthcare services provided ^17-26,30,32. Staff shortages are a persistent reality that has a direct impact on teams' ability to provide quality healthcare. The high demand for care, combined with the shortage of professionals, results in an overload on the nursing staff, with negative effects on productivity, the achievement of work objectives, and the effectiveness of healthcare measures ^18,23,26.

The poor physical structure of healthcare units, such as insufficient consultation rooms, entails additional challenges. Three studies cited the challenge of providing individual appointments in privacy and the need to adapt to these work conditions, as such issues emerge due to inadequate infrastructure ^21,24,32. Another study indicates that this problem is quite recurrent, especially in regions and locations where budget limitations and the demand for healthcare services are more pronounced ⁴².

This review highlights the interaction between healthcare professionals and the allocation of responsibilities in teamwork as key factors. Improving the work process, encouraging cooperation, and promoting regular meetings are elements that contribute to the quality of care ^21,22,24. This finding is in line with another study which indicates that encouraging regular meetings is a productive strategy for fostering efficient communication between healthcare team members. These meetings provide a dedicated space for discussing cases, exchanging information, clarifying doubts, and joint planning ^24,43. In addition, encouraging cooperation between team members in PHC is essential for cultivating a collaborative environment, where individual skills are leveraged in favor of patient care ⁴⁴.

Support from managers in the work environment and recognition of the importance of these environments by leaders are factors that have a direct impact on job satisfaction. Increased support leads to a healthier and more motivating working environment, promoting nurses' well-being ^16,19,24. In turn, low pay and precarious work conditions lead to professional dissatisfaction, hindering continuing education, continuity of care, and generating a tendency of turnover in nursing ³².

The data provided in the articles analyzed are in line with that in the literature, corroborating the understanding that inadequate pay and precarious working conditions are determinant factors for professional dissatisfaction in the nursing field and consequently affect the practice and dynamics of work in PHC ^18,45. The discrepancy between the load of responsibilities, the complexity of tasks, and financial compensation adds to professional frustration and dissatisfaction. This can result in delays in tasks, planning, and the continuity of care provided to the population in PHC ¹⁸. This factor correlates with higher odds of intention to quit the profession among nurses working in PHC. The search for better opportunities, both financially and in terms of professional quality of life, becomes an option for dissatisfied professionals ^35,46.

In terms of violence in the workplace, the summary presented shows that this is a significant aspect that influences nurses' work in PHC ^28,31. Aggression and physical violence by patients cause anguish and mental suffering, and interfere with sleep, creating a work environment permeated by fear and hindering professional-patient interaction ²⁶.

The need to face assaults not only affects nurses' individual health but also the dynamics of the team and the quality of care provided. In addition, the lack of safety in the PHC environment is a constant concern highlighted in studies on the impact of violence in the workplace ⁴⁷. The lack of effective security measures increases the vulnerability of professionals to violent events, increasing the risk of incidents that are harmful to their physical and emotional integrity ⁴⁸.

Meanwhile, the overload caused by the increase in work hours and the accumulation of care and management tasks leads to negligence, a drop in productivity, and interference in the planning and execution of health care ^23,25,34,35. Increased work hours, often the result of long shifts and growing demands in healthcare services, contribute to nurses' physical and mental exhaustion (18). Studies indicate that the fatigue resulting from this exacerbated prolongation of work hours is directly associated with a higher susceptibility to making mistakes, and a decrease in attention and concentration, which compromises the ability to make decisions and perform tasks accurately ^35,49.

In addition, the work environment in PHC is becoming increasingly challenging. Nurses and everything that surrounds their daily work must be considered, as the settings in which they perform their duties can have a significant influence on their performance and professional well-being. Healthy environments tend to result in more efficient and satisfactory work for the staff, as well as having a positive impact on health outcomes in PHC ⁵⁰.

It is worth noting that although there are publications evaluating the work environment in PHC ^51,52, these studies do not focus specifically on nursing and do not associate the work environment with the triggering factors that influence nurses' performance in this setting. In addition, the period of the reviews and the focus of analysis also differ from the objectives of this study.

This literature review has identified the various elements of the work environment that have a negative impact on nurses' work in PHC. Aspects such as precarious work conditions, an overload of tasks, a shortage of human and material resources, inadequate management, and the incidence of violence at work have negative repercussions not only on productivity, but also on the quality of care provided, on nurses' mental health and, consequently, on the services provided to the community.

It is therefore vital to implement measures aimed at improving the workplace for nurses, ensuring excellence in the care provided in PHC, and preserving the health of professionals and, by extension, the population they serve. Investing in infrastructure improvements in healthcare units, increasing the number of nursing professionals, and providing more suitable work conditions are key measures to mitigating work overload, reducing stress levels, and promoting professional satisfaction.