Collective work : a challenge for health management

Based on ergology and work process theorization, the study aims to contribute to refl ections on health collective work, emphasizing its specifi city and diffi culties in building and managing groups of workers. It deals with work as a human activity that dialectically comprises the application of a prescribed protocol and a unique and historical perspective. Health work involves a relationship among individuals who act in the drama of using themselves and manage their own work; it is infl uenced by the history of health professions and macropolitical determinations. In conclusion, this health work complexity needs to be considered in the process of management of professional teams/groups of workers, in a way that actions can interact and enable the implementation of a new health care project in the perspective of comprehensiveness. DESCRIPTORS: Work, organization and administration. Job Satisfaction. Patient Care Team. Health Manpower. Health Services, manpower.


INTRODUCTION
Current forms of work management and organization continue to be predominantly founded on principles that value profi tability and competitiveness to the detriment of subjectivity.If, on the one hand, productivity is increased, on the other, groups of people are broken up and work is separated from life as a whole, thus aggravating work-related pathologies. 3 refl ect over changes in work leads to ethical and political implications.In addition, the relationships and instruments used to produce knowledge and material and non-material products are not separated from value judgments and choices. 10anges in work have occurred throughout the history of humankind under strong economic determination.However, despite process fragmentation and the separation between conception and execution, aggravated with Taylorism and Fordism, groups and individuals have always performed some type of negotiation and management of the relationship between subjective and objective dimension constraints and values. 12us, considering, on the one hand, institutional and personal constraints, and, on the other, health work specifi city in the exercise of professional life, actions are permanently reshaped by individuals' routine choices.As a result, dimensions that surpass the traditional health care model, prescribed by policies, must be considered to change this model.It is necessary to build a process of co-responsibility among professionals, users and managers when defi ning and performing health care, where social control and management are included.
Given this situation, the following questions arise: the meaning of collective work and work team and how these concepts are applied to management of health work groups.
The present study, constructed from ergology and work process theorization, discusses health collective work and characterizes its specifi cities and diffi culties in building and managing groups of workers.

WORK AS HUMAN ACTIVITY: CONTRIBUTIONS OF ERGOLOGY
Considering the fact that work in modern society is becoming more heterogeneous and complex, one promising path is to understand it as human activity.By analyzing work activity/action, an intersection between preceding norms and renormalization attempts in the relationship with the environment can be noticed, where constant debate about values occurs, resulting in choices made by individuals and groups.In the context of work in the strict sense, i.e. a paid activity in the society of market and right, preceding norms are all that anticipates the work activity.Renormalizations result from multiple managements of types of variability that cannot be foreseen, because they are performed by beings and groups that are always unique and in equally unique work situations. 12nagement, in the ergological perspective, is a universal phenomenon that surpasses the macro-political dimension and the prescription of activities and tasks.It involves choices, arbitration, and the establishment of a hierarchy of acts and objectives, in addition to values that guide workers' decision-making in their everyday life.
By discussing the epistemological complexity of the "work" category, Daniellou establishes an analogy with weaving, and affi rms that "in the work activity, women and men weave". 2 The weft would be the technical processes, the properties of matter, the instruments, the clients, the economic policies, the formal rules, and people's control, among other things.The warp would be the individuals' history itself, the body that learns and grows old, the act of belonging to social groups that provide values, knowledge, rules, projects, and anguish, among other things.The weft would be the visible side of work and the warp, the less visible or invisible. 2In addition, the dialectics of the intersection between the visible and the invisible, the global and the local, is permeated by debates about norms and values that will create work situations that are relatively predictable and, at the same time, new and innovative, because all human activity is part of a dimension of transformation. 4 perform a certain work, there is always a prescription that consists in defi ned objectives, rules and procedures associated with the expected results and the way to obtain them.Prescription is carried out by society and the institution, but also by the worker himself and work colleagues, individually and collectively.This prescription is not only what is offi cial, but also what is unoffi cial, the way workers organize themselves to perform what is prescribed or not; and the real work is what is executed and also assessed without certainty, disposed of with sorrow or suffering through an ever present debate about norms.
Work activity "is always a drama of one's use of oneself". 10In this dialectics of one's own use, the worker makes use of himself based on what others demand of him and what he demands of himself, and he also makes use of the others.This game expresses the work group.
One's use by oneself and by others manifests the dimensions of execution and subjectivity; the worker partially gives himself the norms, legislates himself, and recreates knowledge, values and new norms, thus hindering management. 10 understand that what is essential in every type of work may be in the dialectics between weft and warp contributes to reconsider concepts of innovation, routine and resistance to change.Changes must be obtained by workers based on their acquired knowledge, practical knowledge and values. 12 is diffi cult to establish what competences are adequate for work, as exemplifi ed in the area of health, where the object is of great complexity and work situations are diffi cult to be standardized.This occurs mainly because the care process involves a meeting between individuals which is always unique.

COLLECTIVE WORK
In the modern debate about work, Schwartz 11 considers that no human activity can be completely standardized and controlled.Work groups transform themselves, following social, cultural, economic and technological changes, among others, constantly updating the debate about work and use of the collective power.
The prescribed group differs from the real group.Group micro-recomposition around the team enables the work process to be guided, based on reference points and types of logic inherent in the activity where prescriptions are re-appropriated.Schwartz 11 states that, in organizations, work groups, when seeking effi ciency, constitute Entidades Coletivas Relativamente Pertinentes (ECRP -Relatively Pertinent Collective Institutions).They are institutions because people are involved, even though collective borders are invisible are vary according to work activity content and rhythm; people can belong to distinct services and work together as they share values.They are collective because there are several workers seeking effi cacy and sometimes effi ciency in their work.They are pertinent to understand how work unfolds.Finally, they are relative because borders vary, they are formed from work acts, according to people, the need to work together and the history of organizations. 11he ECRP concept contributes to understand the existing cooperation processes when performing an activity, which are different at every moment.By analyzing the micro of the activity, exchanges and actions that weave the collective work relation web can be identifi ed.There are observable and invisible aspects in the groups involved in a formal or informal work activity.The concept of team, often viewed as something stable, is restricted to collective work analysis, because a group is reconstituted according to work requirements. 5sed on a representation of activity, individuals cooperate or challenge each other, and assess what is possible to achieve, with an always unique fi nal composition.To know another's work is a required condition to develop collaboration.Communication, identifi cation of the presence of several forms of logic, and professionals' understanding of the constraints from other professions can contribute to overcome diffi culties in collaboration.Daily management of commitments, whether these are implicit or explicit, can integrate distinct participants' several logics.Building a group is something that depends on the presence of a minimum of stability and a measure of permanence in the organization, because trust and cooperation are built as time passes.Cooperation results from the worker's search for quality of work as a condition to feel pleasure at work and achieve mental health and the construction of their unique identity.
All organizations are permeated by power relationships.In addition, an ethic of responsibility and solidarity is essential to guide actions and build work groups. 11

COLLECTIVE WORK IN HEALTH AND ITS MULTIPLE DIMENSIONS
Health services deal with complex and variable needs and cannot be completely standardized.Professionals need autonomy to translate general norms into particular cases, deciding how and what service to offer to meet specifi c health requirements. 4alth organizations depend on the work of health professionals, but also on other groups of workers who are not health professionals, resulting in a type of heterogeneity that hinders the building of a sense of team. 9t is a context of limited resources and ever changing, multiple, and unlimited requirements.The environment is suitable for confl icts among participants with diverse interests, not always convergent, demanding a constant negotiation process.
To consider all the requirements and needs, in an ethic that involves interests of society and the needs of users and several groups of health workers, has become a great challenge to health service managements.
Health work is marked by the history of professions, which have obtained a defi nition of their domain of particular competences and acts.These, in their turn, infl uence work division and the border between groups.
The complexity of forms of collective work organization, introduced by the capitalist production and its recent changes, as well as the positivist paradigm and biomedicine hegemony, has infl uenced health work.Fragmentation of activities in professional fi elds and the infl uence of scientifi c management in services have resulted in changes associated with autonomy and work process control, characteristic of professions. 9 the health literature, there is consensus, especially about the Brazilian debate on the Sistema Único de Saúde (SUS -Unifi ed Health System), that it is necessary to review the doctor's hegemony in health work and move towards interdisciplinary practices to increase health care quality.
The work of a doctor and remaining health professionals must be conceived as part of a complex and multidetermined whole.Doctor-centered work has been appointed as a paradox, once it has contributed not only to maintain a user-uncompromised and procedure-based health care model, but also to construct new forms of acting in health. 6 the case of Brazil, recent changes indicate possibilities of more collaborative practices with a positive impact on health care results: the establishment of the SUS and investment in the Programa Saúde da Família (PSF -Family Health Program) as a health care model restructuring strategy; the Ministries of Health and Education's promotion of curriculum changes; interdisciplinary team building experiences, where a certain reduction in medical corporate infl uence and greater value of the practices of several health professionals are observed.
Health work mainly occurs in cooperative and multiprofessional collective work, but usually through fragmented actions, where each technical area is responsible for part of the activity. 9e work of a multiprofessional health team is a collective type of work marked by a reciprocal relationship between multiple technical interventions and the interaction of different professionals. 8However, multiprofessionalism has not provided adequate answers to the complexity of health care demands. 13his prescribed team is an important element, but its defi nition is insuffi cient to understand the exchanges among people to perform an activity and make it more effective. 11The work activity of a team is permanently integrated with other services and teams.There is a somewhat informal relationship network which is built in the collective work. 5n health work, according to its nature, activities are permanently distinguished, especially in direct care actions aimed at users, hindering the application of prescriptions, and thus promoting organization of ECRPs.These, in their turn, are manifested in all gestures, initiatives and relationships that occur, without being formalized in the organogram, and which will enable techniques and procedures to have some effi cacy. 11 the development of the work activity, the professional seeks those with whom they can share values and choices and in whom they can trust, and who will contribute to meet a certain health need, seeking effi cacy.
A work process based on comprehensiveness, intersectorality and interdisciplinarity principles broadens interconnections to be managed and poses new diffi culties and challenges in the sphere of competences.In this sense, the concepts of Field (knowledge common to several professions) and Nucleus (specifi c knowledge of each profession), suggested by Campos, 1 are useful to integrate the need for multi-skills and that for specialization, and also to deal with autonomy and defi nition of responsibilities.
Management is an important element that can enable multi-skills, mutual help and exchanges that are not condemned to semi-secrecy, but rather promoted by organograms and management that are sensitive to the requirements of continuous renormalization and fl exibility. 11alth is an activity of great complexity that involves questions related to life and death and which has health and disease in their social sphere as intervention object. 7his reality generates the need for several forms of knowledge and practices to deal with individuals who have unique stories of life, "who have feelings and interests, who participate in groups and are socially integrated, thus enabling them to be given distinct possibilities of falling ill and having access to treatment". 9 a way, there is always something unknown in health work, and in care prescription.Each project will arouse cooperation and confl icts among professionals, when defi ning key problems, as well as the resources and means to resolve them.Knowledge acquired during the qualifi cation process is necessary to act in this situation, even though this is not enough.The organizational and professional context raises the following question: How to advance in the sense of a project that requires fl exibility, humility, and the building of fi elds of knowledge?
Health work is constantly permeated by multi-and inter-disciplinarities, according to the problems faced, the demands arisen and the need for resolution.Does the type of practice depend on the complexity of the problem or demand?Do simple problems not require interdisciplinary interventions?There is urgency for effi cacy and effi ciency, and to achieve such, the professional or the team, which one depending on the situation, will seek resources from other specialties or not.However, this effi cacy and effi ciency will be judged by the professional himself, his colleagues and the user.

FINAL CONSIDERATIONS
In conclusion, work process and ergology theorization states that to know work requires knowing the subjects and the context of work.Work organization, when specifying posts, competences, qualifications, and the relationships among people, implicitly produces a model and an effect about which individuals understand and think about themselves.When the organization tells the workers that they must conform to what is prescribed, it restricts forms of knowledge that could raise questions to identify problems associated with work as place and moment of effi cacy production.
Ergology does not neglect macro-political and economic constraints and determinations, but adds that, in the exercise of daily activities, workers manage themselves and their relationship with other participants of work groups.They take prescribed norms into consideration and weave, between the weft and the warp, permanent renormalizations.
Despite inner and outer restrictions on work performance, it is the worker who develops and sustains the action project, in health institutions, in the group and in daily practice.In addition, as in the case of health, the work object is another concrete individual who infl uences, in a dialectic relationship, the work process of professionals.
The main diffi culties in health work management are associated with the following: the relationship between individuals and groups; the history of health professions and their exercise in the sphere of institutionalized collective work; the complexity of the political and economic game that restricts the sphere of work situations; the individuals' choices; and the fact that work management is performed by individuals and groups in the routine of health services.
Health workers are subjects of work processes that bring them closer to and move them away from the belief that a new health care project, which has care comprehensiveness as its framework, is possible.In addition, to build a new project requires becoming a change agent.