RESTRICTIVE AND DRIVING FACTORS FOR TEAMWORK IN PRIMARY HEALTH CARE FATORES RESTRITIVOS E IMPULSORES PARA O TRABALHO EM EQUIPE NA ATENÇÃO PRIMÁRIA À SAÚDE

To identify, from the professionals' perspective, restrictive and driving factors for teamwork, in the Family Health Strategy. A descriptive study/qualitative approach was carried out involving a Family Health Strategy team, in the State of Minas Gerais. Population constituted of nine professionals working in the team for at least six months, interviewed in August / 2016. Data analysis followed content analysis, thematic modality. Nine professionals participated: six community health agents, one physician, one dentist and one oral health aide. The results that emerged from the interviews were grouped by content affinity, in four thematic units, of which two referred to difficulties (restrictive factors) and two, to facilities (driving factors) for teamwork. Restrictive factors for teamwork were included in thematic units: Inadequate organization and resources and weakened interpersonal relationships. It has been shown that inadequate organization / resources and fragile interpersonal relationships restrict and limit teamwork in the Family Health Strategy. The driving factors for teamwork were gathered in thematic units: In-service training and interpersonal relationships based on appropriate collaboration and communication. It was verified that inservice training and interpersonal relationship, based on collaboration, mutual aid and communication, impelled the said teamwork. Both the restrictive and the driving factors for teamwork are linked to the conditions for carrying out the work and the relationship between team agents. The evidence found in this research can lead to advances in organizational behavior, with emphasis on management practices aimed at ensuring and supporting the effective development of the teamwork modality.


INTRODUCTION
The Health Care Networks (HCN) model aims to integrate and articulate the different levels of health care so that the individual in need of care has a comprehensive and humanized care. For this, Primary Health Care (PHC) constitutes the basis of this model, having as its responsibility the resolution of 90% of the problems and demands of the population (DALUCHE; MENDES, 2017).
In the context of PHC, the Family Health Strategy (FHS) was set up as a care model to reorient health care in Brazil (MIRANDA et al., 2017), and it faces several challenges related to professional practice, especially regarding the replacement of the biomedical care model with the model collective, driven by the integrality and universality of health actions (MIRANDA et al., 2017), In this perspective, due to the diversity of professional categories working in the FHS, such as a physician, nurse, nursing technician, dentist, oral health aide (OHA) and community health agent (CHA), it is essential to create proposals that enable the interprofessional practice in health (REIS et al., 2016) and a collective and integrated doing. It should be noted that the complete composition of the team represents a powerful tool for the implementation of the FHS proposal, in the logic of the integrated work and in the team, with a view to the integrality of assistance.
In order to consolidate this proposal, in the context of PHC, teamwork proves to be a powerful tool to avoid mistakes and overcome the fragmentation of work (LANCASTER et al., 2015), based on collective work and provides for participation and interaction of those involved in the work process, in order to expose and share their skills, insecurities, doubts, suggestions and experiences. (DUARTE;BOECK. 2015). The qualification of health care has a close connection with the existence of teamwork (FARREL; PAYNE; HEYE, 2015).
There is still no single concept of teamwork. In health, the term is still confused with others. (AGRELI; PEDUZZI; SILVA, 2016). Although it is a polysemic term, some assumptions base teamwork and contribute to its understanding, among them communication, collaboration / cooperation, trust, mutual respect, bonding, help, and recognition of the other's work (DUARTE;BOECK. 2015;POLIS et al., 2015;VALENTINE;NEMBHARD;EDMONDSON, 2015;HARRIS et al., 2016;SOUZA et al., 2016).
However, in spite of these assumptions highlighted by the authors, the health services still have hegemonic logic in the work dynamics, fragmentation and actions segmented by professional categories, with a strong hierarchy in the work process, absent or timid articulation between knowledge and professionals, which culminates in impoverished and reductionist actions. The FHS faces one more challenge that is to perform assistance with an incomplete team of professionals, a factor that can restrict teamwork.
Although scientific production indicates teamwork as an important instrument for coping with this fragmentation, this is still not enough to transform the way of working in health. It is worth pointing out that the FHS was conceived from the perspective of integrated work and in a team, with a view to integral care. However, this assumption does not yet have repercussions on consolidated practice, in order to generate impacts on the dynamics and organization of work. The diagnosis of the current situation in the FHS can collaborate to draw up feasible and coherent interventions with reality. It is fundamental to investigate teamwork from the perspective of the facilitators and facilitators, since this can contribute greatly to unveil what needs to be modified and strengthened for the management of the service so that the work is organized in such a way as to favor the effectively collective In view of the above, the question is; what are the factors that make it difficult and which facilitate teamwork in the FHS. It is believed that, when these aspects are unveiled, this can produce results that enable the signaling of changes to be implemented in the daily work, in order to promote and strengthen teamwork. This study aimed to identify, from the professionals' perspective, restrictive factors and drivers for teamwork, in the Family Health Strategy.

MATERIAL AND METHODS
A descriptive study, with a qualitative approach, developed together with a team from the FHS, in a municipality of the State of Minas Gerais.
The health system, in the city in focus, is organized in three Health Districts (I, II and III), and the basic health care network includes Family Health Units and Health Matrix Units (PREFEITURA MUNICIPAL DE UBERABA, 2014).
The FHS team selected was the one, informed by the Municipal Health Department (MHD), as having with the highest attached population. At the time of data collection, the team consisted of six CHAs, a physician, a dentist, and an oral health assistant. It is important to remember that the team, at the time of data collection, was incomplete, not having a nurse or a nursing technician, a fact resulting from the end of the contract of the professionals of the FHS and contest. It should be noted that this is the reality of several teams, in the mentioned municipality, and in other Brazilian cities. However, when the project was designed and made the request for data collection with the MHD, the team was complete. The table was modified when the collection was started. It was decided to continue, also because the incompleteness of the team represented a difficulty for which they were passing several team in the municipality, moment of reconfiguration of the teams.
The nine members of this FHS accepted to participate in the research and met the criterion of inclusion that was to work in said team for at least six months.
For data collection, a semi-structured interview was used based on a script that was previously submitted to the evaluation and content by three experts in the thematic and / or research methodology adopted. Data collection was carried out during the month of August / 2016, by the researcher, face to face, recorded in a digital medium, in a previously scheduled day and place, in agreement between the participants, responsible for the service and researcher, in an environment that ensured privacy and confidentiality. Participants were referred to as E1, E2, E3 and so on, up to E9, with letter E indicating the participant's interview, and the numeral, the sequential order of interviewing. It should be emphasized that it was not the focus of the study to analyze the answers by professional category, so this distinction was not made.
In the data analysis, the interviews were transcribed integrally and organized, in individual files, by the researcher. The data was analyzed based on content analysis, thematic modality. This technique is based on identifying the nuclei of meaning that integrate the material collected and that respond to the objectives of the study (MINAYO, 2013). The aim was to understand the meanings revealed by the participants regarding the difficulties and facilities for teamwork in the FHS, from the perspective of the team.
The content analysis, in the thematic modality, presupposes three stages: pre-analysisexhaustive reading of the material and establishment of the context units; exploration of the materialidentification of categories and grouping of contextual units; the last stage -elaboration of interpretative synthesis and organization in thematic units (MINAYO, 2013). This study was approved by the Research Ethics Committee involving human beings (REC) of the Federal University of Triângulo Mineiro (UFTM), with CAAE 52503616.3.0000.5154. The participants signed the Informed Consent Term (ICT).

RESULTS
The nine participants of the study were female, aged between 26 and 56 years, predominance of complete higher education and absence of complementary training completed, training time between three and 31 years, and time of performance in the FHS between nine months and 11 years.
The results that emerged from the interviews were grouped by content affinity, in four thematic units, of which two referred to difficulties (restrictive factors) and two, to facilities (driving factors) for teamwork.
Restrictive factors for teamwork were grouped in thematic units: Inadequate organization and resources and weakened interpersonal relationships.
The thematic unit Inadequate organization and resources reveals that the flow of inadequate customer service, problems with physical structure, insufficient material resources and incomplete team of professionals represent obstacles to teamwork at the FHS, as evidenced by the following statements: "I think the electronic queue (...) we do not have much access, the patient complains a lot about the delay (...) there is an agenda that we do not have access to (...) there is a lot of difficulty in the service because of this". (E3) "And the question of the electronic queue that patients complain about". (E1) The scheduling of users via electronic queue was identified as limiting for teamwork. Prolonged waiting time impairs the assistance and generates complaints that may weaken the professionals' bond with the community, which also weakens the collective work.
The inadequate location of the FHS unit was also indicated as a restrictive element for teamwork, according to the statements: "Here, what I think is more difficult (...) the distance from the post to our area (...) the location of the unit, so that we can move around it makes it difficult (...) we could even work, do a lot more home visits, but this ends up being hampered by the distance, I think this harms (... The distance between the FHS unit and the scope area compromises teamwork, assistance and creates discomfort for professionals.
Problems with physical structure and insufficient material resources are pointed out as obstacles to teamwork, exemplified in the reports: " In-service training is indicated as a driver for teamwork. It is emphasized that the effort and investment in training provide the professional with greater security and mastery of the tools in their work.
The thematic unit Interpersonal relationship based on proper collaboration and communication reveals that the interviewees identify that the use of non-material instruments, such as collaboration, mutual help, communication and appreciation of the work of the other agent, favors teamwork, being exemplified in the lines: "(. Communication is evidenced as an impeller for teamwork, which can impact on the improvement of the assistance to the attached community.
Regarding the valorization of the work of the other agent, the following statements illustrate: "Each one contributes its share, it is the one that facilitates the most, our part is our experience, our experience of which its individual knowledge and the different look about the community that we treat".

.)you give this autonomy to the community agents, value their work, I think this makes it much easier". (E9)
It is observed that situations that nourish the capacity and the sensitivity of considering the contributions of another professional are impellers for teamwork, as they encourage and credit value in what the other performs.

DISCUSSION
It was found that the restrictive factors for teamwork were more easily identified by the participants, being reported more easily, while the drivers were expressed in a more subtle way. These findings converge with the literature that shows predominance of situations understood as hindering for teamwork in the professional environment (GOULART et al., 2016).
Inadequate flow of care proves to be an impediment to care and to teamwork. This may reinforce the fragmentation of work and lead to the discontent of managers, professionals and users (SANTOS; GIOVANELLA, 2016). In this study, the electronic queue is perceived by the participants as limiting to teamwork and also generates negative consequences for the community served.
The geographical distance between the FHS and the area covered is considered as restrictive for teamwork, as it generates more time spent for the displacement of professionals, which reduces the number of home visits. FHS units should be located in regions that allow greater proximity to users (DOBBINS et al., 2016), otherwise this may compromise the performance of the work as well as the possibility of a more collective and integrated.
It has been shown that problems with physical structure and scarce material resources make teamwork difficult. Inadequate physical structure and insufficient material resources can impair the humanization of care and the quality of care (CABRAL et al., 2017). However, the FHS is considered a technological innovation in health, not considering the material resources that it possesses or does not, but, by the principles it encompasses, the current ideas about health (CALEGARI; MASSAROLLO;SANTOS, 2015). Although the FHS brings innovative essence to the work, not depending so much on the hard technologies, it is emphasized that the team requires availability of the minimum resources necessary so that the professional is not at the mercy of what is lacking.
In this perspective also, it was verified that incomplete team makes difficult work in team. It should be emphasized that one of the components for transforming care and achieving individualized outcomes concerns staff (SORATTO et al., 2015). Incomplete staff may lead to work overload and failures to achieve user expectations and the humanization of care (GALAVOTE, 2016). Timely emphasize that other FHS teams, in the city in focus, were also incomplete, a reality experienced by several Brazilian cities.
It should be emphasized that the absence of the nursing team and the nurse is a difficult aspect in the work, since its performance is multidimensional (SIMAN; CUNHA; BRITO, 2017), being the nurse an articulator between the components of the team, between the actions in their work environment and also, the main informant about the data of the unit. This may hinder the completion of work for integral care and teamwork.
It is pertinent to draw attention to the fact that the collective work can contribute to an improvement in the flow of care, besides collaborating to improve the qualification of the assistance (SIMAN; CUNHA; BRITO, 2017).
Conflicts among professionals were pointed out as limitations to teamwork, being characterized, mainly, by the existence of unpleasant and inappropriate conversations. Conflicts restrict teamwork, since they make it difficult to approach and collaborate between professionals (LANCASTER et al., 2015;SOUZA et al., 2016). It is necessary that these conflicts be overcome through adequate communication, as an aggregating element for teamwork (VALENTINE; NEMBHARD; EDMONDSON, 2015).
Inadequate management was identified as a hindrance to teamwork. A vertical managerial model opposes the principles of teamwork, whose pillar is the integrality of the actions with the participation of all those involved in the work process, so that collective work can be carried out (QUADROS et al., 2016). This shows a close link between managerial model and teamwork, since the type of management directly impacts the maintenance of integrated or fragmented health actions.
Moments of in-service training, according to the interviewees, drive teamwork, such as continuing education, continuing education, training and specialization. However, it is possible to infer that these moments are uncommon in the studied unit.
The academic and complementary training has the potential to constitute professional competence, however, it is crucial to establish situations conducive to the manifestation of these competences (QUADROS et al., 2016). NOCE, L. G. A. et al. The academic and complementary training Union and mutual aid were pointed as impellers for teamwork. The way the professionals interact has repercussions on the care provided and needs to be anchored in collaboration and exchange (GOULART et al., 2016), but for this the teams require structural support (SCHERER et al., 2016), emphasizing support management.
Communication is perceived as a facilitator for teamwork, converging with the literature (POLIS et al., 2015). Proper communication has influence in teamwork as an effective strategy to avoid failure and fragmentation of assistance, as important messages can be lost during inappropriate communication (LANCASTER et al., 2015). In PHC, the team's appropriate communication contributes to qualified assistance (TUBBESING; CHEN, 2015), as well as being indispensable for obtaining trust, mutual respect and understanding among team agents (HARRIS et al., 2016).
Finally, another impelling factor indicated by the participants refers to the valorization of the other's work, an important characteristic that must be highlighted by the service management, recognizing the collaboration of each agent with the team (SCHERER et al., 2016). For professionals, situations in which they feel recognized for their work, such as during meetings, motivate them to engage in teamwork (DUARTE;BOECK, 2015).
In front of the results, interpersonal relationship contemplates two dimensions. If conflicts and inadequate management occur on the one hand, then the relationship gets hampered and restricts teamwork. In another perspective, when this interpersonal relationship makes use of nonmaterial instruments such as communication, collaboration, mutual aid, union and appreciation of each other's work, then interpersonal relationship drives teamwork.
As limitations, the data collection was developed at a time when the FHS underwent personnel restructuring, due to the end of the contract of the professionals and the holding of a competition, which compromised to reveal the perception of all professional categories. However, it is important to note that several other FHS teams in the municipality were in the same situation. It is understood that the absence of the nursing team in the scenario studied may influence some of the restrictive factors that emerged in the study. Although the research was done with an FHS team and that this is a limitation, it is understood that the daily life experienced in this scenario is very similar to other teams, including their incomplete composition. It is not intended to generalize results, but to highlight that they can be convergent with other realities.

CONCLUSIONS
Both the constraining factors and the drivers for teamwork are closely linked to the conditions for performing the work and the environment, and to the relationship between the team agents. Such aspects, depending on how they are experienced, can restrict or impel teamwork in the FHS. These conditions must be understood and respected by both staff and managers, so that the culture of teamwork is implemented in the health services, especially in the FHS, with a valuation of the userprofessional link that can be impacted by the way in which the health team relates.
As limitations, the data collection was developed at a time when the FHS underwent personnel restructuring, which compromised to reveal the perception of all professional categories. It is understood that the absence of the nursing team in the scenario studied may influence some of the restrictive aspects that emerged in the study. Although the research was done with an FHS team and that this is a limitation, it is understood that the daily life experienced in this scenario is very similar to other teams, including their incomplete composition. It is not intended to generalize results, but to highlight that they can be convergent with other realities.
Scientific productions about teamwork still do not impact transformations for more integrated / articulated work. Teamwork does not only require the availability of professionals, but presupposes resources that enable and support this modality of work, highlighting the managerial perspective as a driver for change. There is a need for the management and government spheres to provide full professional staff for FHS, especially considering the nurse as one who articulates and promotes integration among the different professionals, from the perspective of teamwork and integral care.
The results indicate the need for advances in health management and management, in order to institute public policies for valorization and recognition of teamwork as well as the inclusion of the theme in the curricula of the different health training courses so that the professional is trained not only in the aspect of techniques, procedures and tasks, but also with relational competence and understanding for the need to rethink and re-signify the process of health work, from a collective and integrated perspective. The need to reformulate organizational behavior emerges, with emphasis on NOCE, L. G. A. et al. managerial practices aimed at ensuring and supporting the effective development of this type of work.