Collective Health Nursing: desires and practices

Objective: To discuss and reflect on collective health nursing practices, presenting the work-related experience of nurses. Method: This was a reflection paper based on the labor process theory. Results: Studies conducted in research groups, discussions at scientific events, and professional experiences point to the importance of recognizing the intentionality of health work. Furthermore, it is essential t understand the health-illness-care process adopted and advocated by health professionals, and the role of social determinants and the entire historical, political, economic and social context of professional training, healthcare service organization and society. Conclusion: Collective health nursing practices play an important role in the health care provided to the population. Nurses are reference professionals in health care in all stages of life; however, further reflection is required on professional training, politicization, and the concepts of health and illness that guide professional practices. between the team and patients. Community health who are not part of the nursing team, but of primary health teams in different scenarios, report the and


INTRODUCTION
2018: Thirty years since the creation of the Brazilian Unified Health System (SUS). Over these years, many efforts have been made to re-democratize our country. The Collective Health Nursing Department of the São Paulo School of Nursing and the Maternal and Child and Public Health Nursing Department of the Ribeirão Preto College of Nursing of the University of São Paulo also celebrate their 30th anniversary. These departments are a part of the Brazilian social and political scenario which demands resistance to the non-military "war machine" proposed by Deleuze and Guattari (1) , and clamors for the desiring machine, which is defined by the power of connection to the infinite, in all senses and in all directions (1) . How can we produce points of connection?
Of themselves, desiring connections that produce life and health are collectively defined. It is not possible to speak of health without considering collectivities, connections: health cannot be produced or possessed by one individual or a group of individuals; it is the result of encounters, history, contexts, social aspects, culture, and collectivities.
In this study we propose a dialogue and reflection about collective health nursing practices, presenting what nurses have contributed or have failed to contribute to health services. Through this reflection paper we organize some of the authors' thoughts, who have experience with professional nursing, research and teaching in the collective health field. This dialogue and reflection was structured around the following sources: a) Discussions held at the 3rd International Symposium on Policy and Practice in Collective Health, from the Perspective of Nursing, held in São Paulo in March 2017. One of the authors was part of a round table at the event about the practices of nurses and other collective health workers, which addressed some of the dilemmas presented in this paper, such as the limits of nursing education for broader practices in terms of the determinants of the health-illness process.
b) The research and personal and professional experiences of nurses, researchers, and professors in the field of collective health that resulted from the work of the Collective Health Research Center (Nupesco). This center was created by Maria Cecilia Puntel de Almeida, an active participant in discussions about nursing as a social practice, who used the labor process theory to support the understanding of professional education and labor market insertion to analyze the social determinants of nursing professional practice in health services (2) . Therefore, this study does not refer only to specific studies by the authors; it is a result of discussions among the authors and of their readings of the scientific literature (2)(3)(4)(5) , and interaction with students, professors, researchers, and health professionals. Thus, this reflection piece is based on the labor process theory as it applies to health and the professional experience of its authors.
As a social practice, we consider nursing a practice inherent to social, historical, political, economic and cultural contexts, and that carries different meanings. It is a social practice that is not performed in isolation, but is socially negotiated by nature. Nursing is work; one of the forms of work that constitute health care (6)(7) . Therefore, nurses are workers who sell labor power.
Supported by the Marxist framework of labor, Mendes-Gonçalves (8) shows that humans produce and create nature through the work process, and are also products and creators of the work process through nature (8) . In other words, this relationship (humanswork) is dialectical: humans and nature are transformed in this process, in which intentionality differentiates animal work from human work, because man is able to project the results before its production and animals act on instinct (8) .
In health, there is both a technical and social division of labor (6) . In nursing, for example, the distribution of tasks among assistants, technicians, nurses and nurse midwives is not only technical, it is also social and denotes differences in power, salary, positions in society, and scientific knowledge. Health work is a special type of work because the product is consumed right on production (6) ; its products are immaterial and symbolic goods. Health neither storable nor measurable, although the production of procedures is often confused with health production.
Thus, the first reflection here is that our actions do not always produce health (3) . When discussing the contributions of nursing to the implementation of collective health practices, to what practices are we referring?
Consider the complexity of the immaterial goods produced in health practices. These are not actions performed by an isolated professional category that decides about its contributions and actions on its own (9)(10) . Nursing practices are socially and historically built and part of the tensions of the sanitary, economic and political context. This means that they are not only determined, but also dialectically determining: they are the products and producers of contexts, services, and practices.
Therefore, collective health nursing practices cannot be considered separate from a project for society or disconnected from the world of labor and its transformations. Thus, Brazil's health and social policy context cannot be disregarded.
Collective health is not a synonym for public health. Collective health is constructed on biological, political and social aspects and includes the investigation of the determinants of the social production of health, illness, and care, thus taking on an interdisciplinary character that suggests the integration of different forms of knowledge from distinct professional backgrounds (11) .
Thus, reflecting on collective health nursing practices requires associating them with other types of knowledge and considering a specific context. In our case, they will be connected with the SUS. In 2018, the SUS celebrates its 30th anniversary. Throughout this period, several aspects have threatened the implementation of its principles, especially because of economic interests and a scenario of growing privatization (12)(13) .
Other challenges include insufficient funding, system management, staff training dissociated from actual health needs and SUS principles, and healthcare practices that support a fragmented, hierarchical, bureaucratic model with weak social control and participation. Additionally, the system is overwhelmed with thousands of patients every day, communicable disease control, vaccinations, preventive measures, rehabilitation actions, a large healthcare network with different technological levels, and a bad reputation disseminated by all media vehicles. The private healthcare system functions as a complement to the SUS and Brazilian nurses work mainly in the public system. Thus, it is important to ask: What position does this labor force take in the debate that polarizes health as either a "public and lawful good" or a "market good" (14) ? Through its organizations and workers, nursing has been favoring the interests of certain social groups, which do not necessarily include nursing workers themselves, as they do not belong to privileged classes (at least most of them). How does nursing position itself? Does it remain silent, as if these issues do not apply to it? Also, in everyday life, does it reproduce the discourse produced by common sense? This is yet another of the challenges: the politicization of nursing workers.
In 2007, Sanna (15) included political participation as one of the attributes of the nursing work process, in addition other processes (care, research, management, and teaching). Political participation does not necessarily imply joining professional associations, political parties or human rights organizations. Every moral judgment and attitude is a form of political participation, without which it is impossible to live in society and change the world (15)(16) . Lack of positioning results in a political positioning of which nurses are unaware.
One way to transform the object of health practices is to take a political stance in the workplace or in schools, organizing discussions about and strategies to achieve better conditions to operate this and other work processes (15) .
Health practices are political actions, as they present intentionality and defend projects. When nurses, technicians, and assistants consider health as a right and not as charity, they are advocating policies and projects. Likewise, when treating others as objects and an assembly of body parts, they are also taking on a political position.
At the same time, the living conditions of the Brazilian population, unemployment, barriers to access to information, education, housing, food and transportation are all factors that condition health and determine health needs. These in turn support professional practices, projects and political positions. For example, ten years ago, nobody mentioned the need for nursing care for people and communities with yellow fever in the State of São Paulo. Yellow fever is not a result of a mere mosquito bite, in the same way that leprosy is not caused by a bacteria alone; these diseases are related to the life context and the social exclusion process of populations.
Depoliticizing and technifying nursing work often show these problems in their social and economic dimensions, simplifying them. Therefore, our practices are limited to yellow fever vaccination procedures and leprosy antibiotic prescription. We are not demeriting vaccines and medications; they are part of addressing the problem. However, they certainly do not encompass their complexity. As is well known, the prevalence of numerous complex situations in health, such as chronic diseases, violence, infectious and contagious diseases, and re-emerging diseases, such as pertussis, has increased in Brazil in recent years (17) .
We highlight the thesis defended by Agreli (18) at the Nursing School of the University of São Paulo as it shows how the process of how collaborative interprofessional practice and teamwork in primary care became object of discussion in the country. The thesis presents aspects experienced every day in these services: older adults abandoned at home by relatives (in one case, the patient's wife had to travel and left the key with a neighbor, who came in and put some water in a bowl next to the bed, as is done with dogs); children asking community health agents (CHA) if they could go with them because they did not feel loved; young trafficking drugs; sexually abused children; battered women; unemployment; hunger; and rats inside pots (18) .
All these situations question our cause-and-effect training that defines categories by simplifying measures: for diabetics, for pregnant women -as if all diabetics and all pregnant women were the same and had the same needs. They question our reductionist explanations that individualize the conditions of people and blame individuals for their living and health conditions. Another challenge is professional education. The pedagogical tradition in Brazil encourages content sharing and simplification so that students can later put the pieces together. We have lost count of the times we have discussed undergraduate teaching in institutional environments and disciplinary meetings and have argued that specific content should only be presented to students in the last year of the program. Before then, students are still not prepared for it. This results in the misalignment between training and the complexity of health needs.
Furthermore, the nursing education model has led to the uncritical and alienated reproduction of health work processes, especially when based on pedagogical processes that do not allow reflection and are based on biological references. It is often based on learning concepts that give priority to content that must be 'absorbed' and reproduced by students without any connection to professional practices, and that are presented in fragments and out of context (19 ) . And that is produced in authoritarian environments where the professor/student relationship reproduces submission and domination.
There is a concern about the duration of training programs, as if there were enough time to cover all necessary contents. This results in a focus on theoretical content and psychomotor development, with insufficient practice relative to the attitudes that are so essential to care delivery.
This method of teaching also affects the training of nurse technicians and assistants, whose challenge is even more troubling. Nursing programs play an important role in this discussion, because they aim to train nursing teachers to train nursing assistants and technicians.
Another aspect to consider regarding collective health practices is: if the living conditions of the population are degraded and difficult, so are the living conditions of health professionals. While it may seem obvious, it is hidden in an apparent opposition: those who provide care and those who receive it: health workers and patients; those who have technical-scientific knowledge and those who must obey this knowledge, respectively.
The technical and social distribution of nursing work results in a working class with wages that put these workers in situations similar to that of their patients. Obviously, this does not give them the right to choose not to work, but it poses the challenge of the fight for better wages and labor conditions through political participation and positioning.
Other health roles have also been degraded, such as that of psychologists, social workers and others who, just like nurses, earn salaries that close to minimum wage in the country (R$ 937.00). In this context, other challenges refer to the mobilization for salaries, living conditions, and the recognition of health work.
Typical management models used by the private health sector are often used as models for public services. The private sector is uncritically assumed to be more competent in management; thus, its logic, values, culture and perspectives are adopted without question. This is not exclusive to the health sector or even to Brazil: this is a worldwide trend that has been analyzed by experts in terms of its effects on education, social services, and health services. It is called the "new public management" (20) .
The consequences of this new form of management are: flexible working hours, target-based performance payment, staff turnover rates that do not foster bonding and trust among teams and knowledge of the territory covered by the service. Unfortunately, our practices are based on this reality.
Another issue in our practices is the use of digital technologies. In her doctoral thesis, Pilotti (21) , from France, discussed the interference of emails in the professional practice of physical therapists. She questioned the reduced physical contact. In addition to emails, mobile phones, the internet, and instant messaging apps such as WhatsApp have created a different context for work relationships. We can exchange ideas with someone who is far away about a case; patients have access to different information now when meeting a health professional, i.e, time, space, and information in health have taken on a new perspective (21) .
What then, are the contributions of nursing? With all the discussion presented here, we believe that collective health nursing practices have an essential role in providing care to the Brazilian population. This role should be questioned continuously: At whose service? Based on what conceptions? For which project(s) of society?
Nurses are reference professionals in health care in all stages of life and in different territories for managers and administrators in decision-making processes. With their expanded notion of the health-illness-care process, nurses have a great impact on what gets chosen or not to be developed in the different territories, and the possibilities that present themselves for new health practices.
Nursing technicians and assistants facilitate access to health care every day, perform technical procedures, and enable communication between the team and patients. Community health agents, who are not part of the nursing team, but of primary health teams in different scenarios, report the reality and dynamics of the territories to the teams. They visit, talk to, embrace patients, and identify problems, demands and needs.
Several of the challenges perceived in the 1990s are still present (22) , such as the population's demand for consultations with physicians, the distance kept by physicians between them and the reception desk or reception room where control actions are performed, and the repression of spontaneous demands by nursing professionals who are in the front line of primary care units.
Even though they were conducted two decades ago, several studies (3,7,19) have shown the limits of health promotion actions, the technological (re)organization of the work process and teamwork. These aspects can be related to politicization, professional education, and the still prevailing conception of the health-illness-care process that guides our practices.
We conclude this reflection about the contributions of collective health nursing to the implementation of new health practices with an excerpt by a Deleuzian friend (23) : The river and the sea meet as a result of the active action of hope... Patiently, the river seeks the sea: stubborn, respecting its own longings, fearless... it overcomes obstacles, circumvents challenges... slows down and accelerates... but, it never stops dreaming and flowing. It dreams of the sea; but it does not settle; it seeks and fights for it with hope... And the sea dances; never giving up on living for the great encounter... to receive the river and, in this embrace, become a new revitalized sea, enlarged by the fruitfulness of the forests that are carried by the crystalline waters of the river that became sea.