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This is to say, events the subjects considered to have produced changes in the activity system and that represented an innovation by comparison to the actions developed until that moment. Initially, based on annual reports, we selected and classified events in chronological order and according to their similarity, which resulted in categories surveillance, educational and negotiation actions.
Next these actions were analyzed according to the selected theoretical framework, and the ones that led to changes in the structure of the activity system were chosen.
These actions were considered to be historical events. In the construction of the narrative, the development of the targeted activity system was divided into smaller cycles, here denominated subcycles, which were described based on the changes in the object 18 , The main hypothesis of the present study was that a systemic approach to the prevention of accidents leads to the expansion of the object of surveillance, which at an earlier time was limited to the visible risk factors technical aspects , particularly the ones considered in norms, to gradually come to include organizational issues.
Historical analysis of activity systems might help to understand the constitutive elements of the cycles of development and expansive learning, thus providing new perspectives for the future. Surveillance for occupational accidents at companies according to occupational safety and health standards — 1st cycle of expansive learning. OA occurrences were approached as sentinel events 7 , the origins of which were thoroughly investigated and interventions were performed targeting their causes, all according to the causal tree method In the period from to , although the overall goal was to act on the determinants of OA as recommended by VISAT guidelines, the object of the activity system was centered on the attempts to adequate the work conditions at companies to the regulations in force, assuming that compliance with the latter would reduce the occurrence of OA.
For this purpose the companies and sectors with the highest rates of OA were selected and a system of information on OA Instrument was implemented. This analysis allowed identifying the companies that represented a local priority in the terms of OA rate. As a result, this early instrument proved to be poorly practical, especially to trigger surveillance actions for severe and fatal cases, which required prompter intervention.
Introduction of a new program, called WEB CAT, by the Social Security in the beginning of the s, whereby CATs became notified via Internet, did not improve actual surveillance for severe and fatal injuries as was initially expected.
For this reason, CEREST-Piracicaba needed to develop an alternative instrument, a notification and surveillance system of its own, to enable quick and broad-encompassing action and including also accidents occurring in informal labor settings. Implantation of SIVAT-Piracicaba allowed articulating the epidemiological information collected from the emergency and urgent care network with priority-oriented surveillance actions 3. Upgrade of the pilot project 12 to the countywide scale was achieved through a partnership with universities through research projects Community enlargement.
As a result, SIVAT was transformed into a systematic and permanent public policy for surveillance, which operates to this day. SIVAT attained full operation in This is a systematic, continuous-flow program that targets severe and fatal events, as well as the ones involving youths under 18, which are dealt with as sentinel events, thus allowing for intervention at both the original site and at companies with high OA rates so as to meet some of VISAT assumptions 8 , 23 , During the first subcycle subcycle 1.
Considering that similar risks were detected in several companies belonging to one and the same sector, for instance, machines without protection in the baking industry, construction lifts in civil construction, and rotating machines in the paper and paperboard industry, as well as staff limitations Subject limitations , a strategy grounded on collective interventions based on sentinel events was idealized subcycle 1.
Named Cast Net Operation , this strategy allowed for the engagement of companies and their representatives, unions, training agencies, other public agencies, such as the Health Surveillance Agency, LEM and the Labor Prosecutor Office LPO , in sectoral forums, which afforded room for dialogue and articulation of actions Community enlargement.
However, analysis of the agreements implemented along that period shows that the stipulations introduced mostly sought to comply with standarts and addressed risk conditioning factors visible to inspectors Object. The municipal agreement on protection for construction lifts in civil construction, triggered by two deaths involving unprotected lifts, and an agreement with the paper and paperboard industry, triggered by the death of a worker who got caught between the cylinders of a paper drying machine in , are examples of the work performed along that period 8.
Narrowly focused and fragmented action previous Rule was potentiated through inter-institutional articulation, which allowed for community enlargement and commitment, among other aspects. A fruit of a partnership with labor public attorneys from the LPO 15 th region, CEREST- Piracicaba and the 15 th Region Labor Regional General Prosecutor Office signed a Technical Cooperation Agreement 28 , which is crucial to ensure independence and more autonomy to the surveillance agents, especially when their work involves initiatives with greater impact on the more conservative sectors Chart 1 summarizes the main strategies adopted along the first cycle and its outcomes and impacts.
However, the enforcement approach proved to have limited impact, because the rate of OA did not decrease in some of the targeted companies, even after more than year surveillance by unions and basically meeting the legal stipulations This was a highly relevant finding, representing the main contradiction in SIVAT action along the first cycle.
Figure 2 represents SIVAT activity system and the most significant contradictions during the first cycle. The innovations new artifacts, new rules introduced by the staff during the first cycle allowed for the development of SIVAT, as e. However, new developments proved to be necessary to address organizational issues, as is discussed next.
WA surveillance with an eye on work organization — 2nd cycle of expansive learning. Without conceptual tools Instruments to deal with and act on aspects of work organization Object , CEREST-Piracicaba elaborated a project and obtained funds from the Health Ministry, which allowed hiring multidisciplinary staff Subject enlargement and provided resources to deliver a specialization course on ergonomics and ergonomic work analysis — EWA Instrument. The reason is that in its earlier practice, the staff focused on the notion of risk factors, which did not consider organizational issues.
In the classical approaches, embodied in the Brazilian legislation, risk is reduced to the presence or absence of technical or environmental factors and more particularly the visible ones , while their relational nature is not taken into account, and thus cannot be associated to the health problems of workers Inclusion of the aforementioned new approach was a turning point for the activity system, and thus reached the level of critical historical event However, such enlarged object gave rise to tension and triggered, even though empirically, the onset of changes in other elements of the activity system of surveillance; new instruments, new initiatives, new division of labor and new partnerships community enlargement were therefore needed to attain the new object.
A second research project was developed based on ergonomics, which among other goals sought to explain why the rate of accidents had not decreased in the companies subjected to surveillance and that at least partially met the RNs Partnership with universities enabled the actual investigation of six companies based on EWA 33 and MAPA 11 , 34 , which was developed and tested in that study.
Both approaches gradually come to be included in the surveillance toolbox, especially relative to the most complex cases of severe and fatal injuries.
According to the MAPA approach, to understand the origins of an accident it is crucial to first understand the usual work practices, their variability and the strategies adopted by workers. In this way it is possible to make the organizational factors latent conditions become visible, while they remain hidden when conventional tools, such as norm-based inspection, are used.
To reinforce the thus developed methodological instruments, a Work Accidents Forum was launched in as a place for divulgation of the organizational approach, as well as to deconstruct the practice of blaming victims for accidents. The Forum further includes initiatives for continued education, courses, online debates, distribution of videos and news and a Facebook page, among others, so as to develop a social network targeting prevention However, the aforementioned innovations proved to have limitations in the situations to which they were actually applied.
Both MAPA 11 , 34 and EWA 33 are powerful tools to understand the determinants of risks in the work organization by establishing consistent diagnoses. These tools need to be actually employed to stimulate the agency of professionals and organizations by means of a more broadly encompassing social construction.
For this purpose the staff needs to have proper mastery of methods for the design and transformation of the working conditions. Among various possibilities, it is expected that CL might serve as a tool for formative interventions to promote the agency of the internal actors at organizations so as to introduce changes in their activity systems to become more sustainable and healthy.
Inclusion of the VISAT object action on determinants, exposures and consequences into practice stimulated the staff to develop tools and methods to meet the demands in actual practice. Historical analysis including elements of activity theory proved to be consistent to understand the progression of the object of surveillance and its cultural artifacts, which compose the unit of this activity system. Along this process, CEREST-Piracicaba developed more links with universities and the public and private sector, and links and partnership with the mass media were sought for.
Along such development, together with universities subcycle 2. The CL method was selected because it promotes a collaborative environment of learning involving researchers and practitioners and allows for synchronic association and engagement of the internal actors in organizations aiming at understanding contradictions related to ongoing and historical problems, thus enabling the shift to the stage of designing, testing and development of solutions 17 , The diagram in Figure 3 depicts ZDP as a hypothesis explaining the developmental trend of the SIVAT object so as to further develop and innovate its strategies for prevention.
On the horizontal dimension agency , one might notice an expansion from external individual agency auditors, inspectors, external specialists to plural and collective, also including internal agency. On the vertical dimension object nature one might notice a progression from a technical visible and standard-based object toward an object of systemic socio-technical nature.
The diagonal arrow solutions depicts the progression from ready-made external solutions to internal innovations developed by the productive activity actors. Quadrant 1 depicts the traditional inspection action of the state enforcement, which focuses on individual production units company by company. Wider expansion is depicted in quadrant 4, in which in-depth analysis is combined with formative intervention, which might ensure the agency of the internal actors and the formulation of innovative solutions.
The analysis performed shows that the two cycles and subcycles identified are not stagnant, but coexist within a same time and space dimension. The object of prevention calls for the actors to use and appropriate themselves of tools more adequate for the engagement of subjects. However, the traditional health authority tools, as described in the law, lead officials to actions restricted to the aspects ruled by regulations. The efforts to develop the object, however, are hindered by the limitations of the power public agents have to make company actors transform their working conditions, which are increasingly influenced by organization and management modalities deleterious to health.
When power is limited to the observable aspects established in the law, and pathogenic organizational issues are not considered in regulations, might there be any means to sensitize or compel company actors to change? What other alternatives are possible? How to overcome such contradiction? The narrative on the historical development of SIVAT shows that several contradictions were overcome. From the historical point of view, the inclusion of ergonomics and MAPA was associated with changes in how accidents are understood.
Such expansion involved a change in the philosophical perspective, a shift of paradigm that led to understand the object not as an isolated and independent part of a system, but as a systemic or dialectic object, the components of which can only be understood in relation to the whole. This development demanded from CEREST staff a conceptual mastery much beyond the one endowed by the traditional, classic disciplines. The expansion in time and physical space of the object is currently demanding new mediators to deal with the corresponding challenges.
MAPA deals with this side of the expansion of the elements that need to be investigated. The expansion of the object suggests a need to also expand the community. All the aforementioned changes are demands posed by the new object within a cycle that seems to be in its germinal stage. To consolidate the new object, CEREST staff needs to be strengthened and expanded, the autonomy of the agents needs to be reinforced and fortified, which includes the establishment of a typical state career and enlargement of the network involving the community; all of these being essential requirements to ensure the efficiency of occupational health and safety auditing In addition, CEREST staff analytical ability and mastery of tools and methods integrating diagnosis and intervention should be expanded and reinforced, so as to invert the role the internal actors of companies play so that they might shift from informants to protagonists change agents.
Finally, a more democratic and cooperative division of labor needs to be consolidated within CEREST staff itself, with emphasis on shared knowledge not compartmentalized in specialties. The trajectory described in the present article might contribute to reflect on challenges beyond the sphere of local practice.
Indeed, it brings elements to the debates on the need of innovation in public surveillance actions that transcend the healthcare sector. A new object expansion mediated by formative interventions presupposes the strengthening of RENAST links, as well as of other institutions active in this field, as action and intervention targeting organizational issues also presuppose a new network design, a truly encompassing network Cien Saude Colet ; 19