Mobile emergency care service: the work on display

Servicio de emergencia móvil: el trabajo en la vitrina

Abstracts

The aim of the present study was to discuss the way visibility constitutes a power device in the everyday practice of the Mobile Emergency Care Service in Belo Horizonte, Minas Gerais, Brazil. A qualitative case study was developed and data were collected through semi-structured interviews with 31 workers of the service (five physicians, 11 nurses, seven nursing assistants and eight ambulance drivers) and submitted to discourse analysis. The analysis of power relations in the service allowed to verify that there is not an only one source from which the power emanates in this organizational structure. Power is exercised through many techniques and their sources are scattered, diffuse, interchangeable and even confusing. Although there is a hierarchical structure formally established, a parallel network to this structure is formed. It was also observed that the visibility generated by radio communication provides constant supervision, which generates tension within the team.

Power; Professional practice; Interpersonal relations; Emergency medical services

El presente estudio tuvo como objetivo discutir como la visibilidad constituye un dispositivo de poder en la práctica cotidiana de Servicio Móvil de Emergencia en Belo Horizonte, Minas Gerais, Brasil. Se realizó un estudio cualitativo de caso, cuyos datos fueron recolectados a través de entrevistas semi-estructuradas con 31 trabajadores de los servicios (cinco médicos, 11 enfermeras, siete auxiliares de enfermería y ocho conductores) y se sometió a análisis del discurso. Con el análisis de las relaciones de poder en el Servicio, se percibió la no existencia en la estructura organizacional, de una única fuente de la que emane el poder. El poder se ejerce a través de diversas técnicas y sus fuentes son dispersas, pueden intercambiarse y a veces son confusas. Además de su estructura jerárquica establecida formalmente, existe una red paralela a esta estructura. Es evidente, también, que la visibilidad generada por la comunicación radial provee supervisión constante, lo que acaba por generar tensiones dentro del equipo.

Poder; Prática profesional; Relaciones interpersonales; Atención de enfermería; Servicios médicos de urgencia

O presente estudo teve como objetivo discutir como a visibilidade se constitui em um dispositivo de poder, na prática cotidiana do Serviço de Atendimento Móvel de Urgência de Belo Horizonte, Minas Gerais, Brasil. Foi realizado um estudo de caso qualitativo, cujos dados foram coletados através de entrevistas semiestruturadas, com 31 trabalhadores do SAMU (cinco médicos, 11 enfermeiros, sete auxiliares de enfermagem e oito condutores) e submetidos à análise do discurso. Com a análise das relações de poder no SAMU, percebe-se não haver, na estrutura organizacional, uma única fonte da qual emana o poder. O poder é exercido através de diversas técnicas e suas fontes são esparsas, difusas, intercambiáveis e, até mesmo, confusas. Apesar da estrutura hierárquica formalmente estabelecida, forma-se uma rede paralela a essa estrutura. Percebe-se, também, que a visibilidade gerada pela comunicação, via rádio, proporciona uma vigilância constante, que acaba por gerar tensões dentro da equipe de trabalho.

Poder; Prática profissional; Relações interpessoais; Serviços médicos de emergência

INTRODUCTION

A display window is a glassed cabinet where objects for sale are exhibited, in such a way that it will be easier for potential customers to observe them. Back in the middle ages, the display window already counted on internal lighting for the exhibition of products aimed to draw the attention, or to delude and generate the vision of a dream.¹ Our intention here is to compare the work performed at the Mobile Emergency Care Service (SAMU, as per its acronym in Portuguese) neither with a display window in business terms, an aspect that would enable to create possibilities for commercial transactions, nor with an instrument that deliberately aims to delude and produce dreams. Our true purpose is to show the visibility of the work of the SAMU in the everyday life of our cities. In other words, the display window has been assessed as an instrument primarily aimed to cast light on exhibited products, thus awakening the interest of people in what is being exhibited.¹

Given its own work profile, SAMU may be considered as a privileged locus of visibility. Particularly, this is quite a relevant fact in our days in view of the changes experienced by society in its social relationships and productive processes, as there has been enhanced concerns toward the quality of the services offered to the population,² as well as toward people's satisfaction with the offer.

On the one hand, the visibility, compared here to a store window, brings together positive aspects, such as the recognition and the admiration of the population concerning the rendered services. On the other hand, contradictorily, this same visibility may be deemed to be a trap to the own system, as it sometimes provokes disappointment and indignation in the same population. Additionally, it may cause tension and discomfort in the daily service, as the work teams are under constant inspection by the communities through direct observation, bearing in mind that the work of the professionals occurs exactly in the same site where health events take place. Another factor that exposes the health team is related to the contents related to SAMU, which are continually portrayed by the media, a fact that maximizes the visibility of the professionals.

Michel Foucault's background leads us to understand how such visibility, as a characteristic that is present in general health services and more particularly in pre-hospital care processes, is inserted into the context of disciplinary power. It can be assessed as a technique that is applied in the production of the ideal individual, in which considerably simple mechanisms are employed: hierarchical surveillance, normalizing judgment and the exam. Even though in a subconscious form, the application of these techniques, in a general perspective, aims at producing docile and useful bodies, that is, bodies that are prepared to behave in an adjusted manner, or that respond to the interests of a given social group.³

The hierarchical surveillance, considered by Foucault³ as one of the outstanding technical inventions of the 18^thcentury, is remarkably present in the work structure of SAMU. Owing to this hierarchical surveillance, the disciplinary power becomes an integrated system, as observed in multiple, automatic and anonymous ways. Such framework takes place because the surveillance is comprised of relationship networks from top to bottom, from the bottom to top, and also laterally, in such a way that the establishment of a power flow that sustains the structure is maintained. In hierarchical surveillance processes, no one holds or transfers power as if it were a property; instead, power moves throughout the structure in spite of the formal institutionalized pyramid that highlights positions and management levels. Power is produced and distributed by individuals in a permanent, steady way.

Small disciplinary punishments, deemed to be normalizing judgments, are considered as an instrument of disciplinary power by establishing a natural, individualized desired standard aiming to prevent deviations from the pattern, thus allowing people to be classified as better or worse than others,³ as they come closer or draw away from the pattern. Such mechanism continually presses individuals toward fitting into a model, so that a similarity is created among everyone. Diverging professionals will bear the consequences of being different. The normalizing judgment imposes norms or rules, as well as a punishment system to which all of those who drive away from it will be submitted.⁴ In the end, the combination of hierarchical observation and normalizing judgment configures the exam, which sets out the visibility through which the individual will be differentiated and judged.³

Taking the singularities of SAMU into account, the recent insertion of the service into the health care network in the city of Belo Horizonte, and the limited academic production, especially concerning the characteristics of the work process, causes the development of studies addressing this issue to be quite a relevant action. In this sense, the aim of the present study was to discuss how visibility constitutes a power device in the daily practice of SAMU. The results of this study are expected to contribute toward broadening the knowledge on the work process carried out by SAMU, as well as to subsidize new studies.

METHODOLOGY

This qualitative study was carried out at the SAMU located in the city of Belo Horizonte, Minas Gerais, Brazil. The sample was comprised of 31 professionals (five physicians, 11 nurses, seven nursing assistants, and eight ambulance drivers). The research applied the convenience sample selection and the inclusion criterion was the voluntary agreement to participate in the study.

For the data collection process, the research made use of a script for semi-structured interviews carried out between March and May of 2010. The interviews were recorded by a Multimedia Player 4 and fully transcribed. The script addressed the following questions: What caused you to choose working at the SAMU? What is your perception on the relationships among the professionals of the SAMU teams? How about the relationships between the SAMU teams and the professionals from other healthcare network units? Taking into account SAMU's management profile and hierarchical structure, how do you perceive the service's organizational structure? In the data analysis process, the subjects were identified by the initial letters of their professional group (nurse - N, nursing assistant - NA, physician - P, and ambulance drivers - AD) and then consecutively numbered in accordance with each group.

The data collected were submitted to the discourse analysis, that aims to comprehend the operational structure, organization principles and the social production construction of meanings.⁵ Additionally, it is worth highlighting that the discourses are not restricted to the representation of entities and social relationships, but also build and constitute them.⁶

As for the data operationalization process, the following steps were adopted: data organization, data classification and final analysis. The data organization process included the transcription of interviews, thorough reading of the material, and systematic organization of reports. An exhaustive and repeated reading of the texts aiming at the apprehension of relevant structures, as well as the constitution of one or several communication corpuses for non-homogeneous information sets, followed the data classification process. The data analysis process was composed of the correlation between the specificity of the object produced by experiential evidences and the essential relationships.⁵

In compliance with the presuppositions of Resolution 196/96, the research proposal was submitted to and approved by the Research Ethics Committee of the Federal University of Minas Gerais under protocol number ETIC 105/09. After being informed about the details of the study, all participants signed the Free and Informed Consent Form.

PRESENTATION AND DISCUSSION OF RESULTS

SAMU stands out as a connection among the different levels of the health care network. The visibility of the service ratifies such dynamic connection.⁷ Such visibility is directly linked to the permanent surveillance existing in the SAMU's structure, as any individual, regardless his/her formal position, is able to monitor the work of any colleague. The professionals have even more open access to each other's work than their formal supervisors in the structure.

As the work at the SAMU occurs in decentralized units, such technique embodies a singular relevance. The visibility is diffuse in the work structure and what is seen can be reported to a manager by any individual. Hence, all professionals must strive to carry out services that satisfactorily meet the demands of their own colleagues, as everyone automatically holds potential powers. Such condition is mentioned in the following excerpt: [...] there are various managers and they do not participate in the SAMU's integration process. They get extra-official information, you know. They are not aware of what goes on in the streets (P1).

The possibility each professional has of reporting on an occurrence, at any time, to a manager who was not present at the time the event took place, is personally responsible for the consolidation of the power distribution throughout the whole structure. In this sense, in spite of not actively participating in the team work and consequently being unaware of occurred facts, service coordinators have in the diffusion of power a way of controlling the work team. Therefore, the exercise of power must be taken into account in the perspective of a global and decentralized process that operates as a network of mechanisms or devices that permeate the whole society, excluding no one. Foucault deemed the "functionality" of power to be an evident feature, as it works as a machinery that is not located at a specific locus, but disseminated throughout and permeating the whole social structure.⁸

As such, there is not a single source from which power arises in the disciplinary organizational framework. Although a formally established hierarchical structure does exist, power is set out in parallel to this structure. As soon as power is dissociated from a fixed point of origin, it embodies an anonymous, diffuse and multifaceted character. Such fragmented power penetrates all levels and gaps in the structure, produces long-standing effects on individuals and, at the same time, normatizes them.⁹

A deep analysis of Foucault's work^{10 - 11} points out his concerns about the practices involving the visibility issue. As a matter of fact, he argues that there is a clear difference between what is seen and what can be seen. Such visibility, that is, what can be seen, should not be wrongly taken as what is really seen, or in other words, specific visible or more generically perceptible objects, elements or qualities in a given moment. Thus, what can be seen is a consequence of a specific visibility constituting a knowledge and power relationship, an intersection between what is seen and what is said, establishing conditions that allow us to see things the way we see them, a form of visibility that allows things to show themselves to us as they are or as they can be.¹²

In the SAMU's daily work, the visibility issue, or the difference between what really happens and what is seen, is constantly present, as not always what is perceived by the citizens, or even by the work team regarding certain situations, postures and attitudes of the colleagues, corresponds to reality. As it may be observed in the following excerpt, the interferences in the interpretation of situations weaken relationships in the work team, as the quality of the performed work may be questioned in the situational analysis: [...] if a problem occurs, if a mistake occurs, it has an immediate impact on the media, and this comes back to us in our daily service. Sometimes, a problem takes place, 'well, the SAMU did not show up, I don't know why'. This goes to the media and when you are on duty the guys throw that right in your face, 'oh, you didn't show up there'. Well, we work all day long, we stop for lunch when the work allows us to, we pee when it is possible to. We can't leave our shift when we want to, there is no schedule, that is, we don't have any idle time (N3).

One of the negative aspects pointed out by the SAMU professionals is the lack of understanding of the singularities of their functions by the population, which leads people not to comprehend the purposes and the mission of the service.⁷ Despite its symbolic aspect, the core value of the service goes beyond the performed work itself: the way it is perceived both by the professionals' colleagues and by the patients assisted by the service, or the spectators in the scenario of the accident. In the SAMU's work organization, although the work of the teams is restricted to their ambulances and work stations in a certain way, with no visual contact among the groups of professionals, the established communication system via radio is one of the mechanisms that allow for presences and absences to be controlled, as communications are constantly intercepted and behaviors are continually monitored.

Although this communication system is not primarily aimed at monitoring the professionals or inducing the behaviors of team workers, this type of communication, open to the whole group, fatally exposes individuals to each other, thus opening gaps to reasoning, judgment and criticism, as it may be perceived in the following interview: [...] the relationship we have in the SAMU is quite a distant one, because each one of us is located in one spot of the city... There is sort of a competition, sort of, 'well, I have worked so hard and the other ambulance is parked there, has not worked yet. This event was not in my duty area. Why haven't they sent the other ambulance?' So, there is a bit of a competition. There is a bit of a lack of contact. We do not have any contact with the other guys. So, we just see those team members working there in the ambulance with us (N1).

Such statement brings along the power issue as something experienced in the social fabric and not only located at a given spot of the structure, as there is a physical distance between the members of the several mobile units. Nevertheless, even though the groups are far apart, the practices in each team are not hidden, but constantly questioned by the colleagues. In this situation, the inquiries of the interviewee are not only directed to colleagues from other work teams, who in certain moments do not respond to the calls they should supposedly do, based on a more homogeneous work distribution, but it is expanded to a higher hierarchical level, the Regulation Center.

It is important to take into account that every type of society aims to produce new realities by constantly dissolving previously set realities and significations and building an equivalent number of newly unexpected conjunctions. It is exactly the trajectory of such construction that favors new achievements or failures.¹³ Nonetheless, it is worth highlighting that the production and reproduction of realities in a given social apparatus are closely related to the subjectivity and the autonomy of individuals.

It is true that the experience of autonomy is dependent on the practice networks and social relationships in which subjects are inserted, but it also depends on the way the success or failure of their actions are assessed toward maximizing autonomy and leading to the search of new governance practices that are able to enhance the sensation of power.¹⁴ In this sense, whenever the value of the work team as a social network is redimensioned, regardless the hierarchical level, it can give rise to new perceptions on what is understood by success and failure. Although such framework is grounded on the autonomy and on the search for continuous redefinitions of spaces, it can bring into the scenario of the work environment the desire of producing new, more favorable realities. The panopticon prison model clearly illustrates this framework.

The panopticon displays the intentionality of raising in the prisoners the awareness of the possibility of being constantly surveilled. The visibility game leaves the doubt of whether or not the surveillance process is really taking place. Hence, it is turned into a machinery that separates the "to see" from the "to be seen"⁸ binomial. In the work of SAMU, the panopticon framework is not present as a physical, concrete structure where a game of lights and shadows becomes an instrument that allows for the control of individuals; the panopticon is reinvented instead, yet with no minimization of its effects whatsoever.^{3 , 8} This panopticon is not restricted to the "seeing without being seen" binomial. It carries on the broader goal of imposing a certain desirable conduct to a given human group. For this purpose, each social group defines a diagram, that is, a social machine encompassing social relationships proper to each structure. Such machine is highly fluid and instable, and constantly combines issues and functions that produce mutations in the system.¹³

The steady surveillance, associated to the need of being accepted by the system and especially by work colleagues, comprises the notion of an ideal SAMU worker, an individual who is capable of meeting the expectations of the service, or in other words, an individual who adapts to pre-established norms and standards. The assessment of the behaviors of individuals leads not to the attitudes properly saying, but the individuals themselves, taking into account their nature, virtues and values. If, on the one hand, the power of the norm brings along the homogeneity it aims to create, on the other hand it individualizes the workers and allows for the measurement of their deviations from normal standards, thus favoring the determination of distinct levels, creating special classes and making such differences useful, while adjusting each of them to one another.¹⁵

Power, in its modern form, is more and more exercised by the control of the norm, which is far broader than the control of the law itself. Being directly involved in the operation and final purpose of power, the normalization, therefore, refers to a process that involves the regulation of the individual and collective lives of subjects. In this sense, our current societies can be deemed to be normalization societies, where the norm of the discipline and the norm of the regulation are intertwined. "Modern societies are not merely disciplinarian societies, but normalization societies".^16:309 As history is permanently rewritten and new ways of social reconstruction appear every now and then, human groups are also constantly mobilized.¹⁷

In the same way norms are established in a given structure, so do normalizing judgments. They operate through tiny mechanisms inserted into the core of all disciplinary systems. At the SAMU, one of the normalizing judgments recognized by the professionals is the classic embarrassment. [...] I know some stories... I hear them on the radio, inadequate situations in my opinion. About things that should not be said on the radio, because everybody listens to the radio. [...] So, I think that it aims at humiliating us (N9).

The recognition of the inadequacy of certain processed dialogues via radio may cause the speaking professional to be eventually submitted to embarrassing situations in public. This fact reinforces the visibility through the hierarchical surveillance and ensures the automatic operation of power, bearing in mind that the mechanism of observation favors the efficacy and the capacity of penetrating in the behavior of individuals, as it creates in the observed people the need for positively corresponding to the observer's expectations. It is not only a matter of pride: it is a matter of keeping individuals in their places in the social apparatus.

Hence, even though a formal rigid punishment, or the punishment of being embarrassed among his/her colleagues, is not the case, the professional avoids deviating from the standard in order not to be inserted into a situation in which he/she feels humiliated.¹⁵ As soon as the worker realizes that he/she is in the limelight, or in a situation of visibility before his/her colleagues, he/she tries to carry out the assignments the closest possible to the pattern.

SAMU is currently undergoing an organizational transition process. Hence, some norms have been implemented and other already existing have been redimensioned in the daily practices of the work team, as mentioned by the following interviewee. [...] Now, we are right in the middle of a new normatization process and I think that the trend from now on is that the service will improve, it will be tougher, because we were sort of spoiled. Issues like the change of duty time, day-off whenever we wanted to, time schedule, you could do it... Now, things are being normatized, in compliance with what is determined by the HR. So, well, we have to rearrange everything. I think that it tends to get better, yes. [...] But, I think that it will still generate lots of complaints before it gets better, before everything changes (N3).

As observed, there is an increasing awareness of, and even an agreed conformity with the fact that from that moment on the normalization process would be part of the daily work of the team in a more effective way. Although human actions are monitored by specific norms, such norms are not peacefully assimilated, and this feeling is manifested by the resistance against changes. Therefore, although the service can be recognized as a normatization society, it is not necessarily a normatized society.¹⁸

As new norms are introduced, they seek to more accurately define the profile of the individuals that would fit in the service. Additionally, the new norms create a more effective control system in the structure, which improves the possibility of being acquainted with the individuals.

Nevertheless, despite the transparency and apparent simplicity observed in the interviewee's statements, they clearly show the tension between the need for implementing and complying with the norms, and the level of satisfaction of the individuals submitted to the norms. On the other hand, it is worth highlighting that in any context of profound diversity, the reactions of people to norms are quite distinct. Another interviewee explains that [...] sometimes we have to solve some small problems, something. You see, [...] it's my daughter's birthday, it's Sunday. [...] If the boss does not grant me permission to go away, unfortunately, I have never missed work like that, but I will have to. It's my daughter's birthday, you know. But I know she will allow me to go. [...] (NA3).

In this case, the interviewee clearly shows that there are a few personal situations that become priorities, regardless what is recommended by the service. They can count on the understanding of the person in charge of the authorization to change shifts, but the decision of not working in a given day has already been made, regardless the final institutional decision. The statement shows that the imposition of a norm is not enough to enforce the proposed action. In the same measure that the imposition is placed, an equally opposed reaction rises up,¹⁸ which redimensions the rules of the political game in the daily practice.¹⁹

In a normatized society, individuals with higher ability to comply with established patterns are more valued. Such position gives evidence to their more effective adaptation to the work dynamics and causes them to be acknowledged as being useful to society.³ The relevance of such acknowledgment lies in the fact that the subjectivation of the subject is not only processed in its correlation with himself, regardless the established social correlations and forces.¹⁹

The individual is built in the subjectivation process, as well as in his/her correlation with the group and the function he/she develops in the institutional system. As a matter of fact, only those who adapt to the regulatory norms of the system start being acknowledged as being useful to the service. [...] Our colleagues, they do not see how much we work. They saw our work only in the training process, if we had the potential or not. They must have seen our potential because this is why we were kept here. So, I see this recognition, this respect, we were able to develop this work and we are able to adapt to the profile of this service (N2).

Although the recognition of the work at the SAMU, partly as a result of the visibility of the service, is deemed by the professionals to be a rewarding work, the discomfort provoked by the negative judgment of viewers that do not know their real work context, is a remarkable trait. Besides, there is a perception of intentionality on the part of the means of communication toward exploring potentially problematic situations experienced in the service making use of media sensationalism.

The exposure of the team is even more aggravated by the fact that the SAMU does not count on a press office, which could work toward clearing issues in a way of providing a more impartial analysis on the part of the population at large. [...] I also think that we lack a press office here. We don't see it. So, there are many things, unfortunately... There is the Globo Repórter, there are other news programs, they don't even come here to know what happened. Then, they spread the news and, you know, the entire population is seeing it, and unfortunately, sometimes it was just an argument we had with the fireman. (N9).

The media uses the several means it has to promote the homogeneity of meanings, to establish "truths", to maintain or create consensus. The editorial line of a newspaper is aimed at a certain target audience. In order to meet their expectations, the news needs to be specifically treated. Published materials must meet minimum demands both of that media, which has to employ formulas that are already accepted and approved by its audience, and the target audience itself, which is loyal to that means of communication as a result of the identification with its proposals and the confidence in the veracity of that published version.²⁰ Yet, the frequent broadcast of news on the SAMU by the media shows that this health service is positively approved and accepted by the population.

The existing gap between what really happens and the interpretation of what happens depends on the subjectivity of those who analyze the fact; in other words, different interpretations of the same fact exist because the interpretation is not specifically and merely related to the occurred fact itself, but also to the subjectivities of individuals who formally or informally analyze the practices surrounding it.

Any given fact observed in a certain moment in time depends on a previous historical event, which actually represents the origin of a certain way of thinking about the veracity or inaccuracy of such fact:²¹[...] people often say, 'oh, the SAMU did not show up and... I don't know, that person died because the SAMU didn't show up'. Sometimes it can be right!... Is it Ok, the SAMU did not go because there was a mistake, the physician got it wrong. Sometimes we can make mistakes, and I think that it has to be shown. But, what about the other things we do? All the time. Well, we are the turning point in the patients' lives. This is never shown, at any time. I don't think it should be shown. But, I think that when these problems happen, when a problem happens and we are not able to show up, this should be shown in a different way. It's a matter of sensationalism (N3).

In this sense, the sequence of publications on the work of SAMU constitutes part of the historicity involving the analysis of new facts. With that in mind, as a matter of fact, there are diverse ways of analyzing and comprehending the practices per se. The conceptions shaped by different subjects end up constituting an intersection between the analyzed reality and the historicity of those who analyze it, in such a way that the knowledge can be understood as a result of a social production.

The exposure of SAMU in the media, analyzed by the power dynamics, works as an effective control device capable of managing the actions of the professionals, monitoring their behaviors and recreating the power relationships day after day within a context that overwhelms the boundaries of the team, and even the limits of the service. The role played by the service is a result of the requirements of the population, which demands it to adapt continually, aiming at a permanently improved practice. Power has a productive efficacy, a strategic richness that manages the lives of individuals based on the control of their actions, in such a way that it makes possible and feasible their maximum utilization and their full potentials are taken advantage of.²²

Hence, the exposure of SAMU in the media imposes a strong control over the professional practice and regulation, so that not even one detail escapes. Concurrently, the work team is expected to render qualified services at all times. As the SAMU professional becomes visible to the eyes of the population he/she serves, he/she is levered to the condition of being an assessed subject, which constitutes a change of roles, as the health professional is habitually used to play the role of an examiner.

The exam stands out as a technique by which it is possible to establish a normalizing control and surveillance that qualifies, classifies and punishes, exposing individuals to a visibility that is capable of differentiating and sanctioning them. In the exam, the superposition of knowledge and power relations reaches its apex, once such technique permeates an entire knowledge field and a type of power. Additionally, the exam reverses the visibility condition in the exercise of power. It should be highlighted that in the classic power relation, all visibility is centered on the individual that exercises the power. Being diffused in the structure, power imposes on the individuals submitted to it the principle of the compulsory visibility. As a result of being constantly seen, or exposed to be seen, the individual is subjected to discipline.³

CONCLUSION

The present study shows that the power relations observed in the organizational structure of SAMU do not stem from one single source. Unlike the power sources that are exclusively centered on the figure of a boss, the power sources at SAMU are dispersed, diffuse, interchangeable, and even confusing. Such power is exercised by several different techniques, such as the way of looking at, conceiving and organizing objects distributed and imposed in the diverse institutional environments as an integral part of the social relation networks. These objects acquire specific aspects that always comply with the contexts in which they are developed.

The established power balance is not necessarily unequal, although distinct hierarchical levels are addressed; yet, it is a power relation that is able to generate changes in the practices, as it gives rise to feelings of distrust and discredit toward the actions carried out by some members of the group. Consequently, it leads to a lower degree of commitment with the quality of the rendered service, in addition to the disturbances created in the work environment.

The communication made via radio is one of the connections that maintain the structure of SAMU. This means of communication is largely responsible for the relationship among team members, constituting their reality, granting meaning to their practices and building their truths. The constant exposure of the teams' dialogues by radio ends up inducing the awareness of a permanent state of surveillance in the workers.

Although the aim of this study was to stand out as an instrument of reflection on the work process observed in mobile pre-hospital care services, its methodological nature allowed it to be applied to the SAMU in the city of Belo Horizonte, Minas Gerais. Other approaches that allow for the advancement of the knowledge on such complex structure observed in other scenarios and realities should be carried out.

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Publication Dates

• Publication in this collection
  30 Sept 2014
• Date of issue
  Jul-Sep 2014

History

• Received
  25 Jan 2013
• Accepted
  09 July 2013