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\title{Positive and Limiting Aspects in the Work of Health Professionals in Prison Units}
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\begin{document}

             \author[1]{Laura Andrian  Leal}

             \author[2]{Lana Jocasta de Souza  Brito}

             \author[3]{Lucieli Dias Pedreschi  Chaves}

             \author[4]{Cleria  Braganca}

             \author[5]{Silvia Helena  Henriques}

             \affil[1]{  University of São Paulo}

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\date{\small \em Received: 10 December 2019 Accepted: 4 January 2020 Published: 15 January 2020}

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\begin{abstract}
        


This study aims to analyze the positive and limiting aspects in the work of health professionals in federal prison units. This is a descriptive exploratory qualitative study. The information was collected through semi-structured interviews with professionals from federal prison units, between the months of June and October 2018. The positive aspects related to work found in the results were: salary recognition and job stability; good interpersonal relationships with colleagues in the workplace; low activity demand in prison units; flexible work hours; and provision of adequate physical and material resources. The limiting aspects are: lack of professional recognition and appreciation; divergence between work performed and professional activity; violence, fear and appearance of health problems at work.

\end{abstract}


\keywords{health professionals, prisons, worker?s health.}

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\section[{Introduction}]{Introduction}\par
razil is the fourth country in the world with the largest contingent of imprisoned people. It has about 607,731 prisoners, behind only the United States, China and Russia, respectively \hyperref[b0]{1} . Statistically, the North American country is the world leader in incarceration, with nearly over 2.3 million prisoners \hyperref[b1]{2} . Thus, in order to assist the health needs of this big population of prisoners in the various prison realities, there are support health teams within these penal institutions or close to them.\par
It is also known that in these scenarios the rate of appearance of illnesses is higher than in the reality outside the prison walls due to various conditions, such as: closed and unhealthy environments, overcrowding, presence of communicable diseases, people confined with various mental disorders, and chemical dependency, among others. These aspects call attention to the importance of the role of health professionals, because the people who interact in this space are more vulnerable to the transmission of diseases \hyperref[b2]{3} .\par
In this sense, the greater demand and need for health services by this population is explained by this series of predisposing characteristics of reclusion. The context of socioeconomic, educational and cultural vulnerabilities to which most of these individuals in custody are subjected before imprisonment is also noteworthy \hyperref[b3]{4} . In a survey of newly admitted prisoners in Italy, 67.5\% entered the system with at least one chronic illness. The most frequent pathologies were of psychiatric (41.3\%), digestive (14.5\%) and infectious (11.5\%) nature \hyperref[b4]{5} .\par
However, despite the high number of prisons and workers, there are still few studies on working conditions in prisons \hyperref[b5]{6} , especially with regard to the work of health teams in these places. When the researches approach health workers in prisons, they bring the reality of state establishments, not federal.\par
In this sense, the following question arises: What are the positive and limiting aspects in the work of health professionals carried out in federal prison units?\par
This study should provoke reflections in managers and professionals as to the identification of "gaps" in their work process, and also elucidate factors that can interfere with personal and professional growth in this environment, supporting practices and/or interventions appropriate to this context. Still, it is highlighted that rethinking the work process of these professionals within a specific context and identifying the gaps between their training and the requirements of the planned activities are relevant factors for their health, as well as for the society/population that benefits from their services.\par
Thus, the present research study aimed to identify the positive aspects pointed out by health workers in federal prisons, as well as the limiting and/or negative aspects perceived by them. 
\section[{II.}]{II.} 
\section[{Methods}]{Methods}\par
Descriptive exploratory study with a qualitative approach. The study scenarios were four federal maximum security prisons in Brazil. This choice is justified by the fact that at the time of collection only these four prisons were in full operation, with prisoners and workers, custody and assistance. Each unit had a capacity of 208 prisoners, with similar architectural configurations between the four units. These prisons III. 
\section[{Results and Discussion}]{Results and Discussion}\par
The final sample consisted of 22 health workers who worked in Brazilian federal prisons, 16 (72\%) female and 6 (28\%) male. Most of the participating professionals (63.3\%) were in the age group between 31 and 40 years, 4 (18.3\%) belonged to the younger age group, between 25 and 30 years of age, while 4 (18.3\%) were more than 40 years old. Regarding the professional category, 14 workers (63.6\%) had higher education: 6 nurses, 3 dentists, 2 pharmacists; 1 occupational therapist, 1 social worker, and 1 psychologist. Eight (36.3\%) are middle-level workers, 7 were nursing technicians and 1 was dental assistant.\par
Regarding time elapsed after graduation and work experience, 16 (72\%) had graduated more than ten years ago and had already worked in other health institutions. Regarding the time in the prison, 11 (50\%) of the workers had worked in the prison for less than five years. 
\section[{Positive aspects in the work of health professionals}]{Positive aspects in the work of health professionals}\par
In the interpretative synthesis of the speeches, the following aspects emerged: salary; stability in the public service; interpersonal relationships in the context of work in the health sector; low activity demand; flexible working hours for nursing workers and adequate physical and material infrastructure.\par
Salary remuneration was identified as an incentive within the organization, as it was associated with a lower possibility of accumulating working hours aiming at a better salary gain, as shown in the speech: Job satisfaction is the result of several aspects related to the individual and the work environment. Lack of appreciation of work and low salary, for example, have been pointed out as some of the causes of dissatisfaction, which affect not only the professional's life, but also the health care provided \hyperref[b8]{9} . Besides the issue of remuneration, stability in the public service is a positive factor for workers in the face of the uncertainty of the country's economic and rising levels of unemployment:A\par
The positive aspects are I am a public servant, I have financial stability, independence. The fact that it was a public tender. The country is in crisis, so stability is very good. (I 3 )\par
In the last decades, instabilities and uncertainties in the field of private work have shown another object of increasing search on the part of workers: the guarantee of job stability through public tenders \hyperref[b9]{10} . It can be said that the feeling of job stability, the perceived labor benefits and the compatibility between the salary and the activities performed are very have facilities where health care specialists (with higher education) and technicians work.\par
The study population was composed of specialized professionals (higher education level) and technicians (high school level with technical training). The first group consisted of physicians (at the time of preparing this project, no professional had assumed the position in this category, and there were two vacancies for the position in each unit), three pharmacists, 12 nurses, seven psychologists, seven dentists, four occupational therapists, and five social workers. The second group consisted of 15 nursing technicians and four dental assistants.\par
The inclusion criteria were: health workers of both sexes, who had worked in the system for more than six months (for the period of experience in the system), with a workload of 40 hours, either on duty (in the case of nurses and nursing technicians) or in usual working hours (other health workers).\par
The number of respondents was defined by the data saturation criterion \hyperref[b6]{7} , with the final sample consisting of 22 professionals. Data collection took place from June to October 2018 and was made through a semi-structured interview with a script containing closed questions for the characterization of participants and open questions regarding the positive and limiting aspects of the work.\par
The interviews lasted an average of thirty minutes, were held in a place chosen by the interviewees and outside the work environment. They were recorded and later transcribed by the researcher. In addition, in order to preserve anonymity, the participants were identified with the letter I for Interviewees, followed by the number of the interview.\par
Inductive content analysis was used to interpret the data in this study. To this end, the thematic analysis method was chosen and followed the steps: transcription and reading of the data; coding of interesting characteristics of the data in a systematic way throughout the data set; search for themes using grouping codes; review of topics where it was verified whether they responded to the coded statements; ongoing analysis to perfect the specificities of each theme; and final analysis of the selected excerpts related to the guiding questions of the research and the literature, producing an academic report of the analysis \hyperref[b7]{8} . This study was approved by the Research Ethics Committee of the proposing institution (CAAE: 89987718.5.0000.5393). The research was developed in accordance with the Resolution of the National Health Council number 466/2012. All subjects in the study had their rights ensured by the signature of the Informed Consent Form. relevant aspects for the accomplishment of the worker, even in a custody environment.\par
Still, the participants revealed as a positive aspect, the interpersonal relationship in the work context.\par
What gives me pleasure is the interaction with colleagues, who became friends. Also the fact that we are a multiprofessional team, I've learned a lot during this time, with the different careers and professions. (I 6 )\par
A good relationship between workers and companionship among the team members contribute to pleasure at work and minimization of conflicts, which when present, make the work exhausting and bring suffering. Companionship promotes an environment for the exchange of experiences and learning \hyperref[b10]{11} . Another positive aspect reported was the demand for activities to be carried out during the working day, which does not seem to burden the workers:\par
The work itself, the technical work, is not so exhausting, you know... Compared to a hospital or basic health unit, we see far fewer patients here.(I 15 )\par
At the health clinic I used to see many more patients, but here [prison] the demand for work and care is much lower than in the public service in general so I can do the procedures with calm, take my time (I 14 )\par
It is known that the excessive demand for activities is an obstacle in health institutions, especially public ones, because it impairs the quality of the care provided, being a reason for stress for professionals, managers and patients, who do not find adequate circumstances of care, thus favoring conflicts between all the involved people \hyperref[b11]{12} . In this sense, it is worth mentioning that the lower demand for care possibly occurs due to the restricted movement of prisoners in the units' facilities, since they are always taken by security agents and also because the federal prisons have a relatively small and controllable population. 
\section[{I make the appointments, but for them to happen I depend on the availability of security agents to bring and accompany the prisoner in the health (...) and the population is small compared to the area of a family health program, there are 200 prisoners at most(I 15 )}]{I make the appointments, but for them to happen I depend on the availability of security agents to bring and accompany the prisoner in the health (...) and the population is small compared to the area of a family health program, there are 200 prisoners at most(I 15 )}\par
As it is a place of maximum security you depend a lot on security agents to make the service. You have to wait for him to bring the prisoner to you; you can't go there in the room to make the consultation(I 10 )\par
Another positive point reported is the possibility of working 40 hours a week, either on a usual working day (8 hours daily) or on duty (24-hour shifts and 72 hours of rest) \hyperref[b12]{13} . This facilitating aspect is viewed positively, as it allows for a more adequate balance between work and leisure activities:\par
On-call duty schedule is 24 hours of work for 72 hours of rest, so the schedule allows for a good time off. (I 15 ) This possibility of working hours is provided for all positions within federal prison units, but in practice, only security officers (federal prison officers) and the nursing staff can choose to work on the base of on-duty shifts. The other specialists and technicians work on a daily basis and in direct contact with prisoners \hyperref[b13]{14} . In the view of the management of the units, only nursing care is characterized as emergency and this justifies the need for night shifts. As for the assistance of other health professionals, in the organizational view, treatment can be elective.\par
The infrastructure of the prison units was also described as adequate:\par
The infrastructure of the unit is adequate, there is an airy, clean, and aesthetically good space, I have nothing to complain about, you know, compared to other types of services, it is very good. (I 20 )\par
The unit is always clean, the spaces are large, the room has air conditioning, a pantry for employees with a refrigerator, microwave, sink, so it's very good, I think it's favorable. (I 4 )\par
When the company offers good working conditions, the level of satisfaction among workers is maximized, increasing productivity and work commitment  {\ref 15} . Sufficient and quality material resources also contribute to higher yield and productivity. However, this characteristic of the prison environment is specific to the federal level; the same cannot be said about the reality of state environments which, many times, do not receive the same investment and physical/material input compared to those prisons administered by the Government. 
\section[{Limiting aspects in the work of health professionals}]{Limiting aspects in the work of health professionals}\par
Limiting aspects of the work were related to the lack of professional recognition and appreciation; divergence between work performed and professional activity; violence, fear and appearance of illnesses at work.\par
The lack of recognition was associated with a limiting aspect caused by the devaluation of the work by non-health professionals, by society and even by the assisted prison population: 
\section[{I don't feel recognized for the work I do inside the prison, and this is very complicated because nobody recognizes you or knows what you really do (I 4 )}]{I don't feel recognized for the work I do inside the prison, and this is very complicated because nobody recognizes you or knows what you really do (I 4 )}\par
Recognition is only because you are a federal employee. So this recognition, when it comes, it is because we go through economic crises in the country and you are a federal employee earning a certain salary.(I 6 )\par
The process of valuing the worker partly materializes with the recognition of what is done at work. This recognition is not restricted to longing for work, but is materialized as a decisive aspect in the subjective, creative and intelligent mobilization at work 16 . Thus, it is clear that society recognizes health professionals working in prisons only because they are civil servants, individuals who took a contest, were approved in a selection with high competition and, finally, got a stable job before the unstable economic situation in which the Brazilian population is inserted.\par
Health professionals also feel devalued by coworkers who are from different areas of health:\par
Our work is very discriminated because society and security agents think that we are there to be friends with prisoners, they do not understand what we do in our service. (I 13 ) It was noticed that the way of thinking shared by most people, that the prisoners do not "deserve" assistance or that the prison should be a place destined only for confinement, is also common among prison workers, especially among those responsible for custody and surveillance. These professionals are unaware of the importance of the health work as a way of consolidating the citizenship of the incarcerated population and are unable to appreciate the extent of the benefits of this work for all workers and for society.\par
Another important point is that the prisoners themselves are not aware of the care provided by health professionals, not recognizing the work of the team that assists them and this causes a feeling of devaluation in the worker. 
\section[{On part of the prisoners, there is no recognition. You are a good professional only when you do what they want, when you give them the medicine they ask, but from the moment you say no and disagree with the diagnosis, they see you with bad eyes.(I 10 )}]{On part of the prisoners, there is no recognition. You are a good professional only when you do what they want, when you give them the medicine they ask, but from the moment you say no and disagree with the diagnosis, they see you with bad eyes.(I 10 )}\par
Recognition is understood as the symbolic retribution to the workers for the judgment of their actions, being essential for the construction of professional identity, promoting health and pleasure in the work \hyperref[b16]{17} . Thus, the assisted body is also unaware of health work. This is partly due to the difficulty of promoting health actions in their entirety in prison settings and partly due to the limited level of education of the prisoners themselves.\par
The professionals also reported that the health work performed inside prison units differs greatly from what was learned during graduation or from what is recommended in the legislation of each of the professional categories, which can be considered a limiting aspect of the work. 
\section[{You are impaired by the environment, by security, by the system, which determines much of what you have to do, which is different from what is in the law. It differs a lot from what I learned in college. (I 4 )}]{You are impaired by the environment, by security, by the system, which determines much of what you have to do, which is different from what is in the law. It differs a lot from what I learned in college. (I 4 )}\par
Health care for incarcerated individuals faces difficulties in practice due to local specificities, the socioeconomic conditions of the units and of the community in which it operates, and problems such as tension and lack of human resources \hyperref[b18]{18} .\par
Security is another major factor in these environments. The entire structure reinforces the closed and surveilled institute. Prison officers end up exercising the role of regulating access to health. Sometimes, it is up to them to judge whether a request for assistance to the prisoner is necessary or not, or when it is safer to do it \hyperref[b2]{3} . According to the report, it can be seen that health care is mediated by security, resulting in a lack of freedom and autonomy to carry out health care services. 
\section[{We cannot plan and carry out any action, even if it is inherent to our profession, without depending on authorization from other people who are not related or have knowledge of health (in this case, prison officers).(I 17 )}]{We cannot plan and carry out any action, even if it is inherent to our profession, without depending on authorization from other people who are not related or have knowledge of health (in this case, prison officers).(I 17 )}\par
The lack of autonomy influences the quality of life of workers because it prevents them to exercise individual skills, affecting their commitment to work, satisfaction and, consequently, productivity \hyperref[b20]{19} . In a study carried out in Ireland with nurses, autonomy at work was considered to be the most important indicator of job satisfaction \hyperref[b15]{16} . In this sense, organizations with many hierarchical, bureaucratic authorities, without autonomy and lack of specific organizational goals, which are often more present in public sector organizations, can have a negative influence on professional satisfaction \hyperref[b21]{20} . Another limiting factor that differs from the theoretical-practical content taught in college and that it is a phenomenon already present in health establishments and also in prisons is the lack of human resources, which also limits the work of these professionals:\par
The absence of a doctor is a great limitation for the role of the pharmacist and the nurse, because there are certain situations that require a doctor. (I 4 )\par
The insufficient number of nurses of the sector compared to technicians in the unit. That is why there is this error of shifts when there are only technicians, without the supervision of a nurse. (I 20 ) Due to the circumstances previously reported, health professionals are practically obliged to carry out activities that go beyond their legal attributions. The speeches revealed a lack of workers from some professional categories, which ends up preventing the performance of some health activities recommended by law and taught in training centers.\par
The lack of physicians in federal prisons is in line with the reality of Brazilian public health services, which, in general, face difficulties because of lack of physicians resulting from the poor territorial distribution of these professionals and the absence of educational processes and trainers of physicians concerned with the Still, it is necessary to highlight that the characteristics of the environment and the assisted population can limit the working praxis, differing from what was learned in academic training and throughout professional experience.\par
The issue of the public we provide care. There, I can't be the professional I am outside, in terms of contact with the patient, being comfortable while providing care. I am constantly on watch, watching around, I am always attentive to my posture. This for me is a limiting factor in my professional performance. (I 10 )\par
The prison system that we recognize by common sense and by the media is a failed structure that is unable to offer socio-structural conditions to make inmates return to live in society. Furthermore, the primordial character of security that causes many actions aimed at resocialization encounter obstacles to its effectiveness \hyperref[b23]{22} .\par
Ideologically, it is expected that the prison environment help people "recovering" in a context that is not conducive to this recovery, since there are several aspects that disadvantage human dignity and coexistence. Therefore, the occurrence of murders, rebellions, drug use, rape, and so forth is common in these places. Due to all these characteristics, the system is often recognized as a "school of crime", because some individuals enter there for small crimes and, within the prison, they come together, reorganize and strengthen criminality and criminal factions \hyperref[b25]{23} .\par
Due to these characteristics, the professionals feel fear and insecurity about having a more spontaneous relationship or creating bonds with the assisted person, because in the daily experience it is necessary to care for individuals and at the same time maintain a certain distance required by the context. So, caring for prisoners is marked by moral, ethical and social dilemmas that require the workers to give a new meaning to the place of work and the way of seeing the ones who live there. New responses to these work demands are imposed, which results in gaps between academic training and work experience \hyperref[b26]{24} .\par
In this sense, there is another limiting aspect that concerns violence and fear. Due to their insertion in a workplace that has characteristics that conduce to violent actions, health professionals feel very afraid within the prison environment, during care sessions with prisoners.\par
We have to take care with the physical approach to the patient, because we never know when we may suffer violence [...] we are constantly watching out so as not to leave any instrument within reach of the prisoner, all the time on alert. (I 1 )\par
The work performed in prison can also have an impact on the safety of health workers outside prison borders, also causing fear. Workers fear for their lives and that of their families:\par
Fear of being killed by the bandits or suffering an attack, torture, kidnapping... I am very afraid of being executed in front of my children, as it is very dangerous (I 5 )\par
In view of the above, fear, violence and insecurities of multi-causal origin in these work environments can cause adverse reactions in workers, generating illness resulting from the work itself.\par
We have had cases of suicides with a small group of servants in a short period of time... Three suicides in a span of five years... this is serious, and the majority of them were on leave due to psychological reasons.(I 6 )\par
After a long time exposed to professional activities in precarious, unhealthy or hazardous environments, the workers experience the incongruity between their work capacity and the high psychological demand for work, generating mental overload that worsens their mental health conditions. This happens in the prison system, which, because of its organizational and structural specificities, tends to generate suffering and illness among professionals \hyperref[b27]{25} .\par
In this perspective, some measures, such as psychological monitoring, were suggested by workers. They reported how the agency should act in the case of occupational illness: I think that there should be a post-trauma health monitoring with the workers, to take care of this issue and not to leave it to people to take care of it as an individual thing, it would be important. (I 6 )\par
In critical environments, the professionals need to strengthen their mental protection mechanisms. Many of them resort to therapies and psychological treatment \hyperref[b10]{11} . Thus, the diseases are the responsibility of the management of these prisons too, since the illnesses that affect the health worker in federal prisons are directly linked to institutional issues arising from the activities performed in these places.\par
In this environment of limiting aspects, health workers also mentioned the adoption strategies to protect themselves physically and psychologically. The individual strategies adopted were alertness and social isolation. This behavior, of constant alertness and expectation of the worst, frequently generates anxiety and psychic exhaustion. Work within a prison requires this sensory sharpening that can cause physical illness, stress and burnout, for example \hyperref[b28]{26} . According to the reports, this is a behavior that is required even outside the workplace. Professionals also become socially isolated. Involvement with other people and other environments promotes physical and mental health for people. Such interactions may be useful to mitigate depressive conditions and inhibit harmful or selfdestructive behaviors such as suicide, as it acts as a protective mechanism for social control and emotional support 27 . Therefore, social contact is very important for any individual.\par
Other strategies, not personal, but of an institutional nature, mentioned by the interviewees are the flexibility of working hours for all health professionals, not only nurses, as currently occurs.\par
We have been asking for this flexibility for a long time and they do not authorize it, and it upsets us a lot, but they don't change. We go to work every day at the same time, this is terrible for me and it exposes me a lot, because I live in a very small city, we are super stressed going back and forth at the same times. We have to go every day, being easy prey for bandits outside the prison to follow and monitor our routine.(I 13 )\par
The respondents believed that on-call work makes their schedules less predictable than daily work, making their routines more unpredictable for bandits outside linked to factions inside the the prison.\par
It is important to consider that, in health work carried out in prisons, the personal safety of the team that provides care to prisoners should be considered when working conditions are discussed. It is necessary to invest in the safety of these workers, because the constant experience in an unstable and insecure work environment overloads individuals and causes several illnesses \hyperref[b20]{19} .\par
This study has as a limitation the fact that it was carried out only in federal prison units and with health workers. It is suggested that further studies be developed including other workers and the managers of these institutions, in addition to expanding the investigation to state prisons. 
\section[{IV.}]{IV.} 
\section[{Final Considerations}]{Final Considerations}\par
The discussion about the positive and limiting aspects of health work in Brazilian federal prisons made it possible to listen to these professionals and to identify the limitations and possibilities to improve their work in these places. It became evident that relations with peers, stability and salary contribute positively, being considered stimulating factors for the professionals. The lack of professional recognition and appreciation, the divergence between the work performed and the professional activity, the violence, fear and illness at work were aspects expressed as aggravating factors that hindered the work in the service.\par
In this sense, it is essential that managers offer workshops regularly among health workers and prison security personnel to demystify and sensitize custody workers about health care actions, and also provide spaces for talking and listening between managers and workers. Investment in human resources and teamwork is necessary to minimize situations of conflicts and illnesses resulting from violence such as moral harassment, sexist behavior and the depreciation of the female figure.\par
Adequate size of the health personnel is essential to avoid extrapolation of the limits of the exercise of each profession when they have to overcome the gaps in human resources within the team. Some other possibilities presented by the interviewees were the need to expand the flexibility of schedules for all professional categories, in addition to professional psychological support.\par
The promotion of a positive work environment results in a greater possibility of well-being and mental health for professionals, which in turn promotes job satisfaction and better assistance to the imprisoned population.  		 		\backmatter  			  				\begin{bibitemlist}{1}
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