Occupational health nurses : interdisciplinary experience in occupational health

Objective: to analyze the relationship of occupational health nurses with the other members of the Specialized Service in Safety Engineering and Occupational Medicine (SESMT) and characterize joint actions of these professionals in occupational health. Method: qualitative, exploratory, and descriptive study with 34 professionals of seven companies from the South Macroregion of the state of Rio Grande do Sul. Interviews and observations were conducted for content analysis of Bardin. Results: the SESMTs are multidisciplinary and intersectoral workers. Nurses have working relations of an interpersonal, technical/legal, and management of logistics/organizational nature, infl uenced by the technical division of work and by the division in the work environment of the staff, which distances areas, generates confl icts, and fragments the actions of the service. Conclusion: SESMT faces challenges to develop a work befi tting their legal objectives, once staff and companies need to understand the importance of interdisciplinarity for the success of actions on the workers’ health and safety. Descriptors: Occupational Health Nursing; Occupational Health Services; Work; Worker’s Health; Interrelationship. RESUMO Objetivo: analisar a relação profi ssional dos enfermeiros do trabalho com os demais integrantes do Serviço Especializado em Engenharia de Segurança e em Medicina do Trabalho (SESMT) e caracterizar ações conjuntas desses profi ssionais em saúde do trabalhador. Método: qualitativo, exploratório e descritivo, com 34 profi ssionais de sete empresas da Macrorregião Sul, Rio Grande do Sul. Realizadas entrevistas e observações para Análise de Conteúdo de Bardin. Resultados: os SESMTs são multiprofi ssionais e intersetoriais. Os enfermeiros possuem relações de trabalho de natureza interpessoal, técnica/jurídica, de gestão e logística/organizacional, infl uenciadas pela divisão tanto técnica do trabalho quanto do próprio ambiente de trabalho da equipe, o que distancia áreas, gera confl itos e fragmenta as ações do serviço. Conclusão: há desafi os para que o SESMT desenvolva um trabalho condizente com os seus objetivos legais, uma vez que equipe e empresas precisam compreender a importância da interdisciplinaridade para o sucesso das ações na atenção à saúde e segurança do trabalhador. Descritores: Enfermagem do Trabalho; Serviços de Saúde do Trabalhador; Trabalho; Saúde do Trabalhador; Inter-relação. RESUMEN Objetivo: analizar la relación profesional de los enfermeros del trabajo con otros miembros del Servicio Especializado en Ingeniería de Seguridad y Medicina del Trabajo (SESMT) y caracterizar las acciones conjuntas de estos profesionales de la salud ocupacional. Método: estudio cualitativo, exploratorio y descriptivo con 34 profesionales de siete empresas de la Macro Región Sur, estado de Rio Grande do Sul. Se realizaron entrevistas y observaciones para análisis de contenido de Bardin. Resultados: los SESMT son multidisciplinarios e intersectoriales. Los enfermeros tienen relaciones de trabajo de naturaleza interpersonal, técnica/legal,


INTRODUCTION
On the assumption that work generates and modifies living, sickening, and dying conditions of the individuals (1) and, therefore, is considered one of the main social determinants that affect health (2) , worker's health is characterized by a multidisciplinary and intersectoral approach of actions, focusing on health promotion, disease prevention, and curative care.It has, as main axes, the causes or determinants of diseases, the exposure to risks and damages or the consequences (2)(3) .
The worker's health care is guaranteed since the Federal Constitution and advocated by the Brazilian Unified Health System (SUS) as a duty of the State and right to the entire working population.It is inserted at the national level through a broad set of legal documents, such as the National Health Policy of the Worker (PNSTT), whose purpose is to define principles, guidelines and strategies for the development of integral health carein three spheres of management of SUS (4) .In addition to this policy, the National Network of Integral Care to the Worker's Health (RENAST) was created to integrate the SUS service network and implemented through the structuring of a network of Occupational Health Reference Centers (CEREST), inclusion of the actions in the basic care, implementation of promotion actions and monitoring of the workers' health, institution and indication of recovery services, of medium and high complexity, named Sentinel Network Monitoring, and characterization of Sentinel Municipalities in occupational health (5) .
In companies, the health care of workers occurs through the actions of the Specialized Service in Safety Engineering and Occupational Medicine (SESMT), consisted by the Regulatory Standard no. 4, the Ministry of Labor and Employment, which supports professionals in the health and safety occupational area with the aim to promote health and protect the integrity of the individual in his work environment.A complete staff must be composed of an occupational health nurse, occupational physician, safety engineering, occupational nurse technician and nurse technician of occupational safety; it depends on the degree of risk of the main economic activity (1 to 4 correspond to the environmental risks) and of the total number of employees (6) .
Based on this Standard, each professional is a portion of the work force in workers' health, which proves the multiprofessional and interdisciplinary character, composing a set of knowledge and specific assignments that, combined, have the ability to intervene in favor of productive processes and environments safer and healthier.The SESMT objectives focus on the collective interest, aiming at the health promotion and protection of the physical integrity of the individual in the workplace (7) .Thus, the professionals exercise what the legal documents on the worker's health and safety advocate.
According to the Marxist theory, working relationships are based on the relations of production.In the case of a class society, the relations of production are those established among social classes, which, together with the productive forces, represent basic components of the mode of production (8) .In this study, all sectors constitute the workforce in the companies and are related to each other.The working class is the proletariat who works for the employer.Labor relations in the health care of the worker are established among the professionals responsible for the worker's health and safety and of them with the other sectors of companies, in an interpersonal, technical, legal, and organizational way.

OBJECTIVE
To analyze the working relationship of occupational health nurses with the other members of SESMT and characterize the joint actions of these professionals in worker's health care.

Ethical aspects
Scientific and ethical requirements recommended for research with human beings were assured, through Resolution 466/2012.The project was approved by the Committee of Ethics in Research in the Health Area of the Federal University of Rio Grande (CEPAS/FURG).We decided to identify the participants with the letter E and the number corresponding to each of the companies (1 to 7), followed by the initials of the professional (ex: E1NUR).The observations, however, were identified by the letter O followed by the initials NUR and the number that corresponds to each nurse according to the sequence of the companies (ex: ONUR1).

Type of study
Study of qualitative, exploratory, and descriptive approach.

Study background
The study was conducted in seven companies located in two municipalities in the South Macroregion of the state of Rio Grande do Sul.The companies operate in various branches of activity, according to the National Classification of Economic Activities (CNAE) (9) .Thus, four companies are classified as Daniela Inês Thier Roloff E-mail: danythier@bol.com.brCORRESPONDING AUTHOR de gestión y logística/organizacional influenciados por la divisióntécnica del trabajo y el propio entorno de trabajo en equipo, lo quecrea distanciaentre las zonas,conflictos y fragmenta las acciones del servicio.Conclusión: existen desafíos para el SESMT desarrollar un trabajo consistente con sus objetivos legales, pues el personal y las empresas necesitan entender la importancia de la interdisciplinariedad para el éxito de las acciones de atención de salud y seguridad del trabajador.Descriptores: Enfermería del Trabajo; Trabajador de Servicios de Salud; Trabajo; Salud Ocupacional; Interrelación.
manufacturing industries, one manufactures large vessels, a second one products of oil refining, and the last two produce fertilizers.Another company is classified as activity of electricity and gas, represented by a power generation company; one is focused on transportation, storage, and courier, represented by a company of terminal operations; and, finally, an activity is classified as water, sewage, waste management, and decontamination, represented by company of harvesting, treatment, and distribution of water.All seven companies are at the third level of risk because of their main economic activities, according to NR 4 (6) .

Data source
Thirty-four professionals composed the group of participants in the areas of occupational health and safety that integrate the SESMTs staffs, among them eight occupational health nurses, six occupational physicians, six safety engineers, seven occupational nurse technicians, and seven occupational safety technicians.The higher number of nurses is justified by the fact the one of the companies owns two professionals of this category in its workforce.The explanation for the lower number of physicians is that one of them worked in two companies, in this case, it was decided that he represented the one in which he worked longer, by inferring that the institutional knowledge and integration with the rest of the SESMT staff would be greater.Also, the lower number of engineers is due to the fact that one company does not have such a professional in its workforce.

Data collection and organization
Data collection was initiated by interviewing three occupational health nurses (not included in the group of participants), during the period from January to April 2015, to test the understanding and assess the quality of the interview script.Then, the phase of interviews with participants in the research began, which were previously scheduled at the professionals' place of work.The interview scrip of occupational health nurses had more questions when compared with that applied to other professionals, because the former were the focus of the research.In addition, the interview of the nurses lasted from 90 to 190 minutes, with an average of 122 minutes, and of other professionals lasted between 25 to 75 minutes, with an average of 42 minutes.
Non-participating observations were also carried out on every nurse in the workplace to understand in more detail the work process and complement the results of the research, totaling 74 hours and 25 minutes of observation -an average of 8 hours and two minutes for each nurse.The data collection process continued with the transcripts of the interviews and typing of the observations.

Data analysis
For data analysis, we used the method of thematic, categorical, and frequent content analysis of Bardin (10) .In the preanalysis phase (material organization) a theoretical analysis of the work of the SESMT staff was conducted through the project's study, reading of the documents (transcription of the interviews and journals of the observations), constitution of the corpus based on the contents of some of the interviews and journals, in the hypotheses and objectives formulated and elaboration of indices and indicators, considering the content of the text itself.The preparation of the material involved the transcription of the interviews and typing of the observations, using the Microsoft Word and Excel programs, and spell checking of the speech, without changing the meaning.
In the exploration phase of the material, techniques of coding, classification, and categorization were employed in the corpus.The raw data of the text were transformed into register units (words/themes), constituting two categories: The nurses and their working relationship with other professionals of the Service; The joint actions of the professionals in the health care Service of the worker.Four sub-categories of analysis emerged: Organizational structure of the Service; Working relationships between nurse and staff; Joint actions: team of nurses; and Joint actions of the staff: perspective of the other members.
Finally, at the phase of processing the results and interpretation, boxes were adopted to show the results, without using the participants' speech, so that the data could be synthesized in thematic, context, and register units, in addition to absolute frequency (n) as for the number of participants who reported each register unit by the interviews and the records of the observations.The results showed were confronted with the theoretical material, which resulted in the inferential interpretations.

RESULTS
In the group of 34 participants (Table 1), the age group predominant ranged from 31 to 40 years, prevalence of the female sex, highlighting the total of female occupational nurse technicians and, conversely, of the occupational safety technicians.Also: specialization with greater degree, duration of employment in the industry from one to 10 years, prevalence of employment relationship, most occupational categories with weekly workload above 31 hours, except the occupational physician, who works up to 30 hours per week, and the largest monthly incomes of physicians and safety engineers.
As for the total number of employees of the companies, three have less than 1000 workers, two have between 1001 to 3500, and two others have from 3501 to 8000 workers, all of which are at the third level of risk of their main economic activity.

Nurses and their working relationship with other professionals of the Service
This category is based on the reports of eight nurses and on the findings of their respective work regarding the relationship they maintain with the other members of the SESMTs staffs.Thus, two subcategories were created: Organizational structure of the Service, and Working relationships between nurse and staff.

Organizational structure of the Service
This subcategory consists of two thematic units, three context units, and eight register units on the composition of the SESMTs staffs and their physical structural constitution, according to Box 1.
In addition to the basic staff of health and safety professionals that compose a SESMT, five nurses reported that the SESMT workers of their companies had other professionals integrated with the basic staff, such as the ones who work with environment, quality, an administrator, an administrative officer, and a social worker.Some of the professionals mentioned were identified during the observations, such as the ones of the quality area, at the moment when one of the occupational health nurses handed out bottles to collect the material used in periodic exams and also in the dialogue of a social worker with another nurse about the follow-up of a worker on a leave of absence.
Regarding the physical structure of the SESMTs, in all companies, health and safety professionals are allocated in different work environments, since health professionals work in a workspace attached to the administrative building, and the local security are near the operating area of the companies, space identified in all the observations.

Working relationships between nurse and staff
This subcategory is composed of a thematic unit, four context units, and nine register units, related to types of employment relationships of nurses and their characteristics, as ticked by the professionals themselves.
Interpersonal relationships of nurses were characterized as harmonious, which was confirmed during the observations, when it was possible to notice that, in general, nurses have a good relationship with other professionals.In this sense, moments marked by dialogue, respect, collegiality, and collaboration during the implementation of activities and even in relaxed and informal conversations.
A few aspects stood out during the observations: technical division of work by definition of specific tasks to each professional, which, according to the nurses, complicate the relations; position of support, assistance, and leadership of the nurses on the staff, due to their abilities and professional skills; and the physical distance between health and safety professionals who work in different environments, which also distance relations.

SESMT Physical Structure
The conflict with physicians, verbalized by two nurses, was identified in some situations in the days of observations, at moments of imposition of hierarchy of these professionals that delegated to the nurses the filling of the company's administrative documents, which are, in fact, the physicians' responsibility.We also observed that the nurses are in more contact with health workers, because they remain most of the time working in the occupational health sector of their company, sharing the same physical workspace and the same activities, unlike the relationship established with security workers or professionals of other areas, due to the physical distance and the encounter only during the joint activities of SESMT.

The joint actions of the professionals in the health care Service
This category was based on the reports of 34 professional members of SESMTs and on the observations on the work of nurses regarding the joint actions of the SESMT staff on worker's health care.To analyze such actions, we selected three types of the most common activities in the development of the work of SESMT.Thus, two subcategories were created: Joint actions of the staff: perspective of nurses and Joint actions of the staff: perspective of the other members.

Joint actions of the staff: perspective of the nurses
This subcategory consists of four thematic units, six context units, and 11 register units, related to nurses' perception of the work as to their collaboration in activities of SESMT, e.g., for the preparation of legal documents, such as the Program for Medical Control of Occupational Health (PCMSO) and of the Environmental Risk Prevention Program (PPRA), prevention of work-related accidents and diseases, besides the monitoring and surveillance in work environments (Box 3).
Most of the nurses participate in the elaboration of the PC-MSO document in different ways: in the survey of monthly data from the occupational health service, in document formatting or in the implementation of the actions of the Program.On the other hand, no professional nurse participates in the elaboration of the PPRA document in their companies.During the observations, we identified the professionals working in the PCMSO through monthly data survey of the occupational health service and through daily activities carried out by them.
The nurses mentioned a small participation in the prevention of accidents and diseases in their companies; however, they work with educational activities, such as lectures, campaigns, daily dialogues on health and safety, elaboration of posters and folders.This expertise in prevention, focusing on legislation and occupational diseases, during the occupational routine exams in the sector, through some educational activities such as the elaboration of posters and folders exposed in the occupational health clinic, or on the occasion of a first aid training taught by a nurse to a group of professionals for a work at height altitude.
According to their reports, the professionals participate little in the activities of monitoring and surveillance in work environments, and those that do, focus on the worker after any occurrence, complaint or due to behavioral surveillance programs for workers.They may also direct the focus to the environment, through surveillance in workspaces and in drinkers and changing rooms.In the period of observations of this study, we monitored two nurses in surveillance activities in the operational area, conducting preventive and control patrol in the points of pre-hospital care.

Joint actions of the staff: perspective of other members
This subcategory consists of four thematic units, four context units, and 10 register units, related to the perception of the other members as to how the SESMT staff develops activities of elaboration of legal documents, such as the Program for Medical Control of Occupational Health (PCMSO) and of the Environmental Risk Prevention Program (PPRA), prevention of work-related accidents and diseases and of monitoring and surveillance in work environments (Box 4).
For most of the professionals who are part of the SESMTs of the companies represented in this research, the elaboration of the PCMSO document is the responsibility of the occupational physician, coordinator of the Program.They stressed the participation of the nursing staff in the monthly data survey or in document formatting, aspect that was also identified during the observations.According to more than half of other professionals, the PPRA document, in companies where they work, it is the responsibility of the occupational safety engineer, outsourced companies also participate in the elaboration of this document, fully or only in some steps, such as obtaining information, measuring risks or gathering the information of the company.
Regarding the activities for the prevention of accidents and diseases from work, most of the members of the SESMTs develops educational activities (daily health and safety dialogue (DDS), campaigns, conferences, integration of new collaborators and folders), as well as activities related to legislation, such as training, occupational tests, and the Internal Week for Accident Prevention (SIPAT).Some professionals admitted greater involvement with safety in prevention activities, but reported that, despite the low participation of health, they perform actions after occurrence or complaint from workers.
Similarly, most of the other professionals from SESMT reported greater involvement of professionals of the security area in supervisory and surveillance actions in the work environment, through the realization of rounds, checklists of personal protective equipment (PPE), environments and work permissions, with little participation of health, which engages more with complaints from workers and occupational health programs.

DISCUSSION
The scaling of professionals from the SESMT, according to the companies' total number of employees and level of risk, is suitable, according to Regulatory Standard 4 (6) , except for the case of occupational health nurses acting in five companies where their presence is not compulsory, since the number of employees is less than 3,500.This shows that, despite the Brazilian legislation not encouraging its activities, companies recognize the importance of those professionals in SESMTs and in the implementation of qualified actions in occupational health.Nurses are essential for the provision of consistent occupational health services and programs, continuous and of the quality of work environments (11) , influencing the reduction of risks to health by supporting productivity, improving the quality of life of workers, and being profitable (12) .
The presence of professionals of other areas in the SESMTs (such as environment, quality, administration, and social assistance) reveals the broad vision they assume to make workers' health and safety care of increasing quality and multidisciplinarity, Box 4 -Summary of the subcategory: Joint actions of the staff: perspective of other professionals since it satisfies their requirements and needs and also those of workers.This ratifies that the SESMT is dedicated to the interests of the company, which, in turn, guides directly the actions of the professionals involved.The work of a team of occupational health should be based on multidisciplinary participation, with axes in the integration of health, hygiene and safety, company and workers involvement, and proposition of interventions appropriate to their needs (13) .An aspect of great relevance aimed for discussion is the role of the health and safety areas in different working environments in all the companies represented in this study, which favors some difficulties, such as labor relations and joint actions of SESMT, cited by occupational health nurses.Such a way of structuring leads to fragmentation of the look on health and safety and, consequently, breaking of integrality of care.Companies and professionals need to transcends this dichotomized vision (14) and implement health and safety programs that include the promotion, protection, and restoration of the health of the worker in a collectivized way and with a transdisciplinary and intersectoral approach.
The observations confirm that the form of structuring of SES-MTs influences the professional relationships of occupational health nurses with the other members, because, despite claiming to maintain a generally harmonious work relation, which contribute to satisfaction (15) , it was possible to identify that they relate, for the most part, with the rest of the health team by sharing the same workspace and by the distancing of the security team members who are approached in sporadic moments of joint actions.
Labor relations maintained by nurses with the other members of the team are of different natures, which leads to a complex scenario of interactivity, which involves several factors.Interpersonal relations occur by affinity and accessibility with some colleagues.The technical division of labor promotes relations through the organization of tasks according to each professional assignments and joint actions of the team.It also positions nurses as source of support and leadership to others, beyond their ability to manage relationships.Their own employment contract promotes labor relations in which it is expected a kind of professional experience to meet the needs of the company, which does not always coincide with their legal duties.
The organizational and logistics profile of companies hinders the working relationships among the members, separating them while a SESMT team.This constitution of operating plant also influences the work of nurses, who deviate from the large mass of workers exposed to occupational hazards to meet a volunteer demand at the clinic, thus fragmenting the completeness of their actions and minimizing their involvement in administrative work and nursing procedures.This context evidence, thus, the traditional view of nursing in companies.
Conflicting relations maintained by some occupational health nurses with the team's physicians point out that the technical division of the work (8) is a cause of conflicts, since physicians represent a hierarchy between both categories, which leads to the exercise of power and, consequently, occupational stress of professionals (16) .Authors claim that interdisciplinarity should be established through horizontal relationships, without supremacy of one field of knowledge, as no area alone can address the complex relationships and regulations that focus on workers' health (14,17) .
The preparation of legal documents, such as PCMSO and PPRA, is performed separately by companies' health and safety teams.The PCMSO document is prepared by the coordinator physician, however, most occupational health nurses is involved somehow in this activity, which shows that his performance goes beyond the legislation and takes into account personal affinities.
Distinctly to what occurs with the PCMSO, elaborated by the own companies health team, the PPRA document, whose responsibility is of the SESMT, according to NR 9 (18) , is carried out mostly by work safety engineers, with involvement of safety technicians and contractors, since environmental assessments and quantitative measurements of the risks require specific equipment companies and greater number of professionals, with high financial cost.Activities such as the prevention of accidents and occupational diseases and the supervision and surveillance in work environments are performed separately and differently by health and safety professionals.
Despite the progress of the discussions around the theme and the incorporation of professionals of other areas, the integration between health and safety teams still brings up an important focus, the separating of the disciplinary fields of hygiene and safety and occupational medicine, reinforced by legal instruments (15) .The technical division of work is present in a multidisciplinary team, but must be overcome so that the SESMT objectives can be reached.There is a need of making it more flexible, performing their own interventions from the various areas, but also performing common actions and integrating knowledge, which imposes large barriers, as there is both a history of fragmentation into islands of knowledge and power, as well as fear for building bridges with the various areas of knowledge (17) .

Study Limitations
Due to the predominance of small and mid-sized companies in the territory delimited by the study, we point out as limitation the presence of occupational health nurses in few companies, which made the inclusion of more companies in this study impossible.
Contributions to the field of nursing, public health or public policy Since the interdisciplinary work is essential to ensure the provision of care and more effective programs in occupational health and safety, so that the opinions of qualified professionals can govern the prevention and control of dangerous events related to work (12) , we acknowledged the importance of addressing this topic to contribute to the discussion of interdisciplinarity in health, strengthen the work of the multidisciplinary SESMT team, and highlight the importance of occupational health nurses as team members.

FINAL CONSIDERATIONS
More than half of the SESMTs represented in this research has professionals to complement their basic health and safety team, which highlights multi-professionalism as well as the Occupational health nurses: interdisciplinary experience in occupational health Roloff DIT, et al.
intersectoral approach in the care to workers.The professional relationships of nurses working with the rest of the team are of an interpersonal, technical/legal, management of organizational/logistics, and, generally speaking, harmonious nature.
Two strong impact factors were identified in this study: the technical division of labor, according to each professional's specific assignments; and the allocation of health and safety professionals in different work environments in all companies.
Both situations interfere directly in the working relationships of nurses with the team, since that cause detachment of the areas, relationship conflicts, and fragmentation in the actions of SESMT, which should be based on interdisciplinarity.
Therefore, we conclude that SESMT faces challenges to develop a work befitting their legal objectives, once staff and companies need to understand the importance of interdisciplinarity for the success of actions on the workers' health and safety.

Table 1 -
Characterization of professional members of specialized services in Specialized Service in Safety Engineering and Occupational Medicine Box 2 -Summary of the subcategory: Working relationships between nurse and staff