Conflict mediation in SUS as a transformative political action

Luciana Parisi Jandira Maciel da Silva About the authors

ABSTRACT

This research aimed to analyze mediation processes in labor disputes, within the public institution and manager of the Unified Health System of Belo Horizonte - Municipal Health Department of Belo Horizonte (SMSA-SUS-BH) and conducted by the Human Resources and Health Education Office (GGTE) pertaining to the institution itself from 2012 to 2015. The analysis was addressed to the processes carried out in four working collectives, being three health centers and one activity management of the SMSA. Documentary research was used as methodology, analyzed as for two different frameworks: narrative analysis from the perspective of the Circular Narrative mediation and clinical work. Results showed that mediation was successful in two units and partly successful in a third one. In the fourth unit, mediation did not restore the dialogue between leadership and subordinates making possible to understand what factors influenced the outcome. The determinants of the analyzed conflicts made part of the four analyzed units. Results showed that, even in hierarchical environments, mediation practice could be successfully employed.

KEYWORDS
Negociation; Work; Interpersonal relations

Introduction

Most conflicts of human life are not in the script of compulsory and forbidden conduct, that is, it occurs outside the penal sphere and, therefore, happens in daily life, in private life, in social, commercial, labor, international relations etc. In contemporary society, according to Castells11 Castells M. A Era da Informação: Sociedade em Rede. 10. ed. São Paulo: Paz e Terra; 2007., there is a tendency to accelerate social polarization and inequality even within supposedly civilized societies. Boqué22 Boqué MCT. Cultura da Mediação e Mudança Social. Porto: Ciências da Educação-Século XXI; 2008. affirms that such a tendency can only be changed if man takes the reins and takes responsibility for the world that produces and shares. He argues that there is a need for social change in the human fiber that surpasses economic issues. He considers that, for this purpose, the basic principles of understanding respect for plurality and democratic practices are fundamental. For Folger and Bush33 Folger JP, Bush RAB. La promessa de Mediación: cómo afrontar el conflitcto a través del fortalecimento propio y el reconocimiento de los otros. Buenos Aires: Granica; 2008., the relationship that is established between humans is the cornerstone of conflicts, a relationship understood as the experience in the contact with the other and the impact it produces. Maturana44 Maturana H. Fundamento emocional de lo social. Emociones y lenguaje en Educación y Política. Santiago do Chile: Dolmen Ensayo; 2009. affirms that there is only possibility of social relations based on the acceptance of the other as a legitimate one of the coexistence. Celebrating difference rather than penalizing it means that the quest for commonalities must be accompanied by the realization of the uniqueness and diversity of human beings. The point does not lie on cooperating because we have similar interests, but on understanding that what is truly valuable is to collaborate from the acceptance of difference22 Boqué MCT. Cultura da Mediação e Mudança Social. Porto: Ciências da Educação-Século XXI; 2008. .

According to Boqué22 Boqué MCT. Cultura da Mediação e Mudança Social. Porto: Ciências da Educação-Século XXI; 2008., mediation should be understood as a possibility for social cohesion in a society of confrontation. Mediating means opting for a path contrary to exclusion, which extirpates the other with which one has disagreements. It also does not belong to preconceptions about conflict. It proposes to give voice to those involved so that they take their protagonism and construct new stories from the preconceived narratives about the differences. The action and the word enable the human being to print not what he does, not what he produces, but what is his authorship, his signature and his freedom in the men's world55 Arendt H. Labor, Trabajo, Acción: una conferencia. In: Cruz M, organizador. De la história a laacción. Barcelona: Paidós; 1995. p. 89-108. . Mediation, in giving opportunity to dialogue, has the character of facilitating the connections between the complex and multiple dimensions of living together, always permeated by conflicts and contradictions22 Boqué MCT. Cultura da Mediação e Mudança Social. Porto: Ciências da Educação-Século XXI; 2008. .

Cobb66 Cobb S. Prólogo. In: Suares M. Mediación: condución de disputas, comunicación y técnicas. Buenos Aires: Paidós; 2012. p. 15-19. proposes a reflection on the conceptions that explain the human disputes. Understanding how they come and stay is essential to guide its conduction. Opting for mediation is a political choice in societies where citizenship, protagonism, autonomy, participation and accountability are desirable values. Thus, by opening the comprehensive dialogue between conflicting parties, mediation seeks to include differences and avoid exclusions.

Models of conflict mediation

In the specific field of mediation, during the last 50 years, three models have been developed, which are differentiated by focusing on one of the following elements: 1) in the conflict, 2) in the conflicting parts or 3) in the communication process that is established between the parties22 Boqué MCT. Cultura da Mediação e Mudança Social. Porto: Ciências da Educação-Século XXI; 2008.. This way, we have the problem-solving model that is associated with the Harvard Business School, United States of America (USA). It focuses on the objective aspects of conflict and common interests between the parties, neutralizing subjective aspects such as perceptions and emotions. The transformative model, coupled with the authors A. Baruch Bush of Hofstra University, USA and Joseph P. Folger of Temple University, USA, is centered on the relationship that is built from the process of mediation. The Circular Narrative Model, adopted by the authors of this study, was proposed by Sara Cobb, of the George Mason University, USA22 Boqué MCT. Cultura da Mediação e Mudança Social. Porto: Ciências da Educação-Século XXI; 2008.. It was structured from the presuppositions of systemic family therapy, general systems theory, observer theory, social constructionism, theory of the narrative, social psychology of Pichon Rivière, second-order cybernetics, deconstruction theory of Derrida, contributions of Foucault and others22 Boqué MCT. Cultura da Mediação e Mudança Social. Porto: Ciências da Educação-Século XXI; 2008.. It proposes overcoming the explanations about conflict rooted in logical positivism, where each involved party attributes a linear causality, blaming the other for the maintenance of the conflict.

Cobb77 Cobb S. Speaking of violence: The Polithics and Poetics of narrative in conflict resolution. NYC, Oxford University Press; 2013. understands that the narratives are initially linked to give a final image of unhappiness to one of the parties and of guilt to the other. In conflicts, adversaries construct narratives of accusation, reproof, justification and denial. Conflict narratives have similar characteristics to systems, and can be opened or closed. Closed narratives are impermeable and structured in order to prevent the entry of alternative narratives. Thus, a main theme only accepts other narratives to which it aligns or reinforces. This sequence was called Cobb77 Cobb S. Speaking of violence: The Polithics and Poetics of narrative in conflict resolution. NYC, Oxford University Press; 2013. colonization of the narrative. Closed narratives create the dichotomy victim versus victimizer, where there is always a right side and a wrong side.

Mediation makes it possible to open the narratives of the parties involved, allowing them to contextualize their disputes more broadly, to understand the differences, to review positions, forms of interaction, to engage, to assume responsibilities and to create alternative narratives that modify the values and the characteristics of previous narratives77 Cobb S. Speaking of violence: The Polithics and Poetics of narrative in conflict resolution. NYC, Oxford University Press; 2013..

In mediation, the objective would not be to clarify truths, but to stop violence and facilitate the re-signification of narratives88 Suares M. Mediación: conducion de disputas, comunicación y técnicas. Buenos Aires: Paidós; 2012.. Mediation facilitates the opening of several narratives, respecting ethical principles to allow the re-signification of these stories towards a more complete and inclusive one than the previous ones77 Cobb S. Speaking of violence: The Polithics and Poetics of narrative in conflict resolution. NYC, Oxford University Press; 2013.. The mediator facilitates dialogue, acceptance of the other and differences, considering that conflicts are, by nature complex, permeated by the subjective, by individual interests and power. It addresses agreement only as a possibility and not as a purpose. It provides dialogue, facilitates the ordering of affections and, consequently, of reason99 Brasil. Secretaria de Direitos Humanos. Formas não-violentas de resolução de conflitos. Curso de Direitos Humanos e Mediação de Conflitos. Módulo VI. Brasília, DF: SDH; 2007.. The mediator is inserted in the process and not in the conflict. Boqué22 Boqué MCT. Cultura da Mediação e Mudança Social. Porto: Ciências da Educação-Século XXI; 2008. states that the mediator gives the protagonism of the parties, having the main obligation to maintain the equality of powers and to enhance self-determination. Thus, he would play an integrative role, compensating weak parties for achieving balance of power, fundamental for overcoming violence and exclusion. He should not externalize responsibilities, because that is how the parties try to explain the conflict and that is why they perpetuate it66 Cobb S. Prólogo. In: Suares M. Mediación: condución de disputas, comunicación y técnicas. Buenos Aires: Paidós; 2012. p. 15-19..

Mediation of conflicts in health work

The Unified Health System (SUS), the result of resistance to the Brazilian totalitarian regime, supports principles that advocate democratic and participatory management with the production of "active, critical and solidarity subjectivities"1010 Ferreira Neto LJ, Araújo JN. Gestão e Subjetividade no SUS: enfrentamentos de impasses em tempos neoliberais. Psicol Soc. 2014; 26(3):675-684.(683). On the other hand, the SUS suffers the influences of the hegemonic economic models subordinated to the predominant neoliberal model of the private sector, which, embedded in the management of public health, imposes individualizing, fragmented and competitive subjectivities, antagonistic to the universal and solidary nature of SUS.

The neoliberal individualistic subjectivation, by contaminating the professional, the organization of health services and management, produces piecemeal acts, fragmentation of work teams, overvaluation of technical and technological procedures to the detriment of care that distances solidarity and collective subjectivation1010 Ferreira Neto LJ, Araújo JN. Gestão e Subjetividade no SUS: enfrentamentos de impasses em tempos neoliberais. Psicol Soc. 2014; 26(3):675-684.. In this sense, neoliberalism produces exclusion, groups the correlatives, creates ghettos, produces rejection and hinders sociability.

The mediation of conflicts in health work, by proposing understanding, acceptance of diversity and dialogue, acquires a sense of transformation of subjectivities and resistance to the propositions of exclusion and utilitarianism.

The Human Resources and Health Education Office of the Municipal Health Department/SUS/Belo Horizonte (GGTRA/SMSA/SUS/BH) has been developing, since 2001, the socio-functional monitoring of workers of the institution. This activity seeks to meet the workers who are going through suffering, whether or not generated from the work activity, but always establishing a relationship with it. The assistance to workers can happen individually, as well as through working collective. It is worth mentioning that, even in individual follow-ups, what is sought is the restoration or development of the collective subject1111 Parisi L, Rossetti CC. Abordagem de Conflitos no Trabalho. Belo Horizonte: Rona; 2012.. When there is a conflict identified in the follow-up, it is possible to conduct it through dialogic methods such as Psychosocial Intervention or Mediation, which is the object of this article.

Mediation at work in the SUS-BH occurs within administrative, legal and institutional limits, but its field of action goes beyond that produced, the performance and the result. The mediator provides adequate conditions for the unraveling of conflicts and their connections between subjectivity and work processes, establishing a psychological security climate that facilitates freedom of expression, reduction of defenses and equality of rights to speech. As the understanding of conflict increases, the mediator summons the conflicting parties to propose solutions and suggestions for their confrontation by means of a collective pact between the various singularities1111 Parisi L, Rossetti CC. Abordagem de Conflitos no Trabalho. Belo Horizonte: Rona; 2012.. Mediation opens the way to help the worker to understand the origins of his suffering in order to build coping processes.

In this line, this study aimed to categorize the types of conflicts in the work, to investigate the role of mediation in the understanding of such conflicts and to evaluate if the mediation contributed to migrate from a position of confrontation to a peaceful way of conducting the conflict.

Methodology

Qualitative research was adopted as a means of investigation, with documental and narrative analysis as a methodological path. There was a theoretical articulation around the conception of mediation, conflict and work, analyzed under the references of the work clinics and the models of narrative circular mediation.

Under the designation of clinical work, a set of theories is understood that, although they have epistemological and methodological divergences, have as focus of study the relation that is established between work and subjectivity. From the clinical work, for the purpose of this study, emphasis was placed on the clinical practice of the activity, proposed by Yves Clot and Daniel Faita1212 Bendassolli PF, Soboll LAP. Introdução às clínicas do trabalho: aportes teóricos, pressupostos e aplicações. In: Bendassolli PF, Soboll LAP. Clínicas do Trabalho: Novas Perspectivas para Compreensão na Atualidade. São Paulo: Atlas; 2011. p. 3-16.. The clinic of the activity offers instruments capable of increasing the understanding about the power of action of workers in the face of real work situations. It addresses suffering at work without associating it, exclusively, with the individual characteristics of the worker, but rather with the interface between this subject and the social field in which he is inserted. It also brings contributions about the positive and creative aspects of work1212 Bendassolli PF, Soboll LAP. Introdução às clínicas do trabalho: aportes teóricos, pressupostos e aplicações. In: Bendassolli PF, Soboll LAP. Clínicas do Trabalho: Novas Perspectivas para Compreensão na Atualidade. São Paulo: Atlas; 2011. p. 3-16.. Still according to the clinical work, concepts of Danièle Linhart1515 Linhart D. Entrevista. Trab Educ Saúde [internet]. 2011 [acesso em 2016 maio 17]; 9(1):149-160. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1981-77462011000100011&lng=en&nrm=iso.
http://www.scielo.br/scielo.php?script=s...
and Gaulejac1616 Gaulejac V. Gestão como Doença Social. Ideologia, poder gerencialista e fragmentação social. São Paulo: Ideias & Letras; 2015. were incorporated, respectively, on subjective precariousness in the outsourced worker and managerialism.

The theoretical assumptions of the narrative circular mediation model were previously presented. The documentary research was carried out in four cases of collective follow-ups selected in the GGTRA/SMSA/SUS/BH archive, carried out between 2012 and 2015. At the beginning, eight cases were identified. Since, among them, seven were in three different health districts, one case was chosen in each of these three districts, to which the only case of the SMSA central level was added, totaling the four selected cases. It was decided to keep as a fourth case of mediation analysis a case of the central management level, in view of the distinction of the type of activity practiced, while the other cases carry out a final activity in the SMSA.

To validate selection and analysis of documents, in addition to the researcher herself, who is part of the group of technicians working at GGTE, three other professionals from the same institution who did not participate in the selected mediation processes were included in the analysis processes.

The documents analyzed referred to different contents of the conflicts, such as reports, meeting records, documents of the Management of Medical Expertise, communications from the Municipal General Office, e-mail conversations and transcription of statements of the workers.

In the analysis of the data, it was not intended to make judgments on the intentions of the narrators, but to constitute meanings to the situations lived, to bring an understanding about the conduct and evolution of the narrated conflicts, to establish connections with the context and with the activities. For Vieira1313 Vieira A G. Do Conceito de Estrutura Narrativa à sua Crítica. Rev Psicol. 2001; 14(3):599-608., the study of narrative means to study the action of men, their intentionality, their representation of time and life itself. The narrative mediates between the individual and the culture.

This research received a favorable opinion from the Research Ethics Committee of the Federal University of Minas Gerais (UFMG), CAAE 52841916.7.3001.5140 and the SUS-BH Ethics Committee - Opinion 1.508.397.

Results and discussion

The conflicting cases analyzed had been referred to GGTRA with a request for intervention. In all of them, after listening to the narrative brought by the districts and the management, the mediators proposed meetings with the workers and managers to include the narrative of the workers. They asked managers not to take responsibility for finding solutions, but to open up to dialogue in order to collectively build solutions for crises. During the meetings, the technicians placed themselves in a position of neutrality, valuing the speeches, asking questions, summarizing the topics addressed in order to facilitate reflection and broaden the understanding of the conflict.

Unity I

The health district technicians presented the following conflict to GGTRA:

The problem is the violence of the community. The health center is in chaos. There were no such problems with the previous manager. The team was discouraged by the exchange of nurses, who were experienced and could managed the problems with the community. There was replacement by effective, newly formed servants. The physical area of the health center is awful. There are transfer requests related to conflicts with the community. There is internal conflict between two assistants and the manager identifies negative leadership.

The analysis revealed that, during the meetings, the initial narrative was being deconstructed in some aspects and added new elements until reaching a re-elaboration. In the narrative of workers, there was intense suffering and difficulty in understanding their causality:

Sometimes, I feel like covering my ears and leaving. I feel suffocated. If I open my mouth, everything turns against me. I feel the rope around my neck. [...] What is going to happen from now on? If it gets worse, the health center is over. There has never been such a bad time. The Health Center is becoming inhospitable. Many problems and few people to give solution. I think the problems are just the tip of the iceberg.

As the mediation process progressed, workers and managers located events that could have produced instability at work. Among them, the admission of inexperienced servants in strategic care posts; the implementation of the risk classification at the door of the unit (Manchester protocol), which disregarded the socio-affective issues of the territory; the lack of internal deliberative spaces and with the community, the entrance of new manager and the intensification of the work:

I get suffocated by the physical structure, I try to do things, but I can't [...] The demand is huge, the system is slow and people curse. Newbies come to work without knowing it. [...] back pain because the daughter is being raped in the house is green card in the risk classification. [...] extinguishing a fire. The flow of service is confusing, tumultuous, all urgent. I can't meet user expectations.

People approach me, I feel supervised. There is no union between people. Plenty recovery of deadlines. There is no listening. By the time of the previous manager, it was better. Everyone wants to be listened to, but it's not possible. The health center has always been good with indicators. Being first does not do any good [...]. Before, we were protagonists. We become coadjuvant. Today we are extras.

And the mediator made a summary:

I have the sensation that there is impotence and a feeling of working mechanically. Tiredness and helplessness can arise when you don't do what needs to be done. What is contributing to this happening?

In the perspective of the clinics of the activity, suffering in the face of conflicts was a consequence of precarious conditions, impoverishment of the interactions between the workers and the community, which prevented the accomplishment of a work well done. There was a fragmentation of teams and processes. This dissolution of a unit of work is described as weakening of the office, in the concept of the clinic of activity.

For Clot1414 Clot Y. O ofício como operador de saúde. Cad Psicol Social Trab. 2013; 16(esp):1-11.(3), the activity would be a social architecture at work that "can acquire an internal psychic function". This architecture would have four dimensions: personal, interpersonal, transpersonal and impersonal, which would be permanently in creative or destructive disagreement, in connections or disconnections, keeping the activity alive, in continuous movement and construction. The activity is personal, because every situation experienced by the worker is singular and subject to the unexpected. It is interpersonal, because all work done is addressed to a recipient. The activity has a transpersonal dimension, because all work is traversed by collective histories accumulated over generations, situations lived and ways of responding to them. To the transpersonal dimension, Clot1414 Clot Y. O ofício como operador de saúde. Cad Psicol Social Trab. 2013; 16(esp):1-11. denominated professional gender. The gender functions as a password used by those who work together and share tacit knowledge. The impersonal dimension of the activity would encompass the flows, norms, protocols, that is, the prescribed task, which each will 'thaw' in its own way, in the face of the real that imposes itself on the activity, using the presuppositions of collective history.

When, in the architecture of the activity, collective history weakens, the worker finds himself alone in confronting the real. It would be the responsibility of all workers and managers to maintain the standing structure of the activity through professional debate about the work well done. In these debates, heterogeneous groups, dissent and dissonance are expected and desired, as they enlarge the surface of contact with the real. Clot1414 Clot Y. O ofício como operador de saúde. Cad Psicol Social Trab. 2013; 16(esp):1-11.(4) understands that, where the spaces of debate diminish, the "quarrels that poison the means of work" increase.

After the mediation meetings, workers and managers were able broaden the understanding of the conflict and to become involved as protagonists in its conduction. The narrative began to restructure the deliberative spaces. They began discussing the work processes, the structure of the collegiate manager and local commission, reflected on the relationships between them, the district and the community. They understood that they would have to rebuild processes and demand better working conditions:

We need to stimulate the feeling that we are one unit rather than four teams, working in groups, being in solidarity with one another. We need to be co-responsible for the user, regardless of which team he or she is linked to. Improve the work process. We need to identify the stress factors that afflict the teams. We need to anticipate the problems. The Manager must attend collegiate and local committee meetings, with commitment to monthly meetings. The managing collegiate must be more representative. The district should be more present. We need to improve the relationship and information and internal communication with the District and with the community.

Unity II

The demand was sent to the work management with a report signed by the immediate manager and two district managers in 2015:

For some time, we have observed that an employee, who has the function of being in charge, presents difficulties in the management of the team. He presents conflicts in the interpersonal relations and problems of adhering to scheduled times with negative reflexes in the work. He can't act according to his assignment, he has no profile and posture for the good progress of the service. The team is unmotivated. He does not exercise any kind of leadership or control over the activities that the agents should perform. We held individual and collective meetings in an attempt to retrieve his leadership together with the group, established standards and guidelines, discussed compliance with schedules, drafted reports to be delivered to management in a timely manner, but no change in behavior, so far, has been perceived.

In the previous reports to the mediation process, since 2011, the narrative was that the person in charge was not fulfilling his role well, from a conception of supervision with a strong monitoring character that provided for the conference of the visits to the homes made by the agents. In the same conception, the planning of the daily activities of the agents would be under the responsibility of the person in charge, being considered incorrect to delegate the activity to those who executed it. Like his subordinates, the person in charge had no autonomy. Their activities and work organization norms were pre-defined and determined:

The agent himself took the daily planning form and did it on his own. The focal treatment newsletter has been held by the agents during the week, and the correct thing is the person in charge to collect all every day so we can follow the production, quality and plan the day after. The person in charge allows the agents themselves to conduct in whatever way they want the task of the day, leaving them unable to follow the course of their agents. We reinforce the importance of fulfilling the obligations and duties with accomplishment of the daily routines of the work process, the schedule, signing of the point in the management room and delivery of the newsletters at the end of the day.

From the clinical perspective of the activity, the district narrative of the conflict reveals a hypertrophy of the impersonal dimension of the activity, according to the concept of activity of Yves Clot1414 Clot Y. O ofício como operador de saúde. Cad Psicol Social Trab. 2013; 16(esp):1-11.(5):

We are made to create contexts for living in them. Once this possibility is diminished or, especially, if it disappears in a continuous way, we do not live, we only survive, because we are submitted to the professional contexts, without really being able to recognize ourselves in what we do. [free translation].

Based on the mediation records, it is inferred that the narrative of the workers did not confirm the narrative of the management on the causality of the conflict. The team felt isolated, without training, without spaces of debate, without support, with a fragile supervision. Agents did not exclusively assign responsibility for conflicts to the person in charge. They did not praise his performance as a supervisor, but they did not completely deprive him of his role. Nor were they unmotivated. On the contrary, they said that they dedicated themselves, were responsible, creative, and saw meaning in what they did. They felt devalued by the Institution and not by the person in charge:

Person in charge: I like what I do, I do not intend to leave here.

Agents: I think it's cool, I have good relationships [...]. I make friends, I like what I do, it's dynamic, I like to walk and talk. I like to work in a needy community, I do what is within my reach. There were disagreements, but it still is a good team to work on, despite the 'quarrels'. The problem is communication between the two people [...]. Relation with the class has already been good, nowadays the relationship is good with some, not all [...]. Both the person in charge and this colleague are very childish. Each one, the colleague and the person in charge, must recognize the mistakes. The ideal would be for the two to stay so they don't get lost any more [...].

Mediator: What can be done to rebuild what has been lost?

Agents: It is important the team meeting every 15 days to deal with the work process to minimize personal issues and end with the 'grapevine'. The bottom conclusion is working as a team. Something has gone wrong, but it can resume. [...] The district needs to be more agile to address issues beyond the field agent, for example, how to deal with problematic real estate. There are things we need support for. Management must improve dialogue, engage in activities, and be the link to the district. The zoonosis agent is the lowest level of PBH. They do not recognize us. What keeps us together is the team. We have difficulty coordinating zoonosis in the district. I wish I could have a career plan.

Such considerations bring the conception of a supervision that is more supportive and that support the work. They knew about the difficulties and limits of field work and advocated interlocutors with the district to support and guide them. The declarations showed interest in the effectiveness and improvement of working conditions and revealed that the agents acted with responsibility and autonomy.

As for the causality of the conflict, the mediation did not reach the deconstruction of the management narrative, which remained closed, sustaining a linear blame directed exclusively to the person in charge. The meetings broadened the understanding of the context of the work, but did not advance the mediation of the conflict between the manager and the agent. The management opted for the involuntary transfer of the person in charge.

Unity III

The mediation analyzed was carried out in an administrative management unit, that is, which performs an activity in the middle of SMSA, in which effective employees and outsourced workers work. The manager carried the following narrative, according to records of the mediator:

[...] with the arrival of six effective employees, in replacement of a quarter of the outsourced workers, I observed that the newcomers do not have interest in the work, they position themselves as questioners and inspectors. They point out mistakes, they mistreat outsourced employees and do not respect the rules of coexistence and norms of the Institution.

The narrative of the new effective workers was:

Coexistence is difficult. I was happy to have passed the contest, but I was very disappointed. I have worked in public service in another municipality and I liked it very much. I'm discouraged. I identify more with the group of personnel. Here, we can't question anything, it seems we are confronting. The manager exposed me to his colleagues [...]. I have been working under pressure. The table is full of things; the phone rings all day. Demand is high. I did not know that SUS was an 'mess'. There's a lot of cockroaches here and I don't know how people agree to work this way. People here lowered their heads [...]. We want to contribute and not to disturb. I have technical doubts. I have not been trained, I am a fish out of water.

Narrative from the perspective of outsourced workers:

Lack of respect. I cannot grow inside here. There is class difference, there is discrimination. They beat the social class stamp on us. We don't like living with cockroaches, but we cannot complain because we can lose our jobs. The effectives can claim for the stability they have. They have opportunity for growth. But their arrival altered the scheme of the work as if everything that we did was wrong and that we were conniving with the errors and abuses. These differences don't justify privilege, rudeness and lack of respect. When I came to work here people warned me about the manager.

In the clinical conception of the activity, the analysis indicates a weakening of the professional gender. The effective servants did not yet share the common history of that collective and had, in some way, more rights. On the other hand, they felt prevented, by the manager, from appropriating this collective history, since they could not debate the work processes. From this situation, they began to criticize the work and the outsourced colleagues as if they were people outside the context, that is, as if they did not belong to that reality. This attitude compromised the relationship with outsourced colleagues, who were previously able to sustain an activity, even if it was fragile. Such fragility was evidenced when they reported to endure situations of which they disagreed to keep the job. According to Linhart1515 Linhart D. Entrevista. Trab Educ Saúde [internet]. 2011 [acesso em 2016 maio 17]; 9(1):149-160. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1981-77462011000100011&lng=en&nrm=iso.
http://www.scielo.br/scielo.php?script=s...
(151), the precariousness of the bond would also create a subjective precariousness and a greater subordination to the manager.

The aim is to minimize the ability of workers to make opposition, to impose resistance, in the face of the demands of the directions. Create a kind of subjective precariousness so that workers do not feel comfortable at work or between them, so that they cannot develop networks of complicity and support with colleagues, with the hierarchy or their clients, so that they always feel the rope is stretched and stay more receptive to the injunctions that aim to increase the profitability of their work.

The new servers claimed to be interested in the contest and disappointed with the reality they encountered. In addition, they reported a committed relationship with the manager, which was shared by both groups. There was another meeting with the workers and managers, 15 days after the first one. The mediator noted that:

Workers reported that the relationship between effective and outsourced colleagues was much better. They were respecting each other. There was a mutual effort of integration and cordiality. They had not noticed, however, a change in the relationship between manager and subordinates nor any improvement in working conditions. I asked about alternatives. The workers suggested that the manager could give more autonomy, they suggested to exchange some tasks between them, to improve internal relations and with other managements.

The analysis of the records showed an improvement in the interaction between outsourced and actual workers. There was, therefore, a re-contextualization, a reframing of the narratives between the two conflicting parties. Conflicts between the workers and manager remained.

In the narrative of the managers, the new servers were considered responsible for the crisis, and the arrival of new workers was more likely to have been the trigger point. The entry of new servers without the knowledge of the experience, although demanding and stable, has produced a destabilization of the powers and, consequently, the rupture of conflicting latent situations. The replacement of a quarter of the outsourced workers in the sector may have led to the intensification of work, the breakdown of the professional gender and increased pain.

Months later, the exoneration of the function of the manager was recorded by higher instances, and there was no mention of linkage with the conflict experienced.

Unity IV

The demand for intervention or mediation was made by the health district according to the registration of a mediator:

We came to the Unit on the basis of a demand from the district, following an anonymous letter about the performance of the manager as follows: [...] manager coerced community health workers to work in misuse of duties. There are complaints in SOS Saúde and it is not known why no action is taken to resolve the situation. Manager does not have time to listen to the employees and the users who are looking for him, justifying that he has much work to do. Today there is even a grid at the reception, users never find the manager. There is no doctor on staff. I tried to talk to the manager twice, but he was in the meeting.

It is observed that the complaints revolved around the interaction of the manager with his employees and users. The manager was being assessed as authoritarian, inaccessible and unfair in dealing with his subordinates.

The narrative of the district highlighted the efficiency of the manager:

Over the years, we haven't received a complaint about his management or conduct. He is a committed professional who responds in a timely manner to the vast majority of the demands requested by the District. His unit is a reference for dengue care.

There are conflicts where the parties to the dispute are not delineated, as is the case of anonymous denunciations. Anonymous narratives only arouse suspicion, but do not establish interlocution. They are closed in on themselves. Even so, by the repercussion in the unit, the workers were listened to.

Mediator: How do you feel about living this situation?

Workers: I'm outraged and scared. I didn't witness anything about the accusations. I'm surprised and upset. And now how are the relationships in here? Who do we relate to? It's a cowardice with the manager, I don't agree with what was done [...] I agree with what was written about how the manager relates, but this should have been discussed [...] The manager conveys aggressiveness in his way of talking, but there are other ways to solve it. Many people shout in unity with each other, it is not exclusivity of the manager [...] The health center is in need of reform, we are at war. The manager is overworked, has no assistant manager, no social worker.

Most were impacted and considered the anonymity harmful to the manager and to the relationships inside and outside the unit. Aggressiveness was cited as common among workers and overload was considered one of the causes. Many agreed on the difficulty of manager interaction and the unwillingness to receive workers and users when prioritizing administrative activities. For Gaulejac1616 Gaulejac V. Gestão como Doença Social. Ideologia, poder gerencialista e fragmentação social. São Paulo: Ideias & Letras; 2015., there is always a contradiction in the exercise of management that must fulfill the formal requirements of the institution and, at the same time, do not depart from the principle that work exists to build a society and the common good. This contradiction was experienced by the manager of Unit IV, who, due to the requirement to comply with the rules, due to the overload of administrative work and the precarious conditions described, diverted his focus from the essence of care.

After the meetings, the workers and manager understood better the conflicts of the unit and were reviewing positions:

Now the nursing has decided to get together more often. I'm betting on the possibility of dialogue. The manager is striving to improve. We propose more meeting space. After the letter, the mistrust remained among some people, but there are good things going on. It's time to select and go forward, move on. Relations are improving. I think the conversations have diminished [...]. Community workers also want room to discuss [...]. The team is being truer to each other. The manager has his defects, he needs to change some aspects. It's time to stop with this anonymous letter story and rebuild the working relationships.

In a general way, the narratives revealed a relief of the tension and willingness of the workers and manager to organize the work process in a shared way. The meetings of joint thinking are, in general, interpreted as a waste of time. These deliberative spaces, however, foster debates in the search for a work well done, the exchange of knowledge, the development of creative capacity, reduction of hardship against the real, enrichment of work and, mainly, restore the feeling of contributing to a collective work, within the conception of the clinic of the activity1616 Gaulejac V. Gestão como Doença Social. Ideologia, poder gerencialista e fragmentação social. São Paulo: Ideias & Letras; 2015..

Conclusions

In the analysis of the documents, it was found that the records of the work management made possible the understanding of the mediations carried out. It was concluded that the interactional conflicts at work resemble any conflict, in any context, presenting triggering factors, trigger points that deflagrate them, complex dynamic and circular causality.

In the analyzed documents, the conflicts took place in contexts where the spaces of dialogue and deliberation were interrupted, where the practices of the managerial model were intensified, where there was a weakening of the occupation, where the working conditions were too precarious, where care with the other and the subjective aspects were neglected. Conflicts have been strengthened or constituted from inadequately conducted situations of tension, where attributions of culpability, accountability, punitive measures, power narratives closed and impermeable to other narratives prevailed. In the mediations carried out, there was an opportunity to draw out the hegemonic and marginalized narratives, with their deconstruction, the redemption of protagonism and the construction of alternative narrative.

It has been found that mediation is a valid instrument for conducting work conflicts, even considering that they occur in spaces such as subordination relationships and with the privilege of management narratives. The intervention of the mediators made it possible to balance powers, reestablish the dialogue between workers and between workers and managers. The spaces of mediation constitute deliberative spaces that help the understanding of the meanings, allowing to contextualize the conflicts, to elucidate their causality and to give meaning to the work. On the other hand, mediation is not a panacea, even because any deliberative space cannot be idealized77 Cobb S. Speaking of violence: The Polithics and Poetics of narrative in conflict resolution. NYC, Oxford University Press; 2013.. Difference and dissent exist and are desired, because they bring concrete reality to the debate.

It is also necessary to demarcate that the analyzed mediations were carried out in the work spaces of the SUS, which underlies in its guidelines values such as protagonism, shared management and care. These guidelines are against hegemonic to the managerialist management model, that little by little has been infiltrating into SUS. Therefore, the defense of mediation of conflicts in the SUS is of importance as a method of resistance in defense of inclusive, democratic values, of solidarity and equity.

Acknowledgements

We thank Professors José Newton Garcia de Araújo, Andréa Maria Silveira and Crisane Costa Rossetti for their supervision during the research. We thank the support of the Management of Labor Management and Health Education of the Municipal Health Secretariat, City Hall of Belo Horizonte.

  • Financial support: non-existent

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History

  • Received
    10 May 2018
  • Accepted
    03 Oct 2018
  • Publication
    Dec 2018
Centro Brasileiro de Estudos de Saúde RJ - Brazil
E-mail: revista@saudeemdebate.org.br