Analysis of professional implication as a tool of permanent education in health*

Objective: analyze professional implication with the support of humanization and articulators of permanent education in health as a tool of Permanent Education in Health. Method: this is an interventional study of qualitative approach, based on the theoretical reference of Institutional Analysis. Thirty-five humanization supporters and/or permanent education articulators participated in this study. Semi-structured interviews, monthly meetings, restitution meetings and a daily logbook were used as tools for data production. The material was analyzed according to the principles of the study reference and the results were presented according to the ideological, organizational and libidinal dimensions of professional implication. Results: this study identified a contradiction when finding a professional profile for the development of support and articulation; feelings of discouragement, pessimism and optimism in the development of these roles; influences of the nursing profession on the development of support and articulation; length of professional service; and the absence/presence of desire in such development. Conclusion: the analysis of professional implication consisted of a powerful tool generating training processes. It allowed learning and reflection of the practice through analysis of the actions performed by the professionals, generating changes in the conception of work in health.


Introduction
Permanent Education in Health (EPS) has been addressed in several scientific studies developed by nurses associated with the training of health professionals for technical improvements of their daily practices (1)(2) .
However, the National Policy for Permanent Education in Health (PNEPS) has an approach that goes beyond the character of punctual training, looking more like a process aiming to place daily work actions in a collective analysis to allow changes in practices and training. This is due to the understanding that the problems in the territories and those experienced in the daily work in health have a complex nature, requiring solutions based on the context of the professionals inserted in that reality and knowledge that goes beyond the technical fields of health professions (3) .
Because its training characteristic is based on constructions of collective interprofessional proposals contextualized according to reality, the EPS has a strong transforming power -when used in this perspective -to favor dialogue, cope with conflicts, develop teamwork, expand the ability to analyze work processes and the daily reality (4)(5)(6) .
Nursing has performed educational actions in all its professional dimensions due to its historical trajectory of attention and management of work and, consequently, it conducts improvements and training of health professionals, aiming to enhance quality and improve care provided to the population. Then, it has recognized the need to become increasingly closer to training through health work (7) .
At the same time, in addition to the lack of appreciation and attention, all health professionals are distant from moments dedicated to reflect on work processes in their respective scenarios (8)(9) . On the other hand, when these moments actually happen, a model focused on the transmission of vertical knowledge still prevails, from those who 'know more' to those who 'know less' (10) . Also, a great challenge has to be addressed in terms of changing the formats and conception of health worker education, becoming more critical and emancipatory.

Studies indicate obstacles in understanding EPS
and creating spaces for reflect on work processes, and the use of training strategies that consider the context experienced by health professionals, discussing their practices (1)(2)(3)(4)(5) . The number of scientific studies is still insufficient to indicate effective tools to produce reflection through the context experienced by health professionals and that comply with the EPS principles.
In this path toward changes, diversification of methodological proposals focused on discussing learning approaches allowing health professionals to find solutions for their daily problems and develop critical and reflective thinking about the reality, directly contributes to a more resolute health system of superior quality (7) .
In dialogue with problematization and as a concept resulting from the theoretical reference of an Institutional Analysis, the analysis of professional implication can act as a powerful tool for the development of EPS. It is based on a concept, initially proposed by René Lourau in the field of social analysis (11) , and later developed by Gilles Monceau as one of the eight principles of socio-clinique institutionnelle, which corresponds to one of the intervention categories of Institutional Analysis and which has been developed since 2000s (12) .
The implication for this reference does not involve engagement or commitment of participants in the development of their practices, but the way through which they relate to institutions (11)(12)(13)(14) . It can take place at the ideological, libidinal and organizational level (11) .
Institutions, in turn, do not refer to equipment or buildings (considered in this reference as organizations), but to an immaterial dimension related to standards and rules socially built and established, such as family, education, health, among others (11) .
The principles of socio-clinique institutionnelle do not consist of a list of rules to be observed, but characteristics that guide institutional interventions.
These principles are: analysis of orders and demands; participation of individuals in the tool; work of analyzers; analysis of transformations that occur as the work progresses; application of restitution categories; intention of knowledge production; attention to institutional contexts and interferences; and, as explained above, analysis of implications (12) . Therefore, analyzing the professional implication means analyzing the relationship the individuals establish with their profession (identified as an institution) and with the other institutions where they act (12) .   Based on these concepts, the implementation of social clinical interventions in the field of nursing and health is an innovative strategy as it reveals how institutions operate in professional practices (15) , supporting the achievement of goals set by the EPS. Then, this study aimed to analyze professional implications with EPS humanization supporters and articulators as an EPS tool.

Method
This is an interventional study (16) of qualitative approach, based on the theoretical and methodological reference of Institutional Analysis (11) in its institutional social clinical principle (12) .

Discussion
Regarding the ideological dimension presented by the participants in the development of this study, some authors (13,(18)(19)(20)(21) , who also conducted studies with supporters, found questions related to the profile for the development of this role. They reported that the developments of the supporter practice also depend on mobilization and commitment of the subjects to the transformation of work processes in health (22) .
A social clinical intervention and the analysis of professional implication allowed reflections on the functioning of these roles of EPS support and articulation with the professionals that perform them in their daily lives. According to data produced in this study, some profiles have to be achieved or profiles are required for the roles. For this reason, courses are prescribed and skills are determined. The point highlighted and reiterated in this study is that support and articulation are performed through an encounter, a mediator, where one learns from performing a role (23)(24) , that is, the role is learned from daily experience (3)  learning, as they started to identify characteristics of the profession itself, associated with the development of these roles. This fact shows that an implication analysis also produces knowledge (16) .
Another characteristic that emerged in the organizational dimension of professional implications was the time devoted to the development of EPS support and articulation roles. Other studies have also identified that short time, justified by a hard work routine of health professionals, represents one of the challenges for the development of EPS articulation (25) and the professional practice of nurses (26)(27) .
Some authors (23) advocate the allocation of a specific workload to EPS support and articulation In addition, many of them were not asked whether they would like to hold such roles, which affects their performance in such functions.
Another study conducted in a large municipality in the country side of the State of São Paulo reported 83% of local supporters has been invited by the administration to assume this role, also showing discouragement and some immobility among the supporters (28) . However, a study conducted in another municipality in the same state reported desire regarding the role of supporters, concluding that the www.eerp.usp.br/rlae workgroups of that location were enthusiastic about the development of this role (24) .
The feeling of discouragement and pessimism in EPS support and articulation, also observed in the libidinal dimension of professional implications, permeate the process of daily search for legitimacy and recognition as supporters and articulators through visibility of the work performed. These two roles are important management tools, but they have found several obstacles, such as teamwork challenges, improper working conditions, insufficient investment in health, and structural and managerial issues in health (23) . This is also due to the capture of the driving force (the productive feeling provided by the encounter), of consolidated forces that resist the emergence of new styles, that can be powerful or not, of performing EPS support and articulation (29) . In the institutional analysis, the driving forces that generate movement would be the institution forces, and the forces that tend to prevent changes are the instituted forces (11) .
The attempt to set a goal and quantify the actions of EPS support and articulation seems to be a reproduction of consolidated work, replacing the active worker with an appreciation of inactive work, which in this case would correspond to the mere quantification of the work provided (30)