PLEASURE AT WORK IN A FAMILY HEALTH SUPPORT TEAM : A DEJOURIAN ANALYSIS

Objective: analyze the working process of a Family Health Support Center, and identify its impact on workers’ quality of life. Method: this is an exploratory case study with descriptive and qualitative approach. Twenty Family Health Support Center workers of a social health organization located in São Paulo participated in three focus groups between June and August 2014. The empirical material was subjected to content analysis and analyzed in light of the Psychodynamics of Work. Results: this study presents the dejourian category pleasure. Despite adversities faced putting the ideals of the Family Health Support Center into practice, the participants derived pleasure and satisfaction from the work process because they identify themselves with the Family Health Support Center’s mission, have their work recognized, and also because learning is enabled through teamwork, performed from an interdisciplinary perspective, and permanent health education. Conclusion: a new sense of life resulting from pleasure, achievement, and identification were present among the workers, indicating that resilience and self-fulfillment consolidate professional performance. Additionally, the establishment of living spaces and ways to show appreciation can increase pleasure, satisfaction, and the quality of working life in the Family Health Support Center. DESCRIPTORS: Primary health care. Family health strategy. Work. Pleasure. Quality of life. O PRAZER NO TRABALHO NO NÚCLEO DE APOIO À SAÚDE DA FAMÍLIA: UMA ANÁLISE DEJOURIANA


INTRODUCTION
Family Health Support Centers (Nasf) are composed of a team of professionals from different fields of knowledge depending on the health needs, socioeconomic vulnerabilities and epidemiological profile of the areas in which primary healthcare (PHC) services are located.:12 Nasf support the ESP teams in the analysis of needs and in the planning of interventions.The work jointly performed by Nasf and FHS professionals is intended to overcome the fragmented physician-centered rationale, still predominant in the healthcare system, promoting healthcare networks and collaborating in the delivery of integral care to the users of the Brazilian Public Health System. 2 Nasf workers also develop therapeutic and educational actions with users, providing integral care and sharing responsibility with FHS workers in the various stages of life.The purpose is to transform the healthcare practices developed by the FHS, based on tools such as an enlarged clinic, matrix support, and the singular therapeutic project.The team's work is oriented by the PHC guidelines and is intended not only to meet care demands, from a merely quantitative and curative aspect, but also to improve quality and enhance the FHS' capacity to provide care. 1 Even though the support provided to the FHS teams has enabled advancing in the sphere of care and encouraged reflections upon health actions, Nasf workers have increasingly become ill, which negatively impacts their professional performance, the efficacy of their work and their quality of life at work, in addition to their personal lives.
Hence, this study's aim was to analyze the Nasf work process and repercussions for its members' quality of life at work.We are basing our study on the assumption that Nasf is a recent proposal representing a counter-hegemonic healthcare model in the context of FHS and a lack of guidelines and insufficient understanding regarding Nasf's role, on the part of most managers and workers within FHS, leads Nasf to assume different configurations in the various states and cities in which Nasf is located, and even within the same city, generating doubts regarding its object of work causing stress and burden among workers.

METHOD
This is an exploratory case study with a descriptive and qualitative nature.:32 The study is based on Work Psychodynamics, the main representative of which is Christophe Dejours.Its object is the human-work relationship based on the understanding of work organization and how workers feel and experience the gap existing between prescribed work and real work, as well as pleasure and suffering existing at work and the defensive strategies employed by workers to protect themselves. 4he study was conducted in a social health organization responsible for the management of various public services in the eastern part of the city of São Paulo in partnership with the City Health Department.Twenty Nasf workers were included in the project because they presented stress symptoms, previously identified through the Lipp Inventory of Stress Symptoms for Adults. 5:51 Focus groups were recorded, their reports transcribed and read repeated times in an attempt to identify empirical categories.Content analysis was used to treat the data. 7We sought to identify relevant structures in the individuals' testimonies, as well as the central ideas of their reports 8 in order to establish core meanings, which were later analyzed using Dejours' Psychodynamics of Work.
Because this study involved the participation of human subjects, the guidelines established by Resolution No. 466/12, National Council of Health, were followed.The project was approved by the Institutional Review Boards at the Universidade of São Paulo, School of Nursing (report No. 205.892), and the Health Department at the city of São Paulo (report No. 597.535-0), according to CAAE 08751212.0.3001.0086.The study was also authorized by the research sector at the institution and East Regional Coordinator of Health.After receiving clarification regarding the study's objectives, the workers signed free and informed consent forms.

RESULTS
This paper presents the results concerning the analytical category pleasure at work composed of the core meanings: identification of workers with Nasf's proposal and acknowledgment of their work; interdisciplinary work and teamwork; permanent health education.

Identification of workers with Nasf's proposal and acknowledgment of their work
One of the driving forces behind workers' motivations is the extent to which they identify themselves with the model proposed by Nasf, which enables them to acquire new meanings and identity for their professional lives and transforms workers Acknowledgement on the part of patients, teams, and managers for the work performed by Nasf also gives professionals satisfaction and pleasure in everyday work, because it validates their usefulness.Acknowledgment can be seen as a collective and team achievement or a personal and individual achievement, and also involves financial acknowledgment.
It is difficult to be acknowledged by the population but I get that with the Strategy teams.So, for me it is a delight being with the Strategy team and gather with the group, make matrix meetings, I love it.So, I guess it energizes me [...] I cling to the Strategy teams and manage to create things, to think in terms of other work possibilities (G2).

One of the units I work with changed managers and it improved the quality of work a lot. We have a manager in the unit who sends us emails congratulating us for our work (G3).
When we see the patient is getting better, it's something that brings us satisfaction.Or when the group is working out, it's super cool.Some initiatives, some new things we do and the patient responds positively to it, I think it's awesome.I guess that trust is one of the main things (G3).
[...] Well, isn't our salary outdated?We could make more money, we could be better appreciated, we could… there's always this question (G2).
We also verified that appreciation and acceptance of the Nasf on the part of the FHS is different when a physician is integrated into the staff.
Sometimes, we can see a difference in how the physician in the Nasf team is treated.The physician enters the team and everything gets easier, people become more receptive, you are offered some coffee, receive a treat [...] (G1).
The participants also mentioned other aspects that generate pleasure, such as autonomy, creative freedom, and a lack of formal routine in the Nasf work process, given the dynamics and diversity of activities.
I guess that with Nasf within the Strategy you have the opportunity to learn and recycle daily.There is no routine, no routine, because even if you work with the same group, with the same topic, it's always very different, it demands a lot.And I think it's rich, it has a positive impact (G2).
The individuals also referred to the educational groups for patients that are promoted to them, one of the activities related to the work performed by Nasf and that most frequently generates pleasure and fulfillment.
Something else I'd like to add is about the groups.I guess that the work with the groups is the nicest thing here.It's the greatest benefit of it all; the group is very gratifying [.

..]. You know that day you go to work saying: 'I'll resign, I'll quit'. Then, you start working with the group and say: 'Wow, I'm good' (G3).
Note the dialectical perspective present in the pleasure-suffering relationship, translated in some reports concerning appreciation for the work done, as well as the disputes of power existing in the context of work performed in the FHS and Nasf: [...] it's something that makes me think when I'm stressed out, when I'm tired [...].Then, you start seeing, hearing those compliments, the ways people thank you and it really raises my quality of life (G2).
[...] the issue of appreciation, because it's been five and a half years that we've worked at the Nasf.After five years and a half, we left a technical meeting and said: 'Wow, this works, it's going to work, it has a future.' We even get scared.So, I think about lack of recognition.If you get a team that has potential and is willing to do the job, if you encourage and motivate this team, then the work is successful (G1).

Interdisciplinary work and teamwork
The reports show that interdisciplinary work and teamwork are sources of pleasure and strength and give workers the opportunity to grow professionally, exchange knowledge, devise new possibilities for interventions, and acquire practical learning through group cooperative work.The potential for group work was mainly observed among Nasf workers through shared actions and team meetings.
For me, the greatest motivation was my team [...].

It's obvious that I come to work and cross town every day
because of my salary.But there's a time when the salary is no longer enough, depending on your level of stress.It's for my team and for the patients [...] (G1). [

...] You learn a lot, because you become into contact with various professions, so you learn from the physical educator, nutritionist, physical therapist [...] (G3).
We talk so much about interdisciplinary and trans-disciplinary work and I guess Nasf is a place that depends much on us, but we can do that.I don't say trans-disciplinary work, which sometimes seems to be in another sphere.But interdisciplinary work; I guess we can do that.There is no other place we'd be able to do it like we do in Nasf (G2).
The inter-subjective work dynamics at Nasf and its collective construction, based on the interaction between workers and their various types of knowledge and experiences, become apparent in the following reports and represent a significant gain and an broadened view of work by the professional him/herself.
I guess there is daily and constant learning.While we keep working, I joke it's sort of infinite work, there's no way to exhaust the professional -or even as a person -dealing with other people, getting to know people, becoming more tolerant, dealing with differences… I guess that what we do at Nasf we can take to any other place we may go, any work we may do, we can take it.We are no longer the same after working at Nasf.I guess it's a kind of satisfaction, it's knowing how much we've grown, developed, and are no longer the same (G2).
The richness of the teamwork involves this subjectivity.So, the baggage you bring in, the willingness, the understanding one has of life, life experience, how someone puts herself in her relationships with life, family, spouse, you know [...] (G2).
You broaden your perspective, not only of others but of yourself, I guess it's the most important thing (G1).
You don't hold a segmented perspective of things... you see it all as a whole, you see everything [...] (G3).
Respect for diversity and the differences among the team members in the work routine becomes clear in the reports as an attitude that is possible to be learned and developed.
This thing of respect, you also learn with cultural, social and economic differences.You learn a lot with this idea of respecting what others [think] and how they see things... (G2).
I think that you gain a lot from learning to deal with your own team.I'm particularly very different from most people in my team, so for me, it's constant learning [...] dealing with different personalities within the Nasf team is also constant learning (G3).
We verified that the workers derive pleasure from transcending competence in and the specific knowledge of each profession in the logic of interdisciplinarity.There are, however, dilemmas in the loss of professional identity and regarding the boundaries of specific practice.We also observed a search for knowledge of other disciplines and the role of matrix support.
The possibility to broaden your view but also reduce your view, you know?I don't know if this is the experience of everyone else, but sometimes we enlarge our view too much, especially in very complicated cases, when you actually need to reduce your view and focus, otherwise I can lose myself.So, you have to find the common sense way, a middle term.Where I have to enlarge the case and where I have to focus so that I know what I have to ask

[...]. I found the possibility to do things out of the box interesting, and things that you didn't learn at college. So, you learn with your colleagues and know you can do things you never imagined yourself doing [...] (G1).
I guess that you gain experience for life, and even with all the stress I'm very happy with the work I do (G2).

Permanent health education
The reports of Nasf workers express aspects such as appreciation, pleasure and understanding regarding permanent health education, showing it goes beyond formal education, but it is also experienced in the routine work process, as when discussing cases, sharing actions, and in meetings with the team.
A need to seek new knowledge was verified, as well as a need to establish formal and protected opportunities for permanent health education to take place: [...] and there's another very positive thing, which is when we leave the workplace, our routine and goes to a conference, for instance, when you take a course, or have the opportunity to show your work (G1). [

...] welcome what you've learned with the psychologist, speech therapist, physical therapist and take it to your groups [...]. But it's nice for everything you discuss in the team meetings. The matrix we do among us in the meetings, I take that, too. And it makes me happy [...] how much we're able to accomplish by taking a closer look at our practice and see how we can change (G2).
[...] there're forums, people bring their frustrations regarding the institution, colleagues and everything.I guess it makes us to think on how it should be better (G2).
[...] because the permanent education we do at the unit is not something we make plans for… in our calen-dar, yes, but there's no a place for it [...].So, I guess there should be greater investment in permanent education because there are a lot of things and Nasf is not Google where you type in, tap enter and gets there.Easy girl, we're also human beings (G3).

DISCUSSION
A sense of satisfaction is reflected in various aspects of Nasf work, influenced by the peculiarities of each worker, such as personality, conception of work, and personal values. 9The findings reflect the multi-functionality of workers, who even while facing numerous adversities daily, report a sense of pleasure in performing and experiencing their practice, especially from identifying themselves with Nasf's mission and being appreciated for the work they perform.
Even though most of the workers entered Nasf for some other reason than a personal or ideological choice in favor of PHC, many reported that they stay with Nasf because they believe in its mission and because they like what they do.This identification results from a transformation workers experience when performing Nasf work, because as they take part in the process, it changes them and makes them more tolerant, flexible and resilient.
In this context, identification with their work and recognition for the work they do are sources of pleasure, satisfaction and motivation, facts that corroborate a study 10 that also reports great personal satisfaction for the work performed at Nasf, accruing from having autonomy and flexibility.
One study addressing satisfaction at work among PHC workers reports similar results concerning affinity with the work, problem-solving capacity, the satisfaction of users, and teamwork, in addition to the bond established between the team members and the community.Situations that generate satisfaction in the experiences of community health agents, for instance, were mainly related to problem-solving capacity -that is, the concretization of work based on the effort to perform a task and also on the work performed together with other community health agents, to the creativity in doing and being recognized by the collective through manifestations of affection, gratitude and respect, 11 as verified in this study.
3] The solutions achieved within the work performed leads to pleasure and satisfac-tion.In another study, workers considered activities concerning health promotion and health education performed with groups of patients by the FHS also to promote satisfaction. 14atisfaction at work involves objective and subjective elements and can be either concrete or symbolic.Concrete satisfaction refers to protection of life, and physical and biological well-being, while symbolic satisfaction is linked to a qualitative experience at work. 14Recognition represents a form of gratitude and confirms the contribution of workers to the working process, which accrues from a judgment of the individual's technical or social utility. 15ransformation of suffering into pleasure is directly linked to the valorization of work that is manifested by acknowledgement, stemming both from oneself and someone else's perception. 4In the field of work social relations, this perception can be of a supervisor, of colleagues, or even clients, which in this case, are represented by the managers of health services, FHS workers, and patients.
Sublimation and pleasure occur where there is validation and social recognition, which contributes to self-realization and the consolidation of individual and collective identities of workers through the notion of "social utility". 4"Without appreciation, there can be no meaning or pleasure or re-appropriation to alienation.:307 Appreciation and acceptance from the Nasf team is different when there is a physician integrated into the team.One study addressing inter-professional work in PHC verified that team satisfaction was greater in contexts in which the practice took place in a less hierarchical environment, without centering on the professional figure of the physician. 16he results show that recognition and a judgment of utility are still very much incipient in the sphere of the FHS team and management, so that pleasure may be fragile and ephemeral and the context even very close to producing suffering, if defensive strategies are not good enough.
The study participants noted interdisciplinary work and teamwork as being sources of pleasure at work, generating professional growth, new knowledge, and broader interventions through exchanges among workers and their different types of knowledge.Teamwork from an interdisciplinary perspective favored a new vision of the world, a less fragmented view concerning health and disease, by overcoming disciplinary boundaries and by exercising coexistence while respecting differences.
In this study, the teamwork in the routine of Nasf presented positive elements that facilitate and enhance work, such as respect, interaction, availability and learning, which take place everyday through collaborative interaction among workers. 10,17ther studies addressing teamwork in FHS also reinforce these findings concerning satisfaction with teamwork 18 and decreased workload as perceived by workers. 19nterdisciplinarity exists not only in the interaction among workers through sharing knowledge and possibilities of intervention, but also through sharing responsibility to improve quality of care delivery and patient safety. 20Even though the work at Nasf was reported to be the most favorable to interdisciplinary work through matrix support in team meetings and shared actions, its implementation is still a source of doubt and concern on the part of the Nasf workers themselves, 21 as the interdisciplinary practice needs to be increased. 22ven though the work at Nasf drives workers to perform their practice based on interdisciplinarity, the reports show a lack of clarity and reiterates a dilemma between what is specific to each profession and what is generally from the field of health and, therefore, can be shared, such as concerns regarding boundaries of practice and potential loss of professional identity.The reports also show concerns regarding practice that stays "between what is yours and what is others" and the challenge to enlarge one's view without losing identity and the specificity of each profession.
The work in Collective Health has a conflicting dichotomous logic that, on one hand, is based on professionalization and development of specific competencies originating within each profession's practice and, on the other hand, is supported on interdisciplinarity, which needs to establish a common ground of practice and intervention, having the patients' health needs as an axis. 23ther studies addressing Nasf workers have also identified the search for a collective construction of knowledge that overcomes interdisciplinarity and becomes effective in transdisciplinarity. 10,21 Interdisciplinarity made possible through teamwork contributes to the development of new types of knowledge, adding value and pleasure to professional action, collaborating to overcome practical limitations and disciplinary views rooted in the experiences of each profession.
Team meetings and shared actions were identified as opportunities to establish continuing health education, in addition to matrix meetings held by Nasf workers.This study's participants considered the times in which permanent health education takes place as times that produce pleasure.The reports reveal aspects that show the importance of permanent health education, but also the importance of opportunities for Continuing Education.The first refers to a political strategy of health education to qualify health workers through "pedagogical listening in the health work environment," aiming to enhance exchange of knowledge and collective construction that produces meaning in the sphere of health work. 24Permanent health education is a tool that favors the integration of teams, while continuing education is linked to an individual search for updating their knowledge and information to be applied in a given context of practice. 25Other studies addressing FHS corroborate these findings and show that permanent health education generates pleasure and satisfaction at work. 14,26he search for new knowledge and participation in courses, conferences and other events as a way to update knowledge and acquire professional qualification were highlighted because Nasf workers also need opportunities to improve professionally and appropriate their supporting roles.
According to the Primary Healthcare National Policy, 27 health workers need to be acknowledged and motivated, while their education and qualification need to be monitored.] These results show the need for formal opportunities to establish permanent health education in the work routine to enable the exchange of experiences, learning and teaching of new ways of doing, in addition to reflecting upon the working process at Nasf from the perspective of matrix support.The work routine should provide elements to support discussions concerning permanent health educaiton. 30There are weaknesses concerning the conception of permanent health education and the collective construction of competencies and cooperative and collaborative working processes accruing from a lack of involvement on the part of workers who are part of FHS.
One of this study's limitations is the fact that the participants belong to a single facility, which may have limited understanding regarding the phenomenon.It, however, provides elements that can be explored and deepened in other studies conducted in different contexts.

CONCLUSION
The analysis of the working process at Nasf enabled verifying that its workers are resilient in the search for this model to be understood, accepted and put into effect in accordance with its premises.The results show that despite difficulties to put the Nasf mission into effect, from the perspective of workers, pleasure and satisfaction were present in their working process, expressed by identification and appreciation for the work done, as well as opportunities in which permanent health education takes place and in teamwork, which favors interdisciplinarity.
The workers derived satisfaction from the Nasf working process due to their autonomy and creative freedom and the educational actions collectively performed.Interdisciplinary work and teamwork were also pleasant and powerful for their professional development because they favored the exchange of knowledge, especially in team meetings and shared actions.The reports, however, revealed power disputes between FHS and Nasf, even though the identity and usefulness of the Nasf work was valued, especially when a physician was part of the team.
The Nasf workers saw permanent health education as part of the working process that was routinely put into effect, but not only as formal training opportunities; for this reason they suggest that social living spaces be maintained.They also suggest that workers be valued, in addition to other types of support and recognition, which can increase the pleasure, satisfaction and quality of life of Nasf workers.