Processo de trabalho na estratégia saúde da família: potencialidades e fragilidades da atuação do enfermeiro

The present study aims to analyze the nurse s work process at Family Health Strategy, considering its basic elements and dynamic, and searching to identify aspects that may constitute strengths and weaknesses in its development. This is an analytical case study, with qualitative approach and theoretical-conceptual mark grounded in Dialectic Hermeneutics. Empirical research fields were the Family Health Units of Natal, RN, Brazil. The subjects are nurses working in this Strategy. Data collection was conducted through semi-structured individual interviews combined with field observation. The research was initiated after approval by the Ethics Committee of Universidade Federal do Rio Grande do Norte, according to the guidelines and rules for research involving humans (Resolution 466/12), ensuring proper ethical precepts. The project was approved by register number 398.929, CAAE 19588813.7.0000.5537. From the 9 interviewed nurses, 8 were female and 1 male, average age of 52 years, average graduation time of 27 years and average time they stayed at the same Family Health territory of 7 years. It was found that it is up to the professional nurse in the Family Health care the important role of taking care of human beings in their life, family and community contexts, producing conditions to meet their needs through therapeutic act in health, using for such purpose both materials and immaterial instruments. It was possible to relate aspects that characterize strengths and weaknesses in the work process of nurses in the ESF, according to the speech of the interviewed workers, including the meanings and contradictions. Among the potentialities observed, it was possible to highlight the wide role of the nurse at Family Health; the perception of nurses about teamwork; the relative autonomy of nurses; the commitment of professionals to work; Humanization as a technology; the presence of other agents at work, such as directors and officers at the primary health units; the professional s experience time and contract type in the case studied. As weaknesses in the work process of nurses at Family Health Strategy, were highlighted the limited skills of the workforce; the difficulty in 10 identifying specific limits of the work of nurses in this scenario; the disturbances that occur in the process, the existing gaps in multiprofessional teams; Structural deficits of the units in the studied case, the low coverage of the Family Health in the county, and the political vulnerability of the work conditions. It is considered necessary to understand the dilemmas experienced in everyday life of nurses at Family Health Strategy as part of multiprofessional teams, facing actual achievement of changes in work processes necessary for the reorientation of health care in Brazil. In accordance, it is necessary to promote proper working conditions and welfare of labor agents which are protagonists the work at the United Health System

Avaliação da assistência à saúde dos portadores de úlceras venosas atendidos no programa saúde da família do município de Natal/RN

Descriptive research aimed at evaluating the assistance offered to patients with venous ulcers, on lower limbs, attended by the Family Health Program (FHP) team, from the municipality of Natal/RN. The target population was composed of 74 patients with venous ulcers (VU), attended by the FHP teams in the 31 FHUs. The study was approved by the Ethics Committee of the Federal University of Rio Grande do Norte (protocol n.55/05). The data collection was performed in patients homes and in the FHUs, through structured interviews and physical examinations of patients with VU and non-participant observation during the changing of wound dressings in these Units and in users homes. The data was organized into an Excel electronic table and transported into the SPSS 14.0 program, for descriptive analysis on 2x2 contingency tables and inferential (Qui-Square χ2, Spearman Correlation, Binomial Proportion Test and p-value <0.05). The prevalence of VU (0.36/1000) in the target population (over 20 years of age) was greater than in the population registered in FHP (0.25/1000). We detected a greater prevalence in the age area of over 60 years (2.22/1000), with 2.98/1000 for females and 1.3/1000 for males (p-value=0.008). The sociodemographical and health characteristics of patients with VU revealed predominance of females (74.5%), elders over 60 years of age (67.6%), with fundamental education (74.3%), family earnings of up to 2 minimum wages (68.9%), retired (90.5%), ortostatic position (23.0%), inadequate sleep (59,9%), presence of CVI (100.0%), hypertension (44.6%) and diabetes (25.7%). As for the time of existence of the VU, 64.9% had over 1 year, and 35.1% less than 1 year), with predominance of one wound (67.6%). The changing of wound dressings is performed mostly at home, in and inadequate way, especially with incorrect cleaning techniques, likewise incorrect use of products and substances, and reduced participation of the FHP team on the evaluation and application of the dressing and choosing of products and substances. The compressive therapy is not part of therapeutic conducts for treatment in the FHUs. As for the evaluation of assistance to patients with VU, 90.5% were inadequate and only 9.5% adequate. The main inadequacy factors were the absence of: diagnosis (47.3%), consultation with and angiologist (63.5%), compressive treatment (100.0%), adequate optical therapy (98.62%), adequate dressing kit (70.3%), training for the changing of dressings (67.6%), following by the FHP team (51.4%) and performed exams (55.4%). We ve concluded that patients with VU mostly present now socioeconomical level and associated chronic diseases. Considering that assistance offered by FHP is non-systematic, fragmented, with no diagnosis planning, continual evaluation and evolution, we qualify the assistance as inadequate and with low level of solution, directly interfering on the maintenance of the VUs chronic state

Atuação dos profissionais de saúde no atendimento à criança vítima de violência

This study had the purpose of identifying the health professional performance during the care of children victimized by violence. Its objectives were the evaluation of how health professionals diagnose violence on the hospitalized child during the care process; the identification, according to the experience of each health professional, of the types of violence on the hospitalized child, the child's aggressors and the most frequent1y injured area in the body and the analysis of conducts adopted by health professionals upon the recognition of a violence case on a hospitalized child. The study was of the descriptive-exploratory type, using a quantitative approach, performed on Hospital da Criança Santo Antônio (HCSA) in Boa Vista - RR. The population consisted of 235 health professionals, with data collected from June to August 2006. The results show a clear predominance of the female gender, (76,17%); aged 31 to 35 (26,81%); married (45,96%). As for professional formation, 63,9% were nursing auxiliaries and technicians,16,2% physicians, 14,8% nurses, 3,9% social assistants and 2,1% psychologists; 45,96% had completed middle-level education, 51,06% of which coming from private education establishments and 48,94% from public education institutions.; 97,66 % have specialization or improvement courses on their area; 32,77% among 05 to 09 years of work time; 32,06(10 worked on pediatric infirmaries; 75,74% state they have experience with children victimized by violence; 96,22% consider themselves capable of identifying the types of violence suffered by children; 29,00% consider physical violence the most common kind; 91,57% sought to identify the aggressors; 27,72% consider the mother to be the child's main aggressor, 26,36% the father, and 22,28% the stepfather; 26,55% consider the limbs and pelvic waist to be the body region most affected by violence; 26,91% take the attitude of reporting to the nurse and 20,13% to the social service; 70,79% state that the conducts were performed as a team; 26,25% of the professionals consider that the social assistants helped the most on deciding which conduct to adopt; 76,40% state there was no one opposed to the performing of these conducts; but 23,60% that stated there was no one opposed to the performing of these conducts, 77,08% reveal that the family members were against the conducts taken by the team. We conclude that, the hea1th professionals who were part of the study, apparently are not adequate prepared to diagnose and report the violence on child. The results were more drastic when we related the physicians and the nurses' answers, considering that they give directed assistance to these victims social assistants and psychologists are the ones best prepared to conduct cases of child mistreatment. However, we are conscious of our responsibility with professional education not only in upper grade institution but also on the middle-level. We believe also, that a continued education program can help to improve the professional knowledge and improve the quality of care

O cuidado humanístico como foco institucional: um estudo sobre empatia dos profissionais de saúde na área obstétrica

Empathy is a basic facilitating element of the therapeutic helping relationship and the humanization process in health care. The objectives of this study were to identify the empathy level of health professionals working in the obstetrical sector of a university hospital recognized for its humanistic care and the perceptions of the women under their care regarding the empathic behavior shown by these professionals during hospitalization. We conducted a quanti/qualitative study with 47 health professionals that worked in the obstetrical sector (13 obstetricians, 12 nurses, 22 nurse technicians) and an intentional sample of 101 women that received cared from these professionals during the study period. We collected data by means of the Jefferson Empathy Scale for Health Professioals (JEPS-HR) and the Patient´s Perception of Health Professional Empathy (PPHPE), and two additional open questions designed to obtain the subjective opinion about the empathic behavior during the care. We utilized thematic analysis for the data obtained through the open questions and descriptive and inferential statistics for the quantitative data. We identified five thematic categories that represent the aspects valued by the professionals in their relationship with the women under their care: emotional involvement, communication, warm environment, integral vision and technical/scientific knowledge. The mean score on the JEPS-HR reported for the health professionals was 120,40, being that the maximum possible was 140.The Cronbach Alpha for the JEPS-HR was 0,83, indicating an acceptable level of reliability for this population. We consider therefore, that these professionals presented an acceptable empathy level when compared to other populations observed with the JEPS-HR. The results also indicated that women had statistically significant (p ≤ 0,05) higher scores than men and that professionals with higher working hours tended to have lower scores in the empathy scale (r = -0,288; p ≤ 0,05). The analysis of the subjective responses of the women indicated that they were satisfied with the humanistic care provided by the professionals but they also point out the existence of some power relationships. There were no significant differences in the empathy level of the medical or nursing team perceived by the women who registered means of 41,90 and 41,20 respectively on the PPHPE. In view of these results and considering the relevance of the element of empathy for care based on humanistic values, we reiterate the importance of further in-service training for the health team of the hospital in focus, on the topics of empathy and global aspects of humanized care for the implementation of its mission

Abordagem de temas em saúde pública por meio de atividades lúdicas com professoras da educação infantil

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior

Capacitação no Programa de Saúde da Família: divergências sobre o conceito de visita domiciliar nas equipes de Presidente Epitácio, São Paulo

O Programa de Saúde da Família (PSF) tem por intenção - e mérito - mudar o foco da atenção à saúde centrada no médico e na cura das doenças, para uma atenção centrada na promoção da saúde e prevenção de doenças por meio de uma equipe multidisciplinar. Para atingir esse objetivo, tem na prática de trabalho da visita domiciliar um dos instrumentos fundamentais para o entendimento da totalidade dos condicionantes que afetam a vida do cidadão. Neste artigo, discutem-se os conceitos de visita domiciliar com que operam as três principais categorias de trabalhadores do PSF - médicos, enfermeiros e agentes comunitários - , assim como sua relação com a formação no curso básico. A metodologia se baseia na técnica do discurso do sujeito coletivo a partir das entrevistas aplicadas. Concluímos que a falta de uniformidade sobre o conceito de visita domiciliar pode interferir na proposta de mudança do modelo de atenção à saúde. O artigo tece ainda considerações sobre as distintas concepções de visita domiciliar e sua relação com a organização do trabalho no interior das equipes.

O programa Saúde da Família pelo olhar do Cirurgião-Dentista

This study tried to know the social representation of dentists surgeons about the Family Health Program (FHP). Where used as methodological instruments a semi-structured interview and direct observation of work process in tive towns that are part of the metropolis region ofNatal city. During the interview some aspects where broached, such as the reasons of dentists surgeons join the FHP, what are the implications ofthe introduction of this program in the everyday practice, what kind of activities are they practicing and what are those professional missing the most in the FHP. In the direct observation where take in account some aspects related to the physic structure of health units, its service organization and demand, relationship amongst dentist and other member of the team, and about patient receptiveness, when they arrives at health unit. This study also identifY the researches subject showing their age, sex, for how they are graduates, what are them specialty and for how long they work for the FHP. The data had been analyzed through the analysis of content of Bardin5. The dentists depict the FHP for the change in assistance model through the preventive proposal of social work that makes possible to work with an ample concept of health. However what makes the FHP more attractive to dentists is the salary questiono The creation of bonds whit the community and the work whit groups and in team had been the main occurred changes in the daily one of the pratices ones of these professionals. The principal activities executed for these professionals inside of the new strategy of assistance in oral health are the carried trough preventive activities achieved in health units and social area. To them, the absence of institutional support and the employment of only one dentist for each team it is one the main point of strangling. There is no doubt that FHP is new strategy and that it is need a better integration amongst the professional, the institution

Caracterização do processo de trabalho do cirurgiãodentista na estratégia de saúde da família do município de Parnamirim-RN

Family Health Strategy (FHS), founded in 1994 has appeared to play a strategic role in the SUS construction and consolidation. It has reaffirmed its Principles and Guidelines and has elected family as core of attention. The principle that has guided the work concerns the quality of the relationship between professional and family. Thus, the FHS has the family as a subject of health-disease process, and relations with its own characteristics and can be partners in building their health and improvement of quality of life of its members and the entire community. This study aims to characterize the surgeon-dentist (SD) working process in the family health strategy, from the knowledge of the SD integration with other team members; organization of services; development of shares, changes perceived by SDs, as well as knowing the surgeon-dentist profile who is part of this strategy. The collecting tool used was a semi-structured questionnaire, in which participated 30 professionals. As for profile, most professionals were women, completed the graduation in public university and did not have any training to work by joining the FHS. Almost all have other public or private working ties. They often carry out activities with students, and occasionally do home visits. In relation to team work, in activities such as home visits, school health, community activities, among others, they sometimes seek the cooperation of other members. The way of accessing for users in the most part has occurred through the schedule. The most frequently activities made to the Centro Especialidades Odontológicas (CEO), are in Endodontics and Prosthesis. The majority of them participate in team meetings, but they do not have frequency set to happen. As for the planning and programming of activities to be conducted, most said that individually develops them. Concerning the performance of their duties, most reported being satisfied, but that improvements could happen. Besides, they reported improvements in dental care following the inclusion of SD in the FHS in various aspects, such as access, organization, humanization, care and oral disease prevention. The professionals had poor integration with other team members, in addition to have a profile to more individualistic work, a fact seized by way of development and planning of actions. They work the actions in individual and curative way, in detriment promotion and collective ones. They work humanization, definition of territory and adscript population. Thus, it is concluded that the working process developed by SDs, includes the part which is advocated by FHS. This points out to a greater undertaking of this process aiming to detect the weakness met in order to reach the potential that the FHS represents in organization of basic attention

A incorporação da saúde bucal no programa saúde da família do Rio Grande do Norte: investigando a possibilidade de conversão do modelo assistencial

The Health Family Program (HFP) was founded in the 1990s with the objective of changing the health care model through a restructuring of primary care. Oral health was officially incorporated into HFP mainly through the efforts of dental professionals, and was seen as a way to break from oral health care models based on curative, technical biological and inequity methods. Despite the fast expansion of HFP oral health teams, it is essential to ask if changes are really occurring in the oral health model of municipalities. Therefore, the purpose of this study is to evaluate the incorporation of oral health teams into the Health Family Program by analyzing the factors that may interfere positively or negatively in the implementation of this strategy and consequently in the process of changing oral health care models in the National Health System in the state of Rio Grande do Norte, Brazil. This evaluation involves three dimensions: access, work organization and strategies of planning. For this purpose,19 municipalities, geographically distributed according to Regional Public Health Units (RPHU), were randomly selected. The data collection instruments used were: structured interview of supervisors and dentists, structured observation, documental research and data from national health data banks. It was possible to identify critical points that may be impeding the implementation of oral health into HFP, such as, low incomes, no legal employment contract, difficulty in referring patients for high-complexity procedures, in developing intersectoral actions and program strategies such as epidemiologic diagnosis and evaluation of the new actions. The majority of municipalities showed little or no improvement in oral health care after incorporating the new model into HFP. All of them had failures in most of the aspects mentioned above. Furthermore, these municipalities are similar in other areas, such as low educational levels in children from 7 to 14 years of age, high child mortality rates and wide social inequalities. On the other hand, the five municipalities that had improved oral health, according to the categories analyzed, offered better living conditions to the population, with higher life expectancy, low infant mortality rates, per capita income among the highest in the state as well as high Human Development Index (HDI) means. Therefore, it is possible to conclude that public policies that include aspects beyond the health sector are decisive for a real change in health care models

Atuação profissional e vivência do cirurgião-dentista na estratégia do programa de saúde da família

The purpose of this research was to analyze the working profile of dentists from the Family Health Program (PSF Programa de Saúde da Família, Brasil) of some Municipal Districts of Rio Grande do Norte (Brazil) in order to understand the way they handle the experience acquired with the work developed in that Program. This discussion evolves a reflection about the perspectives of consolidation of the FHP as well as the possible advancements of the Brazilian Unified Health System (SUS - Sistema Único de Saúde). The target population was composed of dentists from the FHP of Rio Grande do Norte. Thus we performed twenty-one interviews orientated by a semi-structured guidebook with open questions and identification data. We opted for recording the speech of all the professionals in order to ensure the accuracy of the information gathered. The main results found were: predominance in the female gender; the majority of dentists has no post graduation courses; in those few cases of dentists with some post-graduation a lack of correlation with Public or Collective Health was observed; the dentists interviewed present a profile directed to clinical activities; the dentists used to develop basic restorative and periodontic treatment, simple surgeries and educative and preventive activities, even though the last two ones are carried out in an extremely traditional way (lectures and topical application of fluoride). In addition, as biggest difficulties to manage the work dentists pointed out the lack of permanent and consumer material, inadequate infrastructure, no transport to take them to distant places, no integration with the Health Family Team, technical difficulty such to perform educative and preventive activities as to provide adequate service to a repressed lawsuit. The results indicate the existence of a necessity to lead them to reflect and redirect their practices. In order to reach this aim it must be considered as initial measure the investment and encouragement toward to permanent education as well as a close follow-up and evaluation of the actions developed by them

Avaliação da saúde bucal na atenção básica: a perspectiva do usuário

Nowadays, the basic attention in health works according to the Health Family Program (HFP), which is responsible for the organization of the health services with view to provide an appropriate attendance to the needs of the population. Its expansion is expressive in whole country and, the oral health, included in this process, has been seen as a possibility of change the health practices centered in the disease. In face of this perspective, the proposal of study is to discover possible changes in the health care model of oral health in a district, made possible through the perception, evaluation and degree of satisfaction of the user s health service. To reach such objectives, the district of Macaíba in the State of Rio Grande do Norte, was chosen for operational subjects, such as time of implantation of HFP and great covering of this program. The current research used interviews structured with objectives and subjectives questions and questionnaires of socioeconomic characterization addressed to two hundred and seventy (270) individuals (ninety users of an Urban PSF, ninety of a Rural PSF and ninety of an unit non PSF). The analysis of the data was accomplished through the software SPSS/99, that made possible a statistical and analytic appreciation. The HFP units and non HFP units has shown to sort the common odontology problems of the community, and this didn't establish a direct relationship with the general satisfaction. On the other hands, the programmed consultation is related with lager satisfaction of the users. The access form to the odontology treatment of the Units, the satisfaction with the attendance rendered by the dentist and the equip, enough dentists for the community and the social class of the user were decisive for the general satisfaction with the service of oral health. On the other hand, variables as age and education, resolution of the problem and physical conditions of the unit didn't influence the general satisfaction. In spite of the progresses in the implantation of the oral health in ESF, preventive activities, visits at home, access and social participation still reproduce the traditional model of attendance, showing a primary change process

Impacto do Programa de Saúde da Família sobre indicadores de saúde bucal na população de Natal -RN

The aim of this study was to assess the impact of the Family Health Program (FHP) on a number of oral health indicators in the population of Natal, Brazil. The study is characterized as a quasi-random community intervention trial. The intervention is represented by the implementation of an Oral Health Team (OHT) in the FHP prior to the study. A total of 15 sectors covered by the FHP with OHT were randomly drawn and paired with another 15 sectors, based on socioeconomic criteria, not covered by the teams. A few sectors were lost over the course of the study, resulting in a final number of 22 sectors, 11 covered and 11 not covered. We divided the non-covered areas into two conditions, one in which we considered areas that had some type of assistance program such as the Community Agents Program (CAP), FHP without OHT, BHU (Basic Health Unit) or no assistance, and the other, in which we considered areas that had only BHU or no assistance. Community Health Agents (CHAs) and Dental Office Assistants (DOAs) applied a questionnaire-interview to the most qualified individual of the household and the data obtained per household were transformed into the individual data of 7186 persons. The results show no statistical difference between the oral health outcomes analyzed in the areas covered by OHT in the FHP and in non-covered areas that have some type of assistance program, with a number of indicators showing better conditions in the non-covered areas. When we considered the association between covered and non-covered areas under the second condition, we found a statistical difference in the coverage indicators. Better conditions were found in covered areas for indicators such as I have not been to the dentist in the last year with p < 0.001 and OR of 1.64 and I had no access to dental care with p < 0.001 and OR of 2.22. However, the results show no impact of FHP with OHT on preventive action indicators under both non-covered conditions. This can be clearly seen when we analyze the toothache variable, which showed no significant difference between covered and non-covered areas. This variable is one of the most sensitive when assessing oral health programs, with p of 0.430 under condition 1 and p of 0.038 under condition 2, with CI = 0.70-0.90. In the analysis of health indicators in children where the proportion of deaths in children under age 1, the rate of hospitalization for ARI (Acute Respiratory Infections) in those under age 5 and the proportion of individuals born underweight were considered, a better condition was found in all the outcomes for areas with FHP. Therefore, we can conclude that oral health in the FHP has little effect on oral health indicators, even though the strategy improves the general health conditions of the population, as, for example child health

O ambulatório de Saúde Mental no contexto da Reforma Psiquiátrica em Natal/RN

The years 1990 disclose the consolidation of the Brazilian Psychiatric Reform project, assumed as official politics by the Health Department, also stirring up discussions, lines of direction and new ways of care. Substitutive services to the psychiatric hospital as CAPS, conviviality centers, therapeutical residences and ambulatory clinics are implemented. This work analyzes the relations that the Specialized Ambulatory Clinic of Ribeira establishes to the services of Mental Health of the public system in the city of Natal/RN, as well as its adjustment to the proposal of the Psychiatric Reform. Through semi-structured interviews and observation, it was possible to gather data which allowed picturing a general characterization of the service: activities, technical group, joint with other institutions, daily routine organization. Such institution develops activities that surpass the traditional character of a clinic- in other words, the psychological/medical appointments - and it mainly greets the ones proceeding from CAPS and psychiatric hospitals. It offers group activities, psychiatric appointments, therapeutical workshops, sheltering and strolls, among others. The institution is composed by a multi-professional team of psychiatrists, psychologists, occupational therapists, nurse s aide and art-educator. The joint of this service with others that make part of the Mental Health Assistance network in Natal is incipient. Due to this fact, some actions and activities that could and should be developed together are just not. Although facing difficulties, the professionals of the Ambulatory Clinic of Ribeira are able to achieve good results and establish care in Mental Health that prioritize sheltering, listening and respect to the user s individuality. The Ambulatory Clinic of Ribeira is organized according to the paradigm of the Psychiatric Reform. Therefore, it offers an attention that stimulates the re-socialization of the users and the exercise of the citizenship and autonomy of those

Encontros entre dança, subjetivação e saúde mental

Taking from starting point the contact with the experience of a dancing body language group at Centro de Atenção Psicossocial (CAPS) II in Fortaleza-CE, aiming to investigate the relationship between what we denominate dancing-dispositive and the process of de-institutionalization of insanity. Based in the philosophy of difference and in the cartographic perspective, we used the concept of dispositive in order to make visible the lines that compose it and the way they tangle in the production of different ways of subjectivation through another form of expression using the body. We followed two fortnight groups of body language recording the conversations that took place in the beginning and in the end of the activities. We also recorded our informal talks with the workshopper, with the psychiatrist responsible for the course of formation of artists of CAPS and the choreographer who was part of the artistic formation of the workshopper aiming to elucidate the body, dance and art conceptions which guided such work. Finally, we interviewed some technicians and we participated of a meeting of the team aiming to understand how that activity was perceived. We observed that the use of certain conception of dance in the field of mental health is in consonance with the the Phychiatric Reform, since it provides another way of dealing with the body, different from that produced by the contention and by the discipline. Nevertheless, we understood that there is a risk that, in some moments, the group being more a place of normalization than one of experimenting other ways of relating with yourself and with the others. We also noted that the dancing-dispositive appears as an important analyzer of the connections established at CAPS, indicating a need of the service to be more opened to the production of new care and harboring strategies, breaking the mental health facility logic of incarceration of life which still persists in the quotidian of that institution

Saúde mental na estratégia saúde da família: notas cartográficas sobre processos de trabalho em saúde

This study aims to map the working process in the health area starting from the meeting between the family and health teams and mental trouble carriers./MTC. The area of research was the Family Health Unit of Ozeas Sampaio, which is located in the county of Teresina-PI. As regard to the methodology procedure, we used a semi-structured interview timetable, aimed to detail the care practices, admittance and diagnostics that those teams realize with their users. Three teams of eleven workers each were interviewed. There was a doctor, a nurse and two health community agents in each team. The other tools we used were a camp logbook, in which we wrote down some informal dialogs, daily observations and feelings of the unit, and also the accompaniment of the staffs in house calls as well as the weekly meetings in the unit. Those meetings allowed us the construction of two analytic axes: 1) description of the establishment (Family Health Unit) of the organization, (municipal foundation of health and the service network), and the institutions and practice of health. 2) Analysis of the meetings between the worker and the user of Mental Trouble Carriers. In the first axis, we verified the repetition of the working logic focused on jobs in the hospital with the maintenance of the hierarchical relations between worker and the work processes which dissociate management and watchfulness in health care. We identified the lack of physical structure, the lack of self-confidence of the worker in the attention of the mental health care. At the second axis, we assess that the meetings, at the Family Health Unit (FHU) or at the dwelling of the users cause nuisance, discomfort and anxiety to the workers because they deal with issues that go beyond what is named as being the health order such as life stories, family conflicts, unemployment, hunger, sexual and psychological violence. As a matter of fact, they involve difficulties for having new relationships, reception and responsibility for this request