Practices of power in the Mobile Emergency Medical Service of Belo Horizonte

Abstracts

O trabalho do Serviço de Atendimento Médico de Urgência (SAMU) envolve a participação de diversos profissionais que atendem a demandas de diferentes níveis de complexidade, em um amplo território geográfico, com um planejamento de trabalho diferente dos serviços com estruturas exclusivamente fixas. O objetivo deste estudo foi analisar a configuração de práticas de poder no cotidiano do trabalho dos profissionais do SAMU. Trata-se de um estudo de caso qualitativo, cujo cenário foi o SAMU de Belo Horizonte, Minas Gerais, Brasil. A amostra foi composta por 31 trabalhadores, e os dados coletados por entrevista semiestruturada e submetidos à análise de discurso. No contexto das lutas e práticas de poder, destacam-se 'o poder da vaga-zero' e os 'corpos uniformes e imagens de poder no SAMU'. Percebe-se que, no SAMU, o poder está presente como prática social, com sua centralidade se deslocando de acordo com as situações vivenciadas e os interesses em questão.

Serviços médicos de emergência; Equipe de busca e resgate; Prática profissional; Relações interprofissionais

ORIGINAL PAPERS

Practices of power in the mobile emergency medical service of Belo Horizonte

Prácticas de poder en el Servicio Móvil de Emergencia de Belo Horizonte

Isabela Silva Cancio Veloso^I; Meiriele Tavares Araujo^II; Marília Alves^III

^IShe holds a Doctorate in Nursing from the School of Nursing of the Federal University of Minas Gerais (EEUFMG). An Adjunct Professor of the EEUFMG. Belo Horizonte, Minas Gerais, Brazil

^IIA doctoral student in Nursing at EEUFMG. She is also an Intensive Care Nurse at the Adult Intensive Care Unit of the Hospital Regional de Betim-MG. Belo Horizonte, Minas Gerais, Brazil

^IIIShe holds a Doctorate in Nursing from the School of Nursing of the University of São Paulo. She is a Full Professor at the EEUFMG. Belo Horizonte, Minas Gerais, Brazil

Author's address

ABSTRACT

The work of Mobile Emergency Medical Service (SAMU) involves the participation of several professionals that meet the demands of different levels of complexity in a huge geographic territory, with planning different of services with exclusively fixed structures. The aim of this study was to analyze the configuration of practices of power in the daily work of professionals of the SAMU. It was a qualitative case study which had been set in the SAMU of Belo Horizonte, Minas Gerais, Brazil. The sample was composed by 31 workers and data were collected using semi-structured interview and than submitted to discourse analysis. In the context of struggles and power relations in SAMU, stands out 'the power of zero vacancy' and the 'uniform bodies and images of power in the SAMU'. It was possible to observe that power in SAMU is present as social practice, with its centrality moving according to lived situations and to interests in question.

Descriptors: Emergency medical services. Rescue personnel. Professional practice. Interprofessional relations.

RESUMEN

El trabajo en el Departamento de Atención Médica de Emergencia (SAMU) implica la participación de varios profesionales que respondan a las demandas de los diferentes niveles de complejidad, en un territorio geográfico amplio, con una planificación de trabajo diferente de servicios exclusivamente con estructuras fijas. Este estudio tuvo como objetivo analizar la configuración de prácticas de poder en el trabajo de los profesionales en el SAMU. Es un estudio de caso cualitativo, desarrollado en el SAMU de Belo Horizonte, Minas Gerais, Brasil. La muestra fue de 31 trabajadores. Los datos recogidos a través de entrevistas semiestructuradas fueron sometidos a análisis del discurso. En el contexto de las luchas y las prácticas de poder se destacan el 'poder de vaga-cero' y 'cuerpos uniformes y las imágenes de poder en el SAMU'. Se observó que en el SAMU, el poder está presente como una práctica social, con el centro del movimiento de acuerdo a las situaciones vividas y los intereses en cuestión.

Descriptores: Servicios médicos de urgencia. Personal de rescate. Práctica profesional. Relaciones interprofesionales.

INTRODUCTION

Given the determination of the National Plan for Attention to Emergencies ⁽¹⁾, in 2003, the Mobile Emergency Care Service (MECS) was inaugurated by the Municipal Health Department of Belo Horizonte, Minas Gerais, a pre-hospital care service with free phone access, available to the entire population through the number 192.

The service has a fixed structure, in which its organization and management are centered, and a mobile structure, which consists, basically, in ambulances. The working process of the MECS involves the participation of professionals from various categories that meet clinical demands of different levels of complexity in a large geographic territory, which requires a work plan with different routines from those established in services with fixed structures, exclusively.

In the structure of MECS, considering both the central and mobile structures, their own organization of work have been developed, struggling for space and defense of interests. In these relationships, the struggle for the defense of the interests of each service also conveys and may be considered that the differences, which polarize the various actors, are the result of social positions occupied by them and the different interests at stake, according to each situation experienced in different moments.

This scenario lead us to reflect on how social actors are part of a system of occupations and relationships established, besides considering their everyday interaction. This reflection must travel paths for understanding the factors that are related to integration or the distancing from the actors allocated in different parts of the structure of health services.

In addition to the relationships that are developed within the structure of the MECS, it is part of their working activities as relationships established with professionals from other levels of care, especially from Basic Health Units (BHU), Emergency Care Units (ECU) and Emergency Rooms (ER), which have different organizations among them such as MECS. Indeed, in each of the articulation that is established in the network of health services, there are interests to be defended. This naturally sets professional boundaries, which are constantly being defined and redefined in a continuum of power relations, which interferes directly in the design of the work process of MECS.

In this relationship context, which will be developed as relations of power, in fact, it may be interpreted as power relations. From this perspective, it is important to consider that the power has no center; it is constituted as a network system, strengthened by its links, translated by their interpersonal relationships, where each link in the social chain has its production, reproduction and transformation of power. Thus, the mechanisms of power have their essence in the individual capillary. It permeates their own body and inserts ones gestures, attitudes, speech, learning, finally, in their daily life ⁽²⁾.

Discussions related to how the relations constitute the MECS are relevant, as they can be configured into important tools for a critical analysis of the service, to give visibility to the structure of relationships that constitutes their daily practices. Since it is a recent structure in the context of health care in Brazil, although the unquestionable relevance, it needs to be understood in its various dimensions.

Understanding the practices of power in question is an attempt to explore their own health practices as elements of social construction, considering practice as anything that people live every day. The practices does not constitute themselves, but are built on relationships and interactions, sustained and sometimes contradicting each other in many complex structures ⁽³⁾. Thus, understanding practices requires a comprehension of the organization of power and the establishment of its relationship with the various social, political mechanisms and economic issue ⁽⁴⁾.

We opted for an analysis recognized the poststructuralist framework, because it considers that it allows one to question what reality itself is, who are the individuals who constitute it, and what social relations are established in the scenario. In post-structuralism perspective, it is considered that the realities and truths of each moment are social constructions produced from the tension between emerging and dominant discourses that seek to maintain or change established social practices ^(5,6).

One must also consider, yet in the post-structuralism perspective, the power may not be represented by a theory because it is not something unique. Power is the unthoughtful that is connected to all forms of knowledge, and since there are different forms of knowledge, there will be different power relations being established. In this sense, rather than objects, content and thoughts, the unthoughtful includes historically constituted conditions and the overall style of an organization in a way of thinking ⁽⁷⁾. Therefore, the objective of this study was to analyze the configuration of power practices in daily work of professionals in the MECS of Belo Horizonte.

METHODOLOGY

This is a qualitative case study, which had as scenario MECS from the city of Belo Horizonte, Minas Gerais, Brazil. With a qualitative research, we intend, besides seeking for detailed descriptions about a specific reality, overcome initial conceptions that allow us to generate or revise previously adopted theoretical frameworks, providing basis for descriptions and explanations of specific contexts. ⁽⁸⁾ This article is a resulting part of the PhD thesis titled "Settings of Power Relations in the Mobile Emergency Care Service" defended in 2011 ⁽⁹⁾.

The sample selection was for convenience, considering as inclusion criteria the consent to participate voluntarily in the study. It was composed of 31 workers, 05 physician, 11 nurses, 07 nursing assistants and 08 drivers. Throughout data analysis, subjects will be identified by the initial letters of their professional (physician - P, nurse – N, nursing assistant - NA and drivers - D) and listed consecutively, according to each category.

Data were collected from March to May 2010, using semi-structured interview with the following questions: What have led you to choose to work in the MECS? What is your perception about the relationship between MECS professional team? How is the relationship between MECS team and professionals from other units of the health system? How do you perceive the organizational structure of the MECS considering management styles and hierarchical structure?

The interviews were conducted at the headquarters of the MECS of Belo Horizonte. Its sequence was defined randomly, respecting, through scheduling, the readiness expressed by the study subjects.

All respondents voluntarily signed a Consent Form. The interviews were recorded on a Multimedia Player 4 equipment and, later, they were transcribed in full length for analysis and interpretation of speeches constituted from the speech of the authors, in order to ensure the completeness and accuracy of the information. However, considering the complexity of qualitative research, in addition to the complexity of the subject matter, it is important to note that the descriptive registration was obtained of transcripts and notes from field observations do not provide, by itself, understanding of what is sought. To understand this, we sought to examine the data carefully in an attempt to appropriate the meaning and interpret them ⁽¹⁰⁾.

Data were subjected to discourse analysis, which allowed us to discuss the evidence and explain its ideological character, as well as recognize the concealment ways of political domination expressed in its content ⁽¹¹⁾. It is important to consider that the speeches are not restricted to represent entities and social relations, however, they built or constitute them. Furthermore, it comprises the historical change inherent to the speech, since, as the combination of different speeches in particular social conditions, a complex new speech is produced⁽¹²⁾. Regarding the operationalization of the data, we followed the steps of organizing the data, data classification and final analysis ⁽¹³⁾.

The project was approved by the Research Ethics Committee of the Federal University of Minas Gerais, under the number 105/2009.

RESULTS AND DISCUSSION

In speeches produced by MECS workers on the data collected, the practice of power as a social practice is present, with its center moving according to the situations experienced in each moment and with the various interests concerned. The movement of individuals between the various interests scenario represents the efforts in trying to establish positions in the various relationships established in the daily work, which creates struggles for position, favoring the establishment of power relations.

In the context of struggles and relationships that emerge in practices of power in the MECS, two items deserve special attention and are presented here as 'the power of the vacancy-zero' and 'the power of uniform bodies and images in the MECS'.

The power of the vacancy-zero

The vacancy-zero is the condition defined by Ordinance 2.048 that any health service has to offer vacancies to receive patients transported by MECS, regardless of availability of vacancies, a priori ⁽¹⁴⁾. The MECS has the authority to allocate patients in the service network of the regional system, with the obligation only to communicate its decision to the physician assistants of the emergency services.

However, the biggest problem is not in the legislation itself, but it is in the reactions that it provokes in the different health services. Thus, MECS professionals consider that the legislation in itself is an element that should enable their access to all health services network, independently of any kind of negotiation.

We would not have to ask to get in. We have to come and enter. However, then, we still make contact, does it all. We try to talk. (P1)

Thus, the vacancy-zero sets in a form of institutionalization of power exercised in everyday work practice of all workers in the MECS, which puts them in a position of superiority in relation to other health services since it has autonomy to decide the fate of the transported patient, regardless of availability. In general, the vacancy-zero has recognized its legitimacy by all emergency health services where their hegemony is accepted, although it is experienced in the middle of conflicts, which arise due to the supremacy given to MECS in the scenario of health practices.

Like all forms of power that arise, also the resistance to that power emerge, professionals from other services show signs of resistance to the power of vacancy-zero through small everyday manifestations of dissatisfaction with its practice. Just like power, the resistance points appear on a wide and varied network, as multiplicity or as foci.

In Foucauldian perspective, it is part of the study of power relations the research of resistance against power mechanisms, which would be the only way to understand the history of the operation of the machinery of power. Thus, in order to realize power mechanisms, it must be noted the antagonistic strategies, in one way or another, they are placed against each other ⁽¹⁵⁾.

Nevertheless representing the other side of power relations, this does not mean that they are necessarily doomed to failure, However the resistances that are presented as points and irregularities are distributed in the game of relationships with power in a ratio of greater or lesser intensity. Although it configures more commonly a transient point, mobile and precarious, the resistance may cause profound disruptions or radical uprisings, besides being able to raise regrouping and introducing cleavage ⁽¹⁶⁾.

It is observed that resistance has not been, necessarily, declared or assumed publicly. They constitute in transitional points in the structure, emerge throughout the network of relationships, assuming multiple forms that shape, apparently, small attitudes. Still, in the case of MECS, they generate, in fact, a break in the unique structure that is desired for the health system, as it creates multiple systems, often complementary and not antagonistic, as proposed.

Thus, MECS professionals also bring in their speeches, the perceived resistance of other services in relation to them. The justification that is highlighted, is guided by the fact, that the MECS is blamed for the increase workload of those services, which would generate dissatisfaction among professionals. The excerpts of interviews that follow, illustrate this situation.

The relationship (with other levels of care) is usually bad. So ... we are seen as the person who is giving work to do. [...] When we move the patient from the MECS gurney to the hospital gurney, no one helps. (N1)

[...] Nobody likes the MECS, right? Because MECS delivery problems to them. So, usually people are not willing to help these professionals, the MECS, ambulances. (P1)

[...]It is difficult, because the ECU colleague lies a lot to us, to try illustrating a case, so he will not accept it. Then, the colleague of large hospitals, tertiary hospitals, always claims that they have no vacancy. (P5)

It is interesting to observe that regarding the relationship between the MECS and other levels of care, the speeches of many professionals that mention a bad relationship converge to the same issue, the difficulty of these relationships are associated with inadequate responsiveness of ECUs and emergency care hospitals. However, under further analysis, fragility and hostility of these relationships may be perceived as a form of resistance to the power of the MECS.

As the prerogative to establish the urgency judgment from the MECS professional, there is a sense of autonomy break from professionals from other levels of care. MECS, instead of having their recognition marked by the partnership, they are renowned as a "delivery problems" because patients brought to emergency services must be met, regardless of the unit conditions. Therefore, there is a gap in the integration between the services that should run on network and this situation reflects in the relationship established between professionals ⁽¹⁷⁾.

While it is remarkable, in the speeches of MECS professionals, the responsibility of other services in relation to the difficulties of everyday relationships, there are in some occasions, the recognition portion of the responsibility of the MECS, as seen in the following excerption:

I happened to get, for example, in ECU, you see that, sometimes, for example, the nurse treat with even greater disrespect another colleague who are in ECU. (P4)

[...] The MECS physicians still did not realize that people are consulting in ECU [...] I think the physician from MECS has a lot arrogance and prepotent that he needs to lose, right ? (P2)

What you see is the recognition of an authoritative posture that MECS professionals assume in the relationship with other professionals care levels, more specifically, in this case, with the ECUs. These postures reaffirm the superiority position assumed by MECS professionals before other professionals on daily activities performance. However, considering the circularity of power in relationships, we must consider that this position now assumed is not a stable condition, however it may be modified according to environmental and behavior changes in the various subjects involved in this relationship.

The power of bodies uniforms and images of MECS

In addition to formal and objective factors, such as the establishment of "vacancy-zero" in Resolution 2.048 ⁽¹⁾, there are other factors, perhaps less direct, but no less relevant, favoring the domination posture assumed by MECS professional in many situations. Among these factors, it is noteworthy the uniform worn by the team in their work activities. The commonality, in all meanings, including clothes, it constitutes an important power mechanism, as it standardizes individuals ⁽²⁾.

In the case of MECS, the use of uniform has yet another component, the fact that all the ambulances crews use the same uniform model, which means that they are not recognized specifically for their function, but as MECS workers, which accentuates further standardization. Moreover, few of them use personal identification devices, such as badges, which helps everyone to have their image associated to MECS, independent of professional qualification and their individual characteristics.

MECS workers are always in their uniform, overalls, boots, it is something like the military, they end up imposing, just like a cop. I know because I work in ECU, I see staff talking 'ah, you come with overalls, you think you are the owner of the world' [...] there are professionals, yes, they wear overalls and think they are superior. (N9)

[...] I think the issue of the overalls, it weighs a lot. Generally, people have in mind, because I say so, that's nothing, "ah, they are heroes, they are not sure what." It's nothing. The person is trained, is subject to practical, they have to do it right, I think it seems like pre-hospital service. (N3)

The body and the judgments that are made ​​about it are constantly overlapping ⁽¹⁸⁾ and, indeed, the uniform is, at times, critical to the creation of values that is assigned to the person who wears and also for identity configuration. Considering that their presence is directly related to one's body, it can be considered even an extension of the body of MECS professional. Therefore, it is important to note that the body does not constitute itself in empty materiality, in simple object, however it represents the subject of a culture. It is through their bodily experience that the actors perceive the world and act within it, ie the human expressiveness that is through language has the body as its basis, so that meanings construction passes through, necessarily on it and constitute as a perception and practice field ⁽¹⁹⁾. +

Nevertheless, I believe there are professionals, yes, wearing overalls they think they are superior. But I think there is only the impression of seeing, and have already blocked and they do not even talk. I think it has both sides. Not only is the MECS, but does also have the other side too. (N2)

Accordingly, to this, the perception of the overall as a power device is justified, since the body is not put, in order to be ready and definitive, however it is built on the relationship between the actors, constituting itself socially ⁽¹⁸⁾. Thus, a variety of gadgets may be added to the body and modify its initial social structure. And it is from the encounters and interactions that are consolidated through the body that individuals construct their identity having as reference the other actors.

The individual needs an identity kit for control of their personal look, which would be all the apparatus - clothes, makeup, accessories - involved in the control of their personal look and that are related to the formation of their individuality ⁽²⁰⁾. In MECS, all professionals should wear the uniform, whose main part is the blue overalls with long sleeves. The use of uniform generates a limitation regarding the identity kit of the individual, ie on their ability to control the look and consequently their own identity. This leads to a transfer of personal identity to the institutional identity, which becomes, in fact, necessary as it ensures its differentiation from the other, since their ability to self-identity is minimized because they wear the same clothes, they are transported by similar ambulances, they are not called by their names and neither are distinguished by their professional qualification.

On one hand, by assuming the identity as MECS, the professional assumes the status of an institution recognized by both the population in general as for the provision of health care, which has its image associated with qualified attendance, responsive and involved in highly degree of technology. On the other hand, in situations where faults occur in the working process, they also will not be associated, usually, by general population, who was committed, however the service as a whole.

FINAL CONSIDERATIONS

In MECS work, professionals' relationship play a multidirectional character, since it is a service that provides temporary assistance, ie, it is not the final destination of the person served, but it aims to refer the patient to that destination. Identifying the best destination for the patient may also be understood as an element of constant negotiations and definitions of boundaries, both within the MECS to its relations to the levels of care from the health network services in the municipality.

It may be observed that there is a struggle for supremacy in the context of pre-hospital care, in which there is not, in principle, convergence of efforts in terms of a common goal. There is, in the current structure of the MECS, a constant struggle for territory demarcation involving its own employees, among which there are intense search for space and, also workers from other levels of health care network who have a relationship with MECS workers.

However, we must consider that, for MECS professionals, it is hard to identify and understand the tenuous boundaries between their workspace and the other, since their own space corresponds to the territory of the entire city of Belo Horizonte and trying to delimit it, is another challenge to be faced. Nevertheless, this challenge is maximized by the fragmentation of health services. Thus, what is observed is the maximization of conflicts, which favor individualized actions that undermine the proposed integration of the health system and generate situations that compromise the work environment for health care generally.

With this study, it was possible to understand the widely complexity of the network of power relations that constitutes the MECS, as well as the practical dimensions reached by these relations along the service structure. However, we must consider that, using a case study methodology, the discussions presented here are specifically applied to the MECS of Belo Horizonte, not being amenable to generalization or applicability to other contexts, despite the similarities between the MECS generally because it is a national project.

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Publication Dates

• Publication in this collection
  27 Mar 2013
• Date of issue
  Dec 2012

History

• Received
  19 Mar 2012
• Accepted
  28 Nov 2012