DI AGNOSI S OF THE SI TUATI ON OF HEALTH W ORKERS AND THE TRAI NI NG PROCESS AT A
REGI ONAL CENTER FOR PROFESSI ONAL HEALTH EDUCATI ON
1Neide Tiem i Mur ofuse2 Mar ia Lúcia Fr izon Rizzot t o3 Ar lene Benini Fer nandes Muzzolon4 Anair Lazzar i Nicola2
Murofuse NT, Rizzotto MLF, Muzzolon ABF, Nicola AL. Diagnosis of the situation of health workers and the training process at a regional cent er for professional healt h educat ion. Rev Lat ino- am Enferm agem 2009 m aio- j unho; 17( 3) : 314- 20.
The policy of pr ofessional healt h educat ion has been put int o oper at ion by t he cent er s of pr ofessional healt h educat ion in a decent ralized way. Aim ing t o ident ify t he needs of t he healt h sect or at a regional level, a survey w as car r ied out t o inv est igat e t he sit uat ion of w or k er s in t he public healt h net w or k of 2 2 cit ies in t he 1 0 t h Paraná Healt h Dist rict , Brazil. Quest ionnaires and docum ent analysis were used in t his qualit at ive and quant it at ive explor at or y st udy. Result s r evealed t hat 35.6% of t he w or ker s did not par t icipat e in any educat ional act ivit ies b et w een 2 0 0 4 an d 2 0 0 6 . I n t er m s of w or k con t r act s, 7 8 . 7 % h ad on ly on e j ob , 5 0 . 2 % w er e g ov er n m en t em p loy ees, an d 2 5 . 2 % h ad u n st ab le con t r act s, sh ow in g t h at t h e sect or in cor p or at ed t h e p r od u ct iv it y an d f lex ibilit y r at ion ales. Th e con clu sion is t h at t h e cen t er s of pr of ession al edu cat ion , j oin t ly w it h t each in g an d m anagem ent inst it ut ions, need t o clear ly define policies for t he healt h sect or at a r egional lev el.
DESCRI PTORS: hum an r esour ces; educat ion, cont inuing; single healt h sy st em
DI AGNÓSTI CO DE LA SI TUACI ÓN DE LOS TRABAJADORES DE LA SALUD Y EL PROCESO
DE FORMACI ÓN EN EL POLO REGI ONAL DE EDUCACI ÓN PERMANENTE DE LA SALUD
La polít ica de edu cación cont inuada en salud h a sido ej ecut ada por los Polos de Edu cación Per m an en t e, de m anera descent ralizada. Para ident ificar las necesidades regionales del sect or, se llevó a cabo el levant am ient o de la sit uación de los t rabaj adores de la red pública de salud de 22 m unicipios pert enecient e a la 10ª Región de Salud de Paraná. La invest igación explorat oria, con enfoque cualit at ivo y cuant it at ivo, se ut ilizó de cuest ionarios y del análisis docum ent al. Los r esult ados m ost r ar on que 35, 6% de los t r abaj ador es no par t icipó en ninguna act iv idad de f or m ación en t r e 2 0 0 4 y 2 0 0 6 . En r elación al v ín cu lo de t r abaj o, 7 8 , 7 % , t en ían solam en t e u n em pleo, el 50, 2% er an funcionar ios concur sados y 25, 2% t enían cont r at os pr ecar ios, poniendo de r eliev e la incorporación de la lógica de product ividad y flexibilización en el sect or. Se concluye por la necesidad de cont ar con una polít ica par a el sect or de la salud a niv el r egional, con par t icipación de los ór ganos for m ador es y de gest ión del sist em a de salud.
DESCRI PTORES: r ecur sos hum anos; educación cont inua; sist em a único de salud
DI AGNÓSTI CO DA SI TUAÇÃO DOS TRABALHADORES EM SAÚDE E O PROCESSO DE
FORMAÇÃO NO POLO REGI ONAL DE EDUCAÇÃO PERMANENTE EM SAÚDE
A polít ica de educação perm anent e em saúde vem sendo operacionalizada pelos Polos de Educação Perm anent e, descent r alizadam ent e. Visando cont r ibuir par a a ident ificação das necessidades r egionais do set or , r ealizou- se lev ant am ent o da sit uação dos t r abalhador es da r ede pública de saúde de 22 m unicípios da 10ª Regional de Saúde do Par aná. A pesquisa ex plor at ór ia, com abor dagem qualit at iv a e quant it at iv a, ut ilizou de quest ionár io e an álise d ocu m en t al p ar a a colet a d e d ad os. Os r esu lt ad os r ev elar am q u e 3 5 , 6 % d os t r ab alh ad or es n ão par t icipar am de n en h u m a at iv idade de f or m ação en t r e 2 0 0 4 e 2 0 0 6 . Em r elação ao v ín cu lo em pr egat ício, 7 8 , 7 % , p ossu i ap en as u m v ín cu lo, 5 0 , 2 % são est at u t ár ios e 2 5 , 2 % são con t r at ad os d e f or m a p r ecár ia, evidenciando a incorporação da lógica da produt ividade e da flexibilização no set or. Conclui- se pela necessidade de definição clara do Polo de polít ica para o set or de saúde que envolva os órgãos form adores e de gest ão do sist em a de saúde em nív el r egional.
DESCRI TORES: r ecur sos hum anos; educação cont inuada; sist em a único de saúde
1This research was support ed by Fundação Araucária and Conselho Nacional de Desenvolvim ent o Cient ífico e Tecnológico, CNPq, Brazil; 2Ph.D. in Nursing,
Facult y, Universidade Est adual do Oest e do Paraná, Cam pus de Cascavel, Brazil, e- m ail: neidet m @t erra.com .br, anairln@yahoo.com .br; 3Ph.D. in Public
Healt h, Facult y, Universidade Est adual do Oest e do Paraná, Cam pus de Cascavel, Brazil, e- m ail: frizon@t erra.com .br; 4 M.Sc. in Public Healt h, Coordinat or
Pólo Regional de Educação Perm anente da Secretaria Estadual de Saúde do Paraná, Brazil, e- m ail: arlenem uzzolon@hotm ail.com .
I NTRODUCTI ON
T
he new dynam ics of product ion has led t o int ense t ransform at ion, especially in t he labor area, through the incorporation of new m anagem ent m odes and t echnology, r eor ganizing pr oduct iv e pr ocesses, reducing work positions in the industry and contributing to the expansion of the service sector( 1). I n the health area, as from t he 1990s, t his process in Brazil was f a v o r e d b y p u b l i c p o l i ci e s l i k e t h e Pr o g r a m o f Com m unit y Healt h Agent s ( PACS) , agent s t o fight d e n g u e , a m o n g o t h e r s, w h i ch a b so r b s w o r k e r s d i sm i sse d f r o m o t h e r a r e a s w i t h o u t sp e ci f i c qualificat ion. This pr ocess, coupled t o t he sect or ’s com m odificat ion , h as led t o in cr eased t u r n ov er in public healt h ser v ices and unst able labor r elat ions, w hich im pede t he cr eat ion of t ies bet w een w or ker s and em ployers, knowledge on the real health condition of the com m unity and the work team itself( 2).I n addit ion t o t hese, ot her pr oblem s hav e been discu ssed sin ce t h e begin n in g of t h e h ealt h reform , such as t he need t o change t he care m odel and healt h pr ofessionals’ educat ion, w hich indicat e the gap between professional education and the needs of t h e Br azilian Un if ied Healt h Sy st em ( SUS) , as undergraduat e program s keep t raining professionals without considering the advancem ent achieved in this area by t he public sect or, especially in prim ary care. SUS has pr ogr essed m or e r apidly in t his ar ea t han changes adopt ed in educat ion( 3).
Sev er al Lat in Am er ican count r ies, including Brazil, prom oted large reform s in their health system s in t he 1990s. However, t hese changes were focused on financial aspect s and m anagem ent syst em s, wit h lit t le em ph asis on h ealt h w or k er s. Th is m ay h av e contributed to the continuity of m any problem s in the sect or, such as: unequal access and perm anence of t he predom inant healt h care m odel( 4).
On e sh o u l d a n a l y ze t h e p r o p o sa l o f professional education in the Brazilian health area with this context in m ind. This proposal is based on three sectors: public, private and the one covered by health insurance; and at differ ent lev els of car e: pr im ar y, secon d ar y, t er t iar y an d q u at er n ar y, in w h ich t h e o r g a n i za t i o n o f w o r k p r o cesses i s d i f f er en t a n d possibly m ediat ed by different rat ionales, in t erm s of care levels as well as privat e and public sect ors.
The pr ofessional educat ion pr oposal of t he Ministry of Health ( MH) , in contrast to the concept of continuing education that includes post- undergraduate t eaching act iv it ies and aim s t o updat e and acquir e
n e w i n f o r m a t i o n , i s p r e se n t e d a s a st r a t e g y t o restructure and develop health services based on the analysis of concrete situations, with a view to changing v alu es an d con cept s an d t r an sfor m h ealt h ser v ice pract ices. I n t his perspect ive, professional educat ion present s a close relat ion bet ween t he educat ive and healt h work processes wit h t he use of new t eaching-learning m et hods, especially problem at izat ion. I t also p r o p o se s t o b e a t r a i n i n g / t e a ch i n g a n d sy st e m m anagem ent strategy, so as to change the health care process, t he elaborat ion of policies and social cont rol in the health sector( 5).
The Regional Cent er of Pr ofessional Healt h Educat ion at t he St at e Universit y of West ern Paraná ( PREPS/ Western) , included in this study, is a reference for t h e cit ies belon gin g t o t h e 1 0t h Par an á Healt h Dist rict ( 10t h RS) and it s creat ion was based on t he MS proposal, which has sought t o elaborat e policies for t he t raining and developm ent of healt h w orkers as a st rat egy t o consolidat e SUS. These policies are being put into operation in a decentralized way in the en t ir e Br azilian t er r it or y, at in t er - in st it u t ion al an d regional levels, called Cent ers of Professional Healt h Education. I ts tasks are: to identify the sector needs, e st a b l i sh i n t e r - i n st i t u t i o n a l a n d i n t e r - se ct o r negot iat ions and elaborat e policies for t he educat ion and developm ent of healt h w or ker s, am ong ot her s. The st at e of Paraná received six enlarged cent ers in t he healt h m acr o- r egions and 22 r egional cent er s, one in each regional healt h cent er( 6).
I n order to com ply with its functions defined by the National Policy of Professional Health Education, t h e Ma n a g e m e n t Co m m i t t e e a t PREPS/ We st e r n considered it necessary to perform an initial diagnosis of the hum an resources existent, in term s of quantity and other aspects regarding education, different levels of form al educat ion, refresher t raining, qualificat ion, t r a i n i n g a n d co u r ses t h ese w o r k er s m i g h t h a v e at t ended aft er t heir init ial for m al educat ion in t he st udied period.
I n this perspective, this study aim ed to carry out a survey to know the situation of health professionals working in public health services in the cities included in the scope area of the 10th RS and to identify educational activities attended between 2004 and 2006.
MATERI AL AND METHOD
pr oj ect s appr ov ed and put in oper at ion by PREPS/ West ern and a survey, whose dat a were collect ed by a q u est ion n air e w it h op en an d closed q u est ion s, distributed to people working in the public health sector of the 22 cities* that com pose the 10th RS.
D at a co l l ect i o n w as car r i ed o u t b et w een Oct o b e r 2 0 0 6 a n d Ma r ch 2 0 0 7 . Fo u r t h o u sa n d quest ionnaires were dist ribut ed, which correspond t o the total of workers in the health area of the studied cit ies. Of t hese, 939 ( 23. 5% ) quest ionnair es w er e ret urned, t oget her wit h t he signed free and inform ed consent t erm . The research proj ect was approved by t he Research Et hics Com m it t ee t hat guides research inv olv ing hum an beings at t he St at e Univ er sit y of West er n Parana.
The cont ent of open quest ions was grouped into them atic units and individuals’ discourse identified by a num ber of or der, pr eceded by t he let t er “ Q”. Answ er s of closed quest ions w er e sy st em at ized in absolute frequency and percentage. Occupations were g r ou p ed b ased on t h e m et h od olog y t h at d ef in es occupation in the health area according to its activities and classifies them in three groups: core, related and ot hers. The analysis was based on lit erat ure relat ed to the topic under study.
RESULTS AND DI SCUSSI ON
The m aj orit y of t he part icipant s was fem ale ( 7 8 % ) , w i t h seco n d a r y sch o o l ( 5 5 . 2 % ) , w eek l y w or kload of 40 hour s ( 75.9% ) , w it h only one w or k con t r act ( 7 8 . 7 % ) and fiv e y ear s of w or k ( 55.2% ) . Participant occupation groups are presented in Table 1.
Occupat ions in t he core group predom inat e, considering t hat , from t he 50 occupat ions found, 20 w e r e co r e a ct i v i t i e s ( 6 8 . 9 % ) , 2 5 w e r e r e l a t e d occupat ions ( 23.1% ) , and five were from t he ot hers group ( 3.1% ) ( Table 1) . Am ong the occupations from t h e cor e gr ou p, t h e n u r sin g t eam ( n u r se, n u r sin g t echnician, nur sing aux iliar y and com m unit y healt h agent – CHA) was a m aj ority ( 51.5% ) . Although CHA does not m eet the requirem ent of specific education( 9), which is dem anded in the core group, it constitutes a new m em ber integrated in the health team , according to social policies im plem ented by the MS in the 1990s.
The diverse com position of the work force in the health area dem ands effect ive act ions from t he governm ent t o regulat e occupat ional perform ance, aim ing for t he qu alit y of car e deliv er y, w h ich sh ou ld n ot depen d solely on t he m arket regulat ion( 10).
When we relat ed schooling wit h occupat ion, w e found t hat t he m aj orit y ( 55.2% ) had secondary educat ion and only 1% had a m ast er ’s degr ee, t he highest educat ional level found. Considering t hat t he required educat ional level is prim ary educat ion, t he quantity of CHAs with a bachelor’s degree ( 7.4% ) and specialization ( 2.3% ) is noteworthy. This result m ight b e r elat ed t o t h e r ed u ced su p p ly of j ob s an d t o st r u ct u r al u n em p loy m en t it self, w h ich af f ect s all capit alist societ ies, especially in peripheral count ries. One healt h secret ary w it h secondary educat ion and one coor dinat or w it h only pr im ar y educat ion w er e f ou n d am on g t h e st u dy par t icipan t s. Man y of t h e professionals with a bachelor’s degree had m ore than one specializat ion.
*Anahy, Boa Vist a da Aparecida, Braganey, Cafelândia, Cam po Bonit o, Capit ão Leônidas Marques, Cascavel, Cat anduvas, Céu Azul, Corbélia, Diam ante do
Sul,Form osa do Oest e, Guaraniaçu, I bem a,I racem a do Oest e, Jesuít a, Lindoest e, Nova Aurora, Quedas do I guaçu, Sant a Tereza do Oest e, Sant a Lúcia, Vera Cruz do Oeste.
Table 1 – Num ber of workers according t o groups of occupat ions. Cascav el, 2007
s p u o r
G Occupations N %
) 4 4 6 ( e r o
C CommunityHeatlhAgent 258 27.5
y r a il i x u A g n i s r u
N 115 12.2
e s r u
N 73 7.8
n a i c i n h c e T g n i s r u
N 38 4.0
n a i c i s y h
P 30 3.2
n o e g r u s l a t n e
D 28 3.0
t n e g a s c i m e d n
E 21 2.2
e c if f o s 't n a t s i s s A l a t n e
D 17 1.8
r e k r o w l a i c o
S 11 1.2
t s i c a m r a h
P 9 1.0
s r e h t
O 44 4.7
) 7 1 2 ( d e t a l e
R Operaitonalassistant 42 4.5
t n a t s i s s A e v it a r t s i n i m d
A 40 4.3
r e v i r
D 35 3.7
r e p e e
K 28 3.0
n a i c i n h c e t e v it a r t s i n i m d
A 16 1.7
l a n o i s s e f o r p n o it a e r c e
R 10 1.1
s r e h t
O 46 4.9
) 9 2 ( s r e h t
O Coordinators 15 1.6
s r e h t
O 14 1.5
r e w s n a o
N 49 5.2
l a t o
T 939 100
st udied populat ion ( Table 2) . The Municipal Healt h Secr et ar ies w er e t h e m ain em p loy er s. Reg ar d in g place of w or k , t he Healt h Cent er s ( 33.2% ) , Fam ily Health Units ( 19.3% ) and Basic Health Units ( 17.5% ) concent rat ed t he m aj orit y of occupat ions ( 70% ) , and r epr esent t he r eor ganizat ion pr ocess of t he healt h syst em operat ing in Brazil.
k r o w f o e c a l
P Occupations Total
e r o
C Related Others
) U H B ( t i n U h tl a e H c i s a
B 131 24 6 161
) C H ( r e t n e C h tl a e
H 200 82 11 293
l a r t n e c ( y r a t e r c e S h tl a e H l a p i c i n u M ) S H M ( ) l e v e
l 4 11 4 19
) U H F ( t i n U h tl a e H y li m a
F 163 8 - 171
l a t i p s o
H 56 42 1 99
) D H ( t c i r t s i D h tl a e
H 22 17 5 44
U H F d n a C
H 7 - - 7
r e h t o d n a C
H 2 3 - 5
U H F d n a U H
B 5 - - 5
l a t i p s o H d n a C
H 3 - - 3
l a t i p s o h d n a U H
B 3 - - 3
U H B d n a C
H 3 - - 3
U H F d n a C H , U H
B 1 - - 1
D H d n a C
H 1 - - 1
D H d n a U H
B 1 - - 1
r e h t o d n a U H
F 1 - - 1
D H d n a U H F , S H M , C
H - 1 - 1
* r e h t
O 33 24 - 57
r e w s n a o
N 8 5 51 64
l a t o
T 644 217 78 939
Table 2 – Num ber of w or ker s accor ding t o place of w or k . Cascav el, 2007
*Schools, Outpatient clinic, Em ergency room , I ntegrated Em ergency Traum a
Care Syst em - SI ATE, Blood cent er, Psychosocial Care Cent er - CAPS I and I I I and Mental Health Care Center - CASM.
Alt hough t he m aj orit y of workers were hired as g ov er n m en t em p loy ees ( 5 0 . 2 % ) , u n st ab le j ob p o si t i o n s w e r e e v i d e n ce d b y t h e e x i st e n ce o f tem porary contracts ( 11.7% ) , other kinds of contracts ( 7.6% ) and not report ed t ypes of cont ract s ( 5.9% ) ( Table 3) .
Th e m aj or it y of r espon den t s ( 7 8 . 7 % ) h ad only one work contract and a m inority ( 9.2% ) two to four w or k cont r act s. Mem ber s of t he nur sing t eam ( 4.2% ) , the physician ( 1.5% ) and the dentist ( 0.8% ) were am ong t hose wit h t wo work cont ract s. Working in shift s fav or s m ult iple w or k cont r act s and it has becom e a way to com pensate for wage losses, despite risks and harm s t hey cause t o care delivery and t o workers’ healt h( 11).
Follow ing t he gener al t r end of t he cur r ent econ om y, t h e h ealt h sect or also in cor por at ed t h e r at ionale of flexible w or k r elat ions, r educing for m al contracts, elim inating lim ited workloads and increasing
t he v olum e of cont r act s for undet er m ined per iods. Estim ates are that approxim ately 600 thousand health workers do not have legal support and regularit y of professional workin Brazil( 12).
Table 3 – Num ber of health workers according to the t y p e of w or k con t r act an d g r ou p of occu p at ion s. Cascav el, 2007
t c a r t n o c f o e p y
T Occupations Total
e r o
C Related Others
e e y o l p m e t n e m n r e v o
G 276 154 21 471
o t g n i d r o c c a d e r i H ) T L C ( s w a l r o b a l n a il i z a r
B 182 22 1 220
y r a r o p m e
T 90 13 3 110
y r a r o p m e t d n a T L
C 8 - - 9
e e y o l p m e t n e m n r e v o G y r a r o p m e t d n
a 2 1 - 3
* r e h t
O 54 10 3 71
r e w s n a o
N 32 17 1 55
l a t o
T 644 217 29 939
*Refers t o com m issioned posit ions, cooperat ive and t rainees.
The m ain challenge of t he MS policy called “ Despr ecar izaSUS”, aim ed t o v alu e w or k er s, is t o enlar ge t he consensus on t he concept of unst able work( 12). Unst able work, according t o labor unions, is char act er ized not only by t he absence of w or k er s’ legal right s and social securit y, due t o indiscrim inat e ou t sou r cin g , in ex ist en t or ir r eg u lar con t r act s v ia cooperat ives and com m issioned posit ions t o provide direct care to the population( 13), but also by the absence o f p u b l i c se ct o r r e cr u i t m e n t e x a m i n a t i o n o r governm ent em ploym ent in SUS( 12).
The r educed num ber of st able w or kers and t he increased num ber of professionals in t em porary posit ions( 13) affect t he qualit y of healt h care delivery, especially because t he lat t er occasionally part icipat e in the developm ent of health actions, which fragm ents care and weakens proj ect s based on int egralit y and equity. Thus, discussion of educational practices linked t o professional educat ion proj ect s have t o be t ied t o t he cont ext in which policies aim ing t o enhance t he work force in t he healt h area are elaborat ed.
pr ocesses f ocu sed on t h e im pr ov em en t of ser v ice qualit y and on equit able car e and access t o healt h ser v ices.
I n t he socializat ion process t hat t akes place in health institutions, as a practice area and as cultural and educat ive inst it ut ions, differ ent pr ofessions ar e co n f i r m e d a n d co m p l e t e d a n d t h e n e ce ssa r y professional practices and com petences are m olded( 6). The m ain ways t o updat ing knowledge m ent ioned by the study participants, in a set of nine options, were: in f or m at ion p r ov id ed b y t h e in st it u t ion ( 2 6 . 6 % ) , p ar t i ci p at i o n i n ev en t s ( 1 8 . 3 % ) an d n ew sl et t er s ( 13.8% ) . The least m ent ioned were: library ( 4.5% ) and scient ific j ournals ( 4.9% ) . These result s confirm the im portance of institutional initiatives to update the knowledge of healt h workers.
Dat a on edu cat iv e act iv it ies r ev ealed t h at 35.6% of the workers did not participate in any activity in t he st udied period ( 2004 t o 2006) . Am ong t hose, t he lar gest par t belonged t o t he gr oup of “ r elat ed” act iv it ies ( 46.5% ) , follow ed by t he gr oup of “ cor e” activities ( 31.7% ) and “ others” ( 27.6% ) . Am ong those who part icipat ed in t raining and updat ing act ivit ies, the m aj ority ( 40.6% ) had attended one to two events in a t hree-year period, less t han a part icipat ion/ year, which is considered low due to the rapid changes that occur in t he healt h area.
Regarding educat ional act ivit ies prom ot ed by PREPS/ West er n , 4 0 a ct i v i t i es i n cl u d i n g co u r ses, event s, w or kshops and t r aining w er e appr oved and carried out bet ween 2004 and 2006, 11 act ivit ies in 2 0 0 4 , 1 7 in 2 0 0 5 an d 1 2 in 2 0 0 6 . I n t h is set of activities, 12 ( 30% ) focused on specific diseases, nine ( 2 2 . 5 % ) aim ed t o discu ss aspect s r elat ed t o SUS ( pr inciples and guidelines or sy st em m anagem ent ) a n d f o u r a ct i v i t i es w er e r el a t ed t o p r o f essi o n a l educat ion ( 10% ) . Dem ands from t he sect ors in t he 10th RS determ ined the Center activities, which aim ed t o t rain and/ or sensit ize m unicipal t eam s for specific act ions. The adopt ed t eaching m et hodologies m ainly in clu ded t h e pr oblem at izat ion st r at egy, discu ssion oppor t u n it ies, gr ou p st u dy an d pr esen t at ion s w it h dialogue.
Participation in educational activities is a way t o dem ocrat ize inst it ut ional relat ions and a st rat egy t o recom pose relat ions am ong t he populat ion, healt h workers and m anagers. For t hat , t he organizat ional cult ure based on t he cent ralizat ion of decisions and vert icalizat ion of program s and proj ect s needs t o be overcom e, as proposed by t he professional educat ion
policy( 6 ). Par t icipat ion of m em ber s fr om gr ou ps of healt h occupat ions is unequal and unbalanced, wit h p r i v i l e g e s f o r t h o se w h o o ccu p y m a n a g e m e n t posit ions in t he bureaucrat ic st ruct ure.
Those who part icipat ed in t raining act ivit ies considered t hem a great opport unit y t o updat e t heir techno-scientific knowledge, both to develop their technical abilities and to understand the SUS operating mechanisms, such as social control and management pact.
St rong dissociat ion bet ween healt h workers’ p r act ice an d SUS p r in cip les p r ed om in at es in t h e studied region, which contributes to m aintain a vertical and unequal r elat ion bet w een t hose w ho know and t hose who supposedly do not know, as t he following discourse shows: [ …] t he gr eat est difficult y is t o convince
the population to follow recom m endations on hygiene and adequate t r eat m ent ( Q923) .
Act ivit ies focusing on per sonal r elat ionship, qualit y of ser v ice, m ot iv at ion and hum anizat ion of care were included in the educational activities of the t hree groups of occupat ions. These act ivit ies are in agreem ent w it h flexible m anagem ent , w hich am ong ot her charact erist ics, presupposes workers’ relat ional capacit y( 1). Wor ker s ar e r equir ed t o hav e m inim um education, like in the case of CHAs( 9), but at the sam e tim e, they need to have strong relational capacity for t eam w or k an d t o at t en d t h e p op u lat ion , t h at is, adapt at ion capacit y, pr oblem - solv in g abilit ies an d being able t o int erpret inform at ion. Thus, relat ional at t ribut es like cordialit y, good sense of hum or and a sm ile ar e t ak en as sy nony m s of gr eat er hum anit y a n d a r e m o r e i m p o r t a n t t h a n sp e ci f i c t e ch n i ca l knowledge in t he healt h area.
The st udy part icipant s have incorporat ed t he apparent ly hum anizing discourse: [ …] client s should be
w ell at t ended ( Q910). [ …] and, w hen t alk ing t o people and orient ing, we have t o show love ( Q382) . [ ...] w orkers should sm ile m ore. Be hum orous helping each ot her. Be m ore hum an, k in d ( Q663) .
Thus, difficulties of m any kinds in health work e n v i r o n m e n t s a r e n o t o v e r co m e o n l y t h r o u g h relational m easures. These m easures are not sufficient t o r e a l i ze ch a n g e s i n p r o f e ssi o n a l p r a ct i ce a n d r epr esent only an elabor at ed st r at egy t hat aim s t o o b t ai n i m p r o v ed p er f o r m an ce at t h e ex p en se o f b r e a k i n g so l i d a r i t y a m o n g w o r k e r s( 1 ). An o t h e r charact erist ic required by flexible m anagem ent is t he m u lt ipu r pose w or k er( 1 ), t h at is, people capable of working in different sect ors by perform ing [ …] sev er al
funct ions wit hin his posit ion, t hus avoiding t hat em ployees are condit ioned t o a single t ask ( Q328) .
This report reveals t hat t he incorporat ion of t he m ult i- funct ionalit y and m ult ipurpose discourse is t ypical of t he current process of capit al reproduct ion. The “ new” m ode of work m anagem ent has influenced t h e r elat ion sh ip am on g t h e t eam as r ep or t ed b y int erviewees when t hey list t he following difficult ies: com pet it iveness, lack of unit y, lack of dem ocracy in the work environm ent, lack of respect from superiors, co- workers and users, little et hical behavior from t he leadership t owards t he t eam and pat ient s. These are obst acles in t he developm ent of collect ive work and lead t o conflict s in t he work environm ent , especially b ecau se t h ey ar e r el at ed t o so ci al r el at i o n sh i p s involving several workers wit h different int ent ions, in which people are coherent wit h t heir perspect ive of t he world, work and social pract ices.
Th e p r a ct i ce , st i l l co m m o n i n h e a l t h in st it u t ion s, t o pr ov ide people w it h j obs based on p olit ical cr it er ia, e. g . allian ce est ab lish ed d u r in g elect ion s, lead s t o p r ob lem s b ecau se of t en t im es people without proper training and knowledge occupy leading positions. I n addition to frequent interruptions of proj ect s and program s, which m ake m edium and long- term proj ects infeasible, the health workers’ daily rout ine is m arked by const ant dem ands from users and coordination. Thus, governm ent em ployers expect
[ …] t obe seen as hum an beings and not as working m achines
( Q7 5 8 ) .
Am o n g t h e i r su g g e st i o n s t o o v e r co m e difficult ies, par t icipant s indicat ed t he av ailabilit y of cour ses focused on educat ion, w or k er ’s m ot iv at ion
and im pr ov em ent of t he w or k place. These r epor t s show a work environm ent lit t le consist ent wit h t hose who should prom ot e healt h.
Difficulties faced in work j ustify their dem and to reduce current weekly workload to [ …] 30 hours, t his
work is exhaust ing, st ressful and requires concent rat ion ( Q326). And provide a professional in t he psychological area t o at t end t he st aff ( Q651, Q676, Q831, Q391) . [ …] aim ing t o t ake care of workers’ m ent al healt h ( Q100) .
Th i s d i sco u r se sh o w s t h e w e a r i n e ss experienced by healt h workers in t he work process, which has incorporat ed t he general rat ionale of t he product ive sect or, dem anding product ivity and qualit y of car e w it h ou t eq u iv alen t im p r ov em en t of w or k condit ions.
CONCLUSI ON
Th is st u dy ev iden ces t h at t h e m aj or it y of w o r k er s i n p r i m a r y ca r e a t t en d ed so m e k i n d o f t r ain in g / ed u cat ion act iv it y in t h e st u d ied p er iod . Ho w e v e r, a cq u i r e d k n o w l e d g e w a s n o t a l w a y s im plem ent ed due t o or ganizat ional and m anager ial problem s. Conflict s bet ween workers and users and a m o n g t e a m m e m b e r s w e r e o b se r v e d a s a consequence of ant i- et hical at t it udes.
The m aj orit y ( 50.2% ) of workers were hired as gov er nm ent em ploy ees, alt hough unst able w or k t ies were found, which can hinder t he developm ent of pr ofessional educat ional pr oj ect s due t o r educed adherence, high m obilit y and t urnover of workers in inst it ut ional proj ect s.
Th e d i ag n o si s, w h o se m ai n r esu l t s w er e present ed in t his st udy, should guide t he Com m it t ee of Man ag em en t at PREPS/ West er n f r om t h e 1 0t h Paraná Health District in the elaboration of professional healt h educat ion policies and in t he est ablishm ent of priorities for its im plem entation in the short, m edium an d lon g t er m s. I n addit ion , it w ill sh ow t each in g institutions and public m anagem ent the health sector’s r eal n eeds in t er m s of edu cat ion an d pr ofession al developm ent of healt h workers.
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