A Política Nacional de Humanização como política que se faz no processo de trabalho em saúde

La Política Nacional de Humanización como política que se hace en el proceso de trabajo en salud

Serafim Barbosa Santos Filho^I; Maria Elizabeth Barros de Barros^II; Rafael da Silveira Gomes^III

^IMinistério da Saúde, Política Nacional de Humanização (MS/PNH). Rua Gonçalves Dias, 60/901, Lourdes, Belo Horizonte, MG, Brasil. 30.140-090 <serafimsantos@terra.com.br>
^IIDepartamento de Psicologia, Universidade Federal do Espírito Santo ]]> ^IIIMS/PNH

Translated by Philip Sidney Pacheco Badiz
Translation from Interface - Comunicação, Saúde, Educação, Botucatu, v.13, supl. 1, p. 603 - 613, 2009.

ABSTRACT

This paper aims to conduct an analytical exercise detailing how the National Humanization Policy is undertaken regarding the role of institutional support, based on different mechanisms, directives and principles. The text is divided into three parts: the first provides reflections concerning the concepts of humanness and humanism on which the analyses are based; the second seeks to expand the debate regarding the inseparability of healthcare and management and the means of providing institutional support; while the third discusses the inseparability between the production of services and the production of subjects and furthers the discussion on these three parts so they unfold in other planes of analysis. Throughout the text, emphasis is placed on the inclusion of different subjects and the analysis and collective management of work processes as a strategy for creating productive destabilization and humanization practices within the healthcare services.

Keywords: Humanization of attendance. Institutional support. Co-management. Collective work process analysis. Public policies

RESUMO

Este artigo tem como objetivo realizar um exercício analítico do modo de fazer da Política Nacional de Humanização (PNH) sobre a função apoio institucional, com base em diferentes dispositivos, diretrizes e princípios. O texto está dividido em três partes: na primeira, traz reflexões acerca da concepção de humano e humanismo que fundamenta as análises; a segunda busca ampliar o debate sobre a indissociabilidade entre atenção e gestão e o modo de fazer apoio institucional; a terceira aborda a indissociabilidade entre a produção de serviços e produção de sujeitos, e encaminha a discussão dessas três partes que se desdobram em outros planos de análise. Ressalta, em todo o texto, a aposta na inclusão dos diferentes sujeitos e na análise e gestão coletiva dos processos de trabalho como estratégia para criar desestabilizações produtivas e práticas de humanização dos serviços de Saúde.

RESUMEN

El presente artículo tiene como objetivo hacer un ejercicio analítico del modo de hacer de la Política Nacional de Humanización, sobre la función apoyo institucional, con base en diferentes dispositivos, directrices y principios. El texto está dividido en tres partes. En la primera, trae reflexiones acerca de la concepción de humano y del humanismo que fundamenta los análisis. La segunda busca ampliar el debate sobre la inseparabilidad entre atención y gestión y el modo de hacer apoyo institucional. La tercera plantea la noción de inseparabilidad entre la producción de servicios y la producción de sujetos y encamina la discusión de estas tres partes que se desdoblan en otros planos de análisis. Resalta en todo el texto la apuesta en la inclusión de los diferentes sujetos y en el análisis y gestión colectiva de los procesos de trabajo como estrategia para crear desestabilizaciones productivas y prácticas de humanización de los servicios de salud.

Palabras clave: Humanización de la atención. Apoyo institucional. Co-gestión. Análisis colectiva de los procesos de trabajo. Políticas públicas.

INTRODUCTION

This article arises from guided reflection on concrete experiences that we have had as consultants of the National Humanization Policy (Política Nacional de Humanização, NHP) and as workers in the field of the formation of health professionals. The questions and discussions covered in the text emerged and are permeated by these practices, by our actions of institutional support¹ and by training experiences that we have developed both within and outside of this policy. In this article, we propose to articulate the referentials of the NHP with some aspects of work processes in health, placing their analysis into perspective in a dialogue with the methodological approach of this policy. Thus, we strive to reflect on questions concerning the contribution of the NHP, with regards to the discussion of work processes and the organization of healthcare services.

The NHP is constituted as a "policy" based on a set of principles and directives that operate through devices² (Brasil, 2006, 2004). In principle, we understand what drives actions, triggering changes in position in terms of public policy. In the case of NHP, the displacement that is proposed involves changes in the models of care and management grounded in biomedical rationality (fragmented, hierarchical, disease focused and hospital care). It is established as public health policy based on the following principles: the inseparability of clinical practice and politics, which implies the inseparability of care and management of production processes of health; and transversality, understood as an increasing degree of open communication within and between groups; i.e., expansion of the forms of intra- and intergroup connection, promoting changes in healthcare practices (Passos, 2006).

The directives of the NHP are its general guidelines and are expressed in the method of including users, workers and managers in the management of healthcare services, through practices such as: expanding clinical services, the co-management of services, the valuation of work, reception and the protection of user's rights, among others. The devices, in turn, update these guidelines through collective strategies constructed in concrete collectives designed to promote changes in patterns of care and ongoing management, wherever such models are at odds with what the Brazilian National Health Service (Sistema Único de Saúde, SUS) recommends. Among the devices proposed by the NHP are: reception with risk rating, Administration Committee, open visits and right to a companion, transdisciplinary reference team, the Training Program in Health and Work (Programa de Formação em Saúde e Trabalho, PFST), projects for co-managed environments. The implementation of these devices are applied on a case by case basis, considering the specificity of the services, always initiating with an analysis of work processes, processes that are never repeated. The NHP maintains within its sphere, the articulation of a set of referentials and tools, working with these to instigate processes.

In this article, we affirm the NHP as the contribution and articulation of a set of referentials and instruments, which aim to be central to the work processes, in the displacement of their constitution, seeking to assist in disrupting their arrangements and producing deviations in the established relationships, instigating new compositions, other possibilities of being and working within the field of healthcare. What matters in this analytical administration of work processes, inseparable from the prospect of intervention, is to empower other ways of working that emerge routinely within these services, beginning with that which is experienced by the worker.

Confrontation involving that which is established occurs constantly through the invention of other forms of acting in the workspaces, through the incessant production of knowledge achieved during working activity, but often this confrontation is made invisible or weakened. Thus, analyzing work processes is not dissociated from the perspective of intervention, since it encourages and empowers displacements, deviations and ruptures that suggest transforming the ways of working and being in the workplace. Work processes are processes for the production of subjects, since human and world realities are not ready-made, constituted a priori, the work process is the constitution of subjects. It is in accordance with this premise that we invite reflection regarding the uses of the devices of the NHP.

What can the NHP do? What is its disruptive power? What naturalization forces can make us succumb to "this is how it should be"? These questions force us to think about what has been done to update the principles and directives of the policy in the routine practice of healthcare services. With this objective, the text is divided into certain subitems. Within these, we present ideas concerning the concepts of humanness and humanism, on which we base our analysis and actions of that which has been formulated by the NHP. We seek to broaden the debate regarding the inseparability between care and management and the means of providing institutional support within the sphere of the NHP. We also focus on the inseparability between the production of services and the production of subjects and advance the discussion of these aspects so that they unfold in other planes of analysis, presenting a way to intervene and to support institutional dialogue with referentials we have selected for this discussion.

Among the referentials that permeate the discussion are: the concepts brought by Campos (2006, 2003, 2000, 1998, 1997) to the field of Health Management, as well as certain works applied within the sphere of the NHP by Benevides and Passos (2005), Barros Mori and Bastos (2006), Brasil (2006), Heckert and Nevis (2007), Barros and Santos Filho (2007), Campos (2007) and Santos Filho (2008).

The concept of humanness: an alternative humanism appears…

The NHP indicates a concept of human which is constituted in concrete experiences, in daily struggles and an ethical-political direction that juxtaposes "the human" against "a human", all of us, trying to resist what it conceives as "the ideal human". Thus, the concept of human within which it works undermines "the human" as abstraction, model or ideality in which human existence is inserted (Benevides & Passos, 2005). It is, therefore, a concept of human that arises from the forms of being that are constituted in the concrete experiences of services. A form of being human that is not something that has always been or something defined by a general model of humanity. Consequently, it is not part of an understanding of humanization as a process that aims to bring together the different subjects of this ideal, the human standard.

Humanization, as outlined in the NHP, is put into effect in health practices by these very practices; i.e., from the ways individuals act in routine services. It is directed toward ordinary men and women who make up the SUS, through their experiences with the workers and users who live and produce day-to-day healthcare services. It is in the encounter between these concrete subjects, situated, that the humanization policy is constructed.

From this referential, the principle of work in services focuses on that which contributes to deidealizing the concept of humanness and humanism, as well as "idealized services". In this case, the goal is not be confused with an overall goal to change the service, but rather to enable an understanding of how to establish a service and a process of work in healthcare. A service and a process, always performed by "humans", subjects in a constant process of differentiation, producing new modes of existence, processes that destabilize institutionalized forms of being a worker and experiment with others. So, how has a mode of being human in healthcare services been constructed? Surely this will depend on the attributes with which are proposed to understand humanness and the processes of humanization.

Regarding the NHP, this principle is operationalized by exposing services to analysis, observing within them and through them, with those who comprise and inhabit the same, what founds their modes of constitution, the different ways of being and acting in the SUS. It is our understanding that the NHP does not propose a specific type of service, an ideal SUS, but neither is an "anything goes" approach desirable. It commits to an approach in which collectives within the SUS are invited to analyze the different services and ways of acting in them. Thus, it is intended to institute other modes of action in healthcare that possess, as an ethical-political commitment, the defense of life, based on values like autonomy and leadership that construct the SUS (Brasil, 2006).

Institutional support is a methodological strategy to deal with the numerous challenges that working in the health field poses, since, as Campos (2003, p.86) states, healthcare workers:

[...] deal with human limitation, with our powerlessness, with the evidence that we are not gods [...]. They deal with death, disease and pain. Working in hazardous environments (germs, failures, competition, etc.); thus, besides career and salary plans, they need Support, which has the quality of always being under review. This is a function that is expressed in a particular way of doing that is not located in an individual and pursues the creation of groupality in order to strengthen and build networks of collectives.

Institutional support, in the sense attributed to it by the NHP, establishes a dynamic relationship between the institutional supporter and the team supported: it is neither an attitude of passivity or inaction (on behalf of the supporters), nor of actions in the absence of groups or the elaboration of opinions, plans or protocols and standards for the teams. Rather it is a support for co-management that is intended to affirm and incite the production of organized collectives. The function of the institutional supporter is to contribute to the management and organization of work processes, in the construction of collective spaces where groups analyze, define tasks and elaborate intervention projects.

Support, therefore, involves the discussion-problematization of the ways management is expressed in labor relations. Consequently, this support work is affirmed based on an essential prerequisite: the refusal of any form of guardianship. Support, according to the NHP, is being together with the different subjects that constitute the health system - managers, users and workers - discussing and analyzing the work processes and intervening in the ways services are organized, empowering those who work and use services as protagonists and sharing responsibility for the production of health, combating any relationship of guardianship or delegitimization of the other.

To what extent has this been achieved? To what extent has this type of activity enabled the quality of care for the users and the reorganization of work processes in the direction of effectively shared management? Here, surely, we are not looking for answers. The construction of modes that affirm the principles of the SUS in its radicalism need to sustain these questions, which seek to assert the constituent aspect of the SUS.

On the trail of the premise of the inseparability of care and management…

Beginning with that which the NHP adopts as principle, namely, the inseparability of care and management (Brasil, 2006), the proposal is to contribute to a means of collectively discussing and constructing strategies to improve access to and the quality of services, defined as inseparable from the ways these are managed. In this context, the goal of the NHP is not to be confused with a goal of ensuring access and quality of care based on concepts and resolutions external to the services. On the contrary, its objective is to assist the organized collectives in the production and coordination of arrangements, agreements and concrete actions, capable of assuring changes in management, indispensible for changes in the modes of attendance (Campos, 2003).

And how is this achieved? How do you put into effect the operation of this principle? Conversation circles, collective spaces that include the different actors of the services, are one of the ways believed to be powerful for embracing and expanding such discussions. However, what aggregates, more incisively and distinctly, is the intensity and quality of institutional support, which is applied in the midst of the processes and which materializes by helping to analyze the work processes.

This proposed path opposes and differs from strategies based on prescribing rules for the implementation of a device, which is incompatible with the very concept of the device with which the NHP functions. The path is the assertion of a participatory approach that allows the collectives to attribute meanings, to make and sustain connections in and of the work process. Again we would emphasize the mode of being, of operating, of acting "amidst ", of being together, of intervening... (Barros et al., 2007; Barros & Benevides, 2007; Barros, Mori, Bastos, 2006).

The device of "Reception with Risk Classification" illustrates this well: the institutional interest, the project, the goal and sometimes even the "decrees" by which this device has been implanted in services, seems to assume a natural reorganization of the team to improve the user's attendance, as if this was intrinsic to the proposal. Without dedicating attention and strategies to putting this reorganization into effect - as if it were possible to consider the service extraneous to the network in which this takes place, isolated from other production practices of healthcare and independent of those who work in it - the device turns into an instrument to be implemented, losing its power to transform the practices.

The considerations raised here lead us to another scenario of issues concerning the effective exercise of the know-how of the NHP. Know-how in construction and, therefore, remaining open to constant questioning: to what extent has this know-how of the NHP achieved its ethical-political-methodological proposal? To what extent has this type of action-intervention, within an evaluative perspective, been able to expand coverage of the actions and the quality of care as indicators of the effects produced by this intervention? To what extent has it achieved this kind of support? Extrapolating from the above questions, we contend that the proposal is to serve and help local collectives to strengthen themselves to partake in these discussions and articulate the components of the work process (arrangements, pacts, actions, among others).

Highlighting one aspect: within the NHP, the question is not to occupy either extreme of the discussion, nor be influenced by the pressures of results, nor even the idealization of a harmonious way of working, which is applied from abstract perspectives, detached from what is effectively happening in the day-to-day running of services. It is about the challenge of constructing and occupying the place of demanding analysis, of questioning one's own work and doing this within the collective spaces where the inclusion of the actors, workers, managers and users is essential. As noted at the beginning of this text, the question is to regard the plan of the production of services and subjects as a strategic plan, since it seeks to monitor a process and not just represent a given reality.

On the trail of the premise of the inseparability of the production services and the production of subjects

The sphere of inseparability allows us to recover an axis that the NHP has established as one of its pillars, focused on what is happening "in the midst of work processes". The principle in this case, is to contribute to provoking the mobilization of health workers on the issue of analysis and intervention in their local work processes. Here, inseparability must be pursued in the context of work in healthcare that needs to be expanded and articulated in a threefold manner: the production of services, production sustaining the organization and the production of subjects (Campos, 2003). Within its sphere, the NHP assumes convening workers to look at their work processes, analyzing them as an historical process instituted by those who compose them (workers, managers and users). Therefore, it is a process that can be modified by the mobilization of these same actors. Mobilization that would bring with it a perspective of leadership, the (re)invention of work, producing services and producing themselves, reinventing themselves as subjects (Santos Filho, Barros, 2007).

The operationalization of this principle has been a challenge and we address this issue further, dialoging with certain referentials that help mark the specificity of this intervention.

By working conditions, we understand a larger structure-organization, highlighting that which has been denominated the precarization of work in healthcare, from issues related to labor ties to the degradation of environments and processes in their everyday dimension, in the work routine. The most visible local reactions in the midst of these conditions appear as the immobilization of workers, permeated by disbelief, apathy, anger, pathogenic suffering, pain, displeasure, illness.

A contradiction that we want to emphasize here that it is often witnessed within the daily exercise of healthcare services: at the same time that changes are proposed and demanded, including discourses promoting the autonomy and leadership of workers in their teams, attempts are often made to restrict concrete spaces for the exercise of autonomy and leadership. One such "concrete space" is the sphere of local planning and evaluation, of definition and validation of targets in the work processes, which should be explored in a collective, participatory way, in the local reality.

Another situation that we wish to highlight is the prerogative of "teamwork"; on many occasions, this becomes not a form of "connection" - of knowledge, power and affects (Campos, 2006, 2000) - but a "burden" experienced by workers, since the understanding of "teamwork" is fragile and the creation of multidisciplinary teams has not overcome the fragmentation manifest in everyday actions of the services. It remains present in the dissociation of the procedures and duties of each profession and the relationship between workers from different backgrounds (Gomes et al., 2005). In other words, from a formative perspective, the required strategies are not mobilized to reinvent the work, reinventing themselves as workers articulated in work teams, overcoming divisions produced and maintained by knowledge-power relationships and the asymmetries between professional associations. It is worth emphasizing that the local management style is one of the variables that contributes most in this context.

Following this premise, the direction of intervention that seems in tune with what we are suggesting is to provoke an "effect in the groups", encouraging and supporting the analysis of situations encountered in pursuit of the change in positions and attitudes given all the facts. Taking this methodological axis as one of the underlying principles of the NHP, adversity and the position of the subjects-workers are considered as an analyzer³ of management, that which questions what is established and points to its constitutional process, always historical. Thus, we ask: what concept of management is operating in this methodological path?

A concept of work and management: a methodological way or modes of achieving institutional support

In line with that proposed in this text, initiating from the dialogue with the NHP, we still believe it relevant to treat the issue by assuming a concept of work and management that opens to the following areas: a) understanding that work is the production-invention of services, products, the individual and the world (Schwartz, 2007) and that in the work process, the connection constructed is that of relationships between the actors who inhabit the services, among workers and with managers and users; b) understanding that working in healthcare is an area par excellence of this production of services and subjects (autonomy, leadership) (Campos, 2006, 2003, 2000); c) understanding that work in healthcare is knowledge production, a continuous learning process, and that such training is applied in the experience of concrete situations of work, "becoming competent" to meet the demands and creating strategies for this (including learning to work in a team).

Zarifian (2001) understands competency as attitudes, positions, actions and learning that constitute the subject of confrontation with what is presented in the work situations they experience. The author believes that "[...] one of the most interesting and innovative characteristics of the logic of competency lies precisely in the fact that it involves personal accountability and responsibility, [relating to the posture of] taking responsibility, the prospect of autonomy (Zarifian apud Santos Filho, 2008, p.25).

In this sense, this view of competency can be correlated with what an individual expects from the NHP, which is the increased autonomy and leadership of the subjects (Brazil, 2006), increased capacity for analysis and intervention of subjects in the context in which they live and find themselves (Campos, 2006, 2003, 2000). Such competency, therefore, does not refer to an individual or a quality innate to that individual; it always refers to the collective work and is developed in the encounter between subjects. It is this living experience, the exercise of competency, with the assumption of responsibility for coping with a situation, which is equivalent to leadership, an autonomous, emancipatory attitude.

From this guiding principle, the workspace is understood as co-constructed by the actors who are on stage and each is manager of their own making (Schwartz, 2000), taking into account that all activity involves negotiations and discussions of standards to be achieved. Thus, it is always necessary to manage the infidelities that the medium presents, since all those who work do so leaving their mark (their principals) to the extent they are making-learning and learning by doing.

The process of local work, thus, is not limited to what is embodied in products or what is visible, rather, as Clot outlines (2006, p.116), it also includes "[...] what is not done , what cannot be done, what is attempted without success - the failures - that which you would want to or be able to do, that which you think or dream you could do elsewhere [...]" and also "[...] what is done to avoid doing what has to be done or what is done without wanting to" (Clot, 2006, p.116).

The activity of work is always marked by the dramatic relationship between autonomy and heteronomy. We always work in the midst of negotiations, choices and arbitrations, not always consciously, which considers not only the type of insertion of each individual and everyone who shares that working environment, but also health policies, established values and practices of healthcare, relations of forces and powers in each work situation. We all share responsibility for managing work situations and have the potential to help transform them or maintain them as is.

Thus we consider that the direction proposed for institutional support in the NHP is involved in helping to understand that destabilization is part of work processes and the path is mobilization to provoke other and new destabilizations. In other words, understanding that, contrary to ideally conceiving work processes as "expected balance", it is necessary to analyze and manage the imbalances. These imbalances compose the living experience, hence the importance of understanding them as powerful, when the goal is the production of collective strengths, which can trigger modes of work that affirm the very invention of the living. Therefore, the concepts of Humanness and Humanism are very important here, as indicated at the beginning of this text, since the destabilizations are provoked and pursued, or denied, depending on the collective effort (coresponsibility) toward an understanding and desire to achieve the "humanization of the service", at a given historical moment.

This is the challenge that the NHP advocates must be included as work material and it is with this material that we intend to operate. This is not neutralizing the displacements that emerge in daily work in order to start working, but rather dealing with all of this, expecting transformations that alter positions, that produce other forms of subjectivity and modes of subjectification. The production of health is not disarticulated from the production of subjects. This is one specificity of institutional support/NHP (Brasil, 2006).

The methodological strategies used excel in situating this discussion within the sphere of management: both in the sense of how we understand the insertion of subjects in the work (in which all work activity mobilizes them for different levels of management of their activities and knowledge), but also in the sense of managing the work processes as a collective challenge, as co-management. What does this "choice-direction" bring to the challenge? That of shifting the discussion of "precarization", "dissatisfaction", "tiredness" and "illness" in work to the field of collective analysis of the work itself. This means displacing or overcoming the pole which traditionally hosts this discussion, reducing it to the sphere of "treatment" (of the cases, the problems, the patients, absenteeism, dismissal, etc) and of "sanitization" of the environments. Therefore, the changes that are desirable are put into effect in and based on the ongoing management processes.

The role of institutional support is, thus, permeated by a provocation of the collective exercise of regulation, in the manner in which we understand this logic, which permits adjustment of the foreseen (norms, rules, goals etc.), the needs and ways of the subjects, with interests and demands, based on a power of invention in their own lives (Santos Filho, 2008). And it is this act of adjustment that the NHP discerns as emancipation. This is where we can more specifically indicate leadership and autonomy in the organization and reinvention of self, of the teams and the provision of services.

Focus on the "process of humanizing work": the necessary inclusion of users and workers/managers

Frequently, we witness in health services, certain situations that are expressed from the fragmentation of actions and a feeling of isolation-loneliness at work. Such situations indicate the difficulty of putting teamwork into effect (Santos Filho, 2007a). Fragmentation of work occurs in the midst of a contradiction that is expressed in the clash between new models of care-management, which presuppose work processes based on dialogue and a culture of vertical communication and management style that does not foster moments for communication-analysis of action, thus also impairing innovation in the sphere of attendance of the user.

Thus, guided lateral communication as a valuable field in the debate concerning the humanization of healthcare services, as an indispensible component for the affirmation of attendance-management inseparability, seems important to us. In this context, the organization of the work process must always be thought of as dialogical and polyphonic, in which multiple voices and ways of seeing are under discussion and negotiation.

Thus, the proposals of the NHP, taken here as challenges, are placed under analysis. To what extent have these interventions been realized? What clues help us assess the effects of this way of working? Has care been taken in dimensioning the scope of these interventions? In what way? With what referential and with what instruments? (Santos Filho, 2007b).

Such questions, of course, call for the construction of paths that help broaden the debate regarding the inseparability between care and management, the way of achieving institutional support proposed by the NHP and the evaluative strategies that can help dimension the work of the institutional support offered.

The inseparability between the production of services and production of subjects leads to the affirmation: commitment to the inclusion of different subjects and the analysis and collective management of work processes is an important strategy for the production of practical and productive destabilizations of the humanization of healthcare services that are focused on the work processes.

COLLABORATORS

The authors worked together at all stages of the production of the manuscript.

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1 The notion of institutional support will be developed throughout the text. ]]> 2 The concept of precept used in the PNH, based on Foucault's formulation, places the established under analysis and seeks the destabilization of that which is assumed as natural.
3 We use the notion of analyzer based on the proposition of Institutional Analysis, "The analyzers are events, that which produces ruptures, which catalyzes fluxes, which produces analysis, which decomposes. In the course of this review, new arrangements are imposed, passing from virtual immobility to movement and transformations occur " (Silva, 2002, p.36).