Continuing Health Education: an interprofessional and affective policy

This study aimed to reflect on interprofessionality as a dimension of the nature of Continuing Health Education (EPS), as a process that involves professionals learning about others, with others, and among themselves, from their encounters. As a result, it addressed two dimensions: Continuing Education in Primary Health Care: a meeting place; and Continuing Health Education and the circular affections. These reflections pointed out that ways of producing knowledge associated with the power of health teams can be thought of in the daily life of health practices, making encounters between subjects a tool enabling group collaboration and improved resolution of problems in the daily health work. Finally, the centrality of the dynamics of affections and interprofessionality in EPS meetings in the ESF is affirmed as a field of body relationships in a micropolitical process of transformation and education in action.


Introduction
The National Continuing Education Policy (PNEPS) was an initiative of the Secretariat for the Management of Work and Education in Health (SGTES) of the Ministry of Health (MS) in 2003.Its normative framework for the inclusion of the topic in the agenda government in the field of health is the enactment of Ordinance GM/MS Nº 198 of February 13, 2004 1 and, later, Ordinance GM/MS Nº 1.996 of August 20, 2007 2 , which gave the policy the proposal of new guidelines.
Among other initiatives, the PNEPS is an effort to comply with Law Nº 8.080/90 regarding the responsibility in the education of workers by establishing teaching-service and teaching-health care relationships, besides organic relationships between education and management, institutional development and social control in Brazilian health 2 .
This policy also proposes to review the training process under the aegis of the Unified Health System (SUS) to the detriment of adopting historically established conventional education models.Thus, the PNEPS cannot be considered a pedagogical tool or a teaching method but a complex system that begins with the health work process with the teams in the services, integrating different stakeholders in this discussion process -an interprofessional education policy.
According to Freire et al. 3 , interprofessional education is one in which members of two or more professions learn together to work together interactively and collaboratively to meet increasingly complex health needs.Some of the principles of interprofessionality are teamwork, debating professional roles, and negotiation in decision-making.
This complex health field also requires a shifting arrangement in the educational policy to produce interaction in/with everyday life under macro and micro-political interfaces.These interfaces are defined as different ways of governing health policies, sliding between formal and informal actions in health services 4 .Such macro and micropolitical sliding of the EPS can be expressed by norms, rules, ordinances, agendas, programs, protocols, financing forms, and dialogue in action between professionals and users, during a meeting, during work intervals and breaks, in the agreements and negotiations that underpin the daily work of health services -in short, in meetings 4 .An encounter is understood in Spinoza 5 as a (material or immaterial) body union underlying a mutually affective relationship.
As a policy that seeks to mobilize relationships and affections between the subjects involved in the care process in the territories, PNEPS actions analyze the process and how we produce health based on Continuing Health Education (EPS) meetings.
EPS can be understood as a learning-work process.In other words, it occurs in the daily lives of people and health services 2 .Therefore, EPS' nature is summoning professionals to the meeting based on exchanging knowledge and experiences.However, this 'meeting place' is not something simple, natural, and given with the circumscription of meeting space, since the development of the EPS is not performed with a people gathering or in a delimited space to be formative, nor only with dynamics of professional education and, much less, from office-idealized teamwork.
EPS, therefore, takes place in all spaces favorable to its effects and involves the authentic capacity of mobilizing groups in their socializing spaces.However, these spaces can be hegemonically occupied by workers who operate under the biological paradigm, whose behavior is hardly prone to changes resulting from relational dynamics, centering the work on a professional core 6 .
Thus, a challenge to the EPS practice is focusing on pedagogical processes that cause a shift of professional practice fragmented into disciplines to a collaborative and integrated practice, which transcends the dynamics experienced in uniprofessional practice, advancing to the domain of work from an affective and relational and, therefore, interprofessional logic.
As a policy that articulates the macro and micro-political dimensions, the EPS points, then, to an interprofessional experience permeated by the interactions of the professionals composing the teams between the levels of involvement of the workers, in which collaboration is fundamental in guaranteeing better quality health services to meet individual and community health needs 7,8 .
Given the above, we should highlight that the complex nature of the health field overly challenges professionals in the daily health practices in the Family Health Strategy (ESF) as they experience demotivating working ways that affect socialization between workers and the quality of care provided to the public.As a result, this essay aims to reflect on interprofessionality as a dimension of EPS' nature as a process that involves professionals learning about others, with others, and among themselves, from the meetings.
Thus, daily scenes were created to reflect on the importance of interprofessionality as a dimension of EPS, whose analysis axis was exercising interprofessionality and its micropolitical effects in the light of Baruch Espinosa's theoretical framework.Selecting the ESF as a reflection setting was due to the complexity of the care undertaken at this point of care and because it was an academic and professional work context of the authors.

Continuing Education in Primary Health Care: a meeting place
What would be the 'meeting place' from the perspective of EPS?A room?An auditorium?A meeting?A course?Not necessarily.The meeting place is where the possibility of analyzing the work process occurs, as a way of being at work in which workers from different professions are open, through the circulation of affections, to collective engagement for the resolution and discussion of their typical everyday issues.
The ESF is a lively place to provide meetings of this quality insofar as the work involves acting in the dynamics of the complexity and diversity of people's daily lives.The multiple situations and health demands involved in the work of the ESF (nothing basic or primary) require the mobilization of workers' sensitivities and an intensely creative and inventive exercise -projecting their previously acquired knowledge.
Another fundamental challenge facing the reality of the ESF in Brazil has been the working conditions and structures, which tend to produce mechanical and naturalized actions of crystallized professional practices and procedures, guided by the accumulation of tasks and the production of emergencies 9 .The accumulation of tasks in the contemporary world of work has also been the cause and effect of the need for ongoing training, in which the perception of a professional always lacking in knowledge persists 10 .
At the same time, the production of emergencies, resulting from the constant acceleration of daily demands, which require immediate actions, has also contributed to an extensive process of institutionalization of work structures linked to performance, profitability, and competence from the perspective of productive efficiency.
As a result, relationships and encounters have been increasingly hasty, superficial, and without solidarity, alienating a profound work of collective engagement and causing strong individualized actions and difficulty for workers to process analyses about their implications, who, guilty and feeling obliged to solve all the problems alone, start to carry all the solutions on their shoulders.
Contrary to the production of omnipotent subjectivities, always lacking, blamed, marked by anguish, fear of failure, and a sense of permanent fragility 9 -which unfold in individualistic, omnipotent, and arrogant behaviors -the PNEPS intends to point to another process of knowing-doing in health.Adopting community engagement to allow the collective construction of solutions by sharing experiences is also a movement of shared responsibility for producing other types of subjectivities in the EPS process.
However, what should an EPS dynamic be like to produce the expected effects?Next, we present two hypothetical scenes, considering the ESF's operationalization of the EPS in a given daily routine.

Scenes of Continuing Health Education in a Family Health Strategy
In the municipality of Jardim das Flores (fictitious name) was an ESF unit in the Paraíso district managed by the Social Health Organization (OSS), a type of management of SUS health services in partnership with the municipal secretariat.The OSS operated under the logic of evaluation and pay-per-performance and sought to improve quality through standardization and managerial rationality.In this unit, the team consisted of a unit manager, doctors, nurses, nursing technicians, a dentist, an oral health technician, Community Health Workers (ACS), a receptionist, and a General Services Assistant (ASG).From this ESF unit, one can reflect on the following two scenes: Scene 1: the ESF manager scheduled a continuing education meeting with the doctors and nurses to discuss the actions to address COVID-19 in the territory.Much pressured by the OSS regarding the health secretariat's goals to be achieved by the unit, she follows the meeting with previous protocols about the management and care of patients with the disease and still uses a roadmap containing all the goals established for the month.The discourse is well delimited in its slides (standardized by the area management).The auditorium is prepared with rowed chairs and audiovisual resources.The meeting time was predetermined to be one hour long to avoid interfering with the service's progress.
The positions among the workers are clearly defined: the manager occupies the (unique) place of institutional discourse in a position to inform data from the secretariat; workers are divided by professional categories and in a position to receive the orders of the day and transform them into daily actions.When transmitting the information to the workers, the manager reproduced a very harsh statement from the health secretariat that they (the ESF workers) were not reaching the pre-established goals.This situation produced great discontent among those present, as the demands were not sensitive to the intense work reality.A heated argument ensued.The meeting ended abruptly, and the workers left sad.The manager left the meeting feeling guilty and obligated to solve all the problems alone.
Scene 2: Simultaneously with the EPS meeting with the doctors and nurses, we had three ACS, a dentist, a unit receptionist, a nursing technician, and an ASG in the kitchen, talking while having a cup of coffee.The conversation was good, with laughter and complaints.Each one brought a snack and shared the table and their lives.During the conversation, an ACS shared with the team the need for greater attention to older adults in the territory who were depressed because of the social distancing caused by the pandemic.Thus, informally, they talked about the meaning of depression and its impact on the life of an older adult.The idea of building a virtual music circle through the Instagram social network emerged from this conversation, as some workers revealed they knew how to sing and play musical instruments.The ASG would be the singer, the ACS would play the guitar, and the nursing technician would play the violin.The dentist would be filming the circle.The other ACS would help the older adults connect to Instagram so they could watch the circle on their cell phones from within their homes.Others ideas emerged from this one, including the support of a psychologist, inviting them to a virtual consultation if they wished.In this informal cafe, they discussed the work and found collective solutions for the problems presented.
Given Scene 1, can we say that the meeting entitled 'EPS' was a place for meetings and work discussion?When analyzing the scene, it is worth claiming the need to rethink the training processes of the health worker within the ESF from the perspective of the EPS.It is worth noting that the scene is not intended to blame the manager but reveals the system and machinery she is a part of.Thus, the complexity involved in the work in the ESF is not limited to continuing education (transmission of information without discussing reality) and verticalized practices (coming from the management to the health services), and that somehow produce the capture of the workers' sensitive and creative forces, favoring the adoption of mechanical, automatic and less reflective work.
This, therefore, is a point that deserves to be highlighted.The ESF's prerogative is transforming the existing biomedical care model through innovations in providing care and managing health services.However, there is still a particular mismatch in this mission due to excessive goals, norms, vertical orders, and bureaucracies inducing workers to operate by goals, making them prisoners of their disciplinary bars without space to question the collective work process.In other words, being in a group of people means something other than that the work is being analyzed by everyone who participates in it.This fact makes workers act in the ESF from the perspective of what they 'must' do instead of envisioning what they indeed 'can' do.
Being disconnected and away from what can be done means that the ability to act is inert, immobilized, fixed in dead and instrumental work that subsumes living work, producing a certain dehumanization in the work process 11 .Therefore, there are also changes in the care model proposed by health policies by placing the ESF as a central device for the adoption of other management and care modes.Therefore, it is necessary to impact the core; that is, the concentration of knowledge and professional practices for the effectiveness of EPS 6 .
The predominance of an educational model that shapes the worker's body addresses a teleological formation that fixes knowledge as universal, consistently utilitarian, and transcendent, disconnected from the dynamism of everyday life.Based on the so-called continuing education (content transmitter), this type of job qualification disputes the hegemony of worker training in ESF settings.
We could attribute to continuing education movements a force that comes from outside, which exerts in the workers' body the idea of a 'duty' 12 , constraining them in their creative ability.These constraints derive from wrong ideas about learning since they consider knowledge hierarchies as smaller or larger, more important or less important.In this context, workers suffer because hierarchization is how power operates its subjectivation.Education is sad, and work is impotent if the rigid format of educational processes is not open to the immanent forces of the encounter.As a result, workers lose interest and embody a pragmatic modus operandi of the profession, doing only what they are determined to do.In this sense, knowledge is recognized, not produced.It is what has already been said, concluded, thought, and uninteresting.This finalized knowledge has an economic and utilitarian function that seeks to save time and effort and avoid errors in the name of efficiency.However, doing so makes the exercise of (self ) reflection unnecessary.A transmitting education, from those who know to those who do not know, whose strength teaches to learn without having to think, makes interprofessionality extremely challenging due to the devaluation of the other's knowledge, considering it as lesser knowledge.Contrary to this perspective, we can say that, for EPS, learning is not a process of acquiring knowledge but producing life, encounters, intensities, and subjectivities at work 13 .
Returning to Scene 2, there was clear EPS, regardless of physical spaces and so-called educational activities.EPS can occur in WhatsApp groups, on the way to home visits, during coffee, and outside institutional spaces, such as at a bar table.Thus, this reflection dismantles the idea that a very well-structured institutional arrangement is necessary to have EPS -as in team meetings in which professionals do not discuss daily life.We may be surprised to realize that, in a formal meeting, there is no space for collective reflection on the work process, only the transmission of information in management-preset packages.Nevertheless, we can have spontaneous and unscheduled encounters that are spaces for relationships, affections, and interprofessional learning 14 .
Thus, the meeting place speaks of the collective construction of spaces that increase the possibilities of affecting and being affected and, therefore, of producing knowledge from experience in the field of work in the ESF.Affections can promote agencies of joy and increase the capacity of these workers to act and know 12 .Thus, knowledge production and the production of experiences share the same nature 15 .The more workers are exposed to encounters, the more knowledge they will have.The more the experiences, the greater the possibility of expanding thought and capacity for action.In the Spinozian logic, it would be the same as saying: I only think because I affect myself.By affect, the author understands affections (the body being affected by the world), by which the power to act is increased ( joy) or decreased (sadness) 12 .In this sense, affection is a power of being since Spinoza considers the forces that strive to maintain themselves in existence as power 12 .From this perspective, knowledge is not something transcendent but immanent -it does not come from outside but from within, in the forces of affection that occur in the relationship with the other.
The meeting between workers in the EPS logic is an increase in the power/strength of doing and knowing.The more the body is exposed to encounters with other workers, the greater the ability to perceive and understand the reality of work, and the more the mind will express its ideas and propose actions.
Thus, the field of (self )reflection is frayed by analyzing feelings, perceptions, actions, and events hitherto considered harmful and strange, as deviations and errors that would prevent successful health actions 9 .Workers are special powers that can compose a collective power/force 16 .
In other words, work in the ESF is a power/ strength issue.The more free workers have spaces at work to think, the greater their ability to act.In this sense, the EPS must be the place of the invention that operates the problems differently from the logic of continuing education (transmitter), to which work serves as the prescription machine for appropriate behaviors in the face of knowledge mutilated by the division of professional disciplines 17 .
The invention of problems or problematization 17 is an effective way of producing group reflection; that is, it is an encounter that occurs with the thoughts of the other.It is, therefore, a sign not yet thought of, which, according to Gabioneta 18 , we could call Maieutic; that is, it is the intellectual parturition produced by an estrangement that forces workers to think and be affected in this meeting.The production of knowledge and other health care practices occurs in the 'between', in the intersection of knowledge 19 .

Continuing Health Education and the circularity of affections
In health, it is not uncommon to hear that affection gets in the way and interferes with the exercise of the profession.Phrases such as 'I cannot be affected by the problems of the other, because then I will be neutral in the care' or 'when I put on my lab coat, I leave my problems outside' are part of the daily work in health.
The denial of human affectivity is not something new.With the advent of modernity and the scientific revolution, affections have been conceived as biases, imperfect, and something to be purged to make way for the so-called 'scientific neutrality'.Taken as scientific truth, this 'neutrality' is the founding architecture of health professions.
To this end, we were educated to master and control care.Thus, we had to understand that affection is something to be contained, repressed, and silenced at times, understood as something unusual that transcends human nature 12 .From another perspective, affection is considered a body affection, through which a subject's power to act can be increased or decreased, differing from the common sense that circumscribes the sphere of feelings, tenderness, passions, and warmth 12 .
This matter is of interest to the EPS since the affections circulating in groups of ESF workers are ways the potency varies from one state to another.The more meeting spaces are produced, the more influential the work will be, and the fewer possibilities for the circulation of affections, the more significant the weakening of workers in what they can do 12 .
Returning to scenes (1 and 2) previously presented, we can see that every encounter produces affections that can be of joy or sadness.By joy, we understand it is a passion that the mind traverses toward greater perfection 12 .A good encounter increases intrinsic strength; however, a lousy one curbs the power of thinking and acting and weakens interprofessional work.The question that arises here is not the production of just happy encounters, as happened in scene 2, but that the ESF team understands the effects of affections on the body without immobilizing them.Do they increase or decrease action power?Understanding how affections circulate and act can be a powerful analyzer for EPS since affective dynamics can enhance the ability to act and think about health.
Thus, scene 2 shows an EPS meeting whose joy affect could be perceived when the bodies collided; that is, the joy affect occurred because one body entered into a composition with the properties of the other, thus increasing the collective conatus; that is, strength to exist and act, affect and be affected 12 .
To this end, what would a worker in a happy state be?A powerful body?A happy body is one capable of many things.Yes, the joy generated by the encounter produces a state of greater potency at work.Joy raises the possibility of learning and derives the affections of love, satisfaction, contentment, and freedom, which are fundamental to work in the ESF.
Love says about the ability of workers to establish a good relationship with their peers and users, and underpins what we call bonding.Contentment speaks of a specific ability to generate internalized joy; lasting joy is necessary to preserve care longitudinality 20 .Satisfaction makes work more resolute.Finally, freedom fosters the ability to create and invent new ways of caring from the comprehensiveness perspective.
Therefore, through EPS, we can shift from the logic of a vicious circle of sad affections in health work to the virtuous circle through joy.As a result, there is an urgent need to invert the constitutive forces of health education: from the impotence of sadness to joy power, from a weakened conatus (diminished strength to exist and act and affect and be affected) to a strong one (increased strength to exist and act and affect and be affected) 12 , which cements interprofessionality in group work.
Thus, joy affection in the EPS is political; that is, it can enhance the ability to affect and be affected by relationships, expanding the scope of possible resources for adequate care.What can a cheerful body do?It can join with other bodies and invent collective solutions to complex ESF problems, as seen in Scene 2.
Otherwise, as in scene 1, when work and training processes shrink power, sadness prevails, and conatus decreases.The possibility of interprofessionality is weakened, and group work tends to be configured into a technical and hierarchical division.The sadness' affect occurs with a declining body acting strength 11 .
What is a sad worker?Would it be an impotent body?Sadness is also a political affect, as it can weaken bodies and actions 11 .Sadness is a lousy encounter: a decomposed relationship that has produced a domestication and control policy in workers' training.Sadnessbased education cannot result in joy.It does not produce nor will it teach -and it is weak knowledge when it does.
When sadness circulates in the ESF spaces, it produces a lesser power in the workers' bodies and a lesser way of thinking and acting, reverberating in a declining capacity to experiment and produce sensitive openings, exposing people to erratic experiences.When we observe Scene 1, we recognize the affections that derive from it, such as melancholy (disposition to sadness), hatred, servitude, and fear.Work that operates in sadness makes workers adapt worse to complex situations and isolate themselves in their disciplinary bars, making them more susceptible to internalized rules, competition, and work structured into goals and productivity.
This situation means that opening the way to joy and freedom at work and seeking recognition of the sad affections that circulate in the professional environment can be a tool for building the collective conatus 12 , and that requires the production of other educational qualities.Learning is no longer seen as a process of acquiring a given knowledge but also as producing life, encounters, and intensities 21 .

Final considerations
Discussing the PNEPS is more than just about intellectual capacities, innovative methodologies, and information or new knowledge transmission.It is also to debate the forces that traverse education and health spaces.
We know that we were and are formed from specific rationalities that underpin movements of mortification of affections (ways of affecting and being affected), lowering collective encounters and reducing the possibilities of group work among workers -as proposed by the principle of interprofessionality.
As a result, the contrast of the two analyzed scenes facilitated the understanding that the power of encounters structures the EPS.Furthermore, these meetings must be thought out and taken care of from the perspective of valuing productive and educational interactivity that expands the collective conatus.Thus, thinking about EPS also says how to organize and create spaces that increase the community's possibility and capacity to affect and be affected, thus increasing the ESF team's action potential in producing knowledge adequate to daily contingencies.
Establishing 'meeting places' dispenses with the sensitivity and understanding of professionals about the importance of circular affections as a principle for interprofessionality and EPS.Furthermore, based on this assumption, understanding how affections circulate in action is paramount for operationalizing the PNEPS in the SUS.In this sense, the EPS is an interprofessional and affective policy.