ABSTRACT

The aim of this report was to present the evaluation of students/managers, participants of the third class of the Improvement Course in Management of Basic Health Units, Clinical and Care Management in Piauí and participants in the application of the Circular Process tool, as a strategy proposal to reflect, debate and evaluate processes in basic health units. The Circular Process values everyone’s contributions by respecting each participant’s presence and perspective. The use of the tool by students/managers presented strategies for participation and collective management of work processes, provided self-assessment and evaluation on the use of the tool in the Basic Health Unit and the possibilities and potentials of the circular process to promote the care management interface with the work process.

KEYWORDS
Health management; Organization and administration; Primary Health Care; Group processes

Introduction

The Family Health Strategy (FHS), still called Family Health Program (FHP), appears in the late nineties of the last century with the objective of strengthening and organizing primary care in the Unified Health System (SUS). Since then, there has been a significant expansion of the Family Health (FH) approach in Brazilian municipalities, which has become the priority and preferential care model in the management of primary health care, with individual and collective actions at the first level aimed at promoting health, prevent disease, treat and rehabilitate. Today, the country has a coverage of 98% of FH units in the 5.570 municipalities¹1 Brasil. Ministério da Saúde. Departamento de Atenção Básica [internet]. Brasília, DF: 2018. [acesso em 2019 fev 16]. Disponível em: https://egestorab.saude.gov.br/paginas/acessoPublico/relatorios/relHistoricoPagamentoEsf.xhtml.
https://egestorab.saude.gov.br/paginas/a... . However, important studies²2 Escorel S, Giovanella L, Mendonça MHM, et al. O Programa de saúde da família e a construção de um novo modelo para a atenção básica no Brasil. Pan Am. J Public Health. 2007; 21(2/3):164-176.

3 Viana ALd'Á, Rocha JSY, Elias PE, et al. Atenção básica e dinâmica urbana nos grandes municípios paulistas, Brasil. Cad. Saúde Publica. 2008; 24(supl1):S79-S90.

4 Pinto E, Menezes R, Villa T. Situação de trabalho dos profissionais da Estratégia Saúde da Família em Ceará-Mirim. Rev. Escola Enferm. USP [internet]. 2010 [acesso 2019 fev 10]; 44(3):657-664. Disponível em: https://doi.org/10.1590/S0080-62342010000300015.
https://doi.org/10.1590/S0080-6234201000...

5 Giovanella L, Mendonça MHM, Almeida PF, et al. Family health: limits and possibilities for an integral primary care approach to health care in Brazil. Ciênc. Saúde Colet. [internet]. 2009 [acesso em 2019 fev 24]; 14(3):783-794. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232009000300014&lng=en.
http://www.scielo.br/scielo.php?script=s... ^-66 Arantes LJ, Shimizu HE, Merchán-Hamann E. Contribuições e desafios da Estratégia Saúde da Família na Atenção Primária à Saúde no Brasil: revisão da literatura. Ciênc. Saúde Colet. [internet]. 2016 [acesso 2019 fev 18]; 21(5):1499-1510. Disponível em: https://doi.org/10.1590/1413-81232015215.19602015.
https://doi.org/10.1590/1413-81232015215... point to the diversity of its implementation and consolidation process in Brazil.

Regarding the work process in primary care, the figure of the manager of the health unit ended up being concentrated in the nursing professional⁷7 Vélez BGA, Corrêa BL, Duarte J, et al. Conhecimento gerencial requerido no Programa Saúde da Família. Rev. Bras. Enferm. [internet]. 2005 [acesso 2019 fev 18]; 58(6):635-640. Disponível em: https://www.redalyc.org/articulo.oa?id=267019624002.
https://www.redalyc.org/articulo.oa?id=2...

8 Lima OFE, Carneiro AFS, Lopes OL, et al. A Gerência do Enfermeiro na Estratégia Saúde da Família. Rev. Rede Enferm. do Nordeste [internet]. 2012 [acesso em 2017 maio 15]; 13(4):834-844. Disponível em: https://www.redalyc.org/articulo.oa?id=324027983013.
https://www.redalyc.org/articulo.oa?id=3... ^-99 Ximenes Neto FRG, Coelho SJJ. Gestores do Território na Estratégia Saúde da Família: analisar o perfil das necessidades de qualificação. Rev Bras. Enfer. [internet]. 2007 [acesso em 2017 maio 15]; 60(6):687-695. Disponível em: https://www.redalyc.org/articulo.oa?id=267019609014.
https://www.redalyc.org/articulo.oa?id=2... . However, some challenges pointed out by studies on performance and management profile of primary care are relevant to understand the work process of these managers, since these studies indicate the fragility in the process of formation and continuing education of these professionals. Given this scenario, the Ministry of Health has triggered several processes of qualification of health management, highlighting the integrated support Guideline for qualification of management and care in SUS¹⁰10 Brasil. Ministério da Saúde. Diretriz de apoio integrado para qualificação da gestão e da Atenção no SUS. [internet]. Brasília, DF; 2013. [acesso em 2019 fev 16]. Disponível em: https://central3.to.gov.br/arquivo/240607/., this is one of the strategies used by the Ministry of Health in the cooperation process with states and municipalities with the objective of enhancing health actions in a context of regionalized and networked health management.

The various competencies required to act as manager of basic health units, range from managing inputs, personnel, to monitoring health indicators. Clinical management and health care management skills are also needed to work in the Health Care Networks, in addition to investing in intra and intersectoral articulation.

The present study aims at reporting the experience of applying the Circular Process (CP) tool as a proposal to reflect, and to evaluate work processes in basic health units.

Tool application assessment

The Management Improvement Course of basic health units, clinical and care management is promoted by the Federal Fluminense University (UFF), in partnership with the Ministry of Health, with the objective of qualifying the management of Basic Health Units (BHU) and the management of care in primary care. The proposal is to train managers and professionals with managerial function in basic units, systematize knowledge and experiences in unit management, analyzing clinical and care management practices already experienced in several Brazilian scenarios and supporting the incorporation of clinical management tools and care by primary care professionals¹¹11 Universidade Federal Fluminense. Coordenação de Educação a distância. Curso de Aperfeiçoamento Gerencia de Unidade de Saúde, Gestão da Clínica e do Cuidado. [internet]. Niterói; 2019. [acesso em 2019 fev 16]. Disponível em: http://epubs.cead.uff.br/site/#info_curso.
http://epubs.cead.uff.br/site/#info_curs... .

The preferred public are graduated health professionals who are acting as managers of primary care or in direct interface functions with primary care in order to qualify the clinical management processes and health care. The course has a national coverage and in 2019 is in the third offer, with an average participation of 700 students per edition¹¹11 Universidade Federal Fluminense. Coordenação de Educação a distância. Curso de Aperfeiçoamento Gerencia de Unidade de Saúde, Gestão da Clínica e do Cuidado. [internet]. Niterói; 2019. [acesso em 2019 fev 16]. Disponível em: http://epubs.cead.uff.br/site/#info_curso.
http://epubs.cead.uff.br/site/#info_curs... . The present study was conducted with students/managers from the Piauí class, participants of the third course offer.

The course operates in a semi-presential modality, with a total workload of 180 hours, with 48 hours being presential and 132 hours worked in Virtual Learning Environment (VLE). The classroom workload is divided into three meetings over six months. The course has as pedagogical proposal the exchange of experiences in the context of SUS and a contextualized learning with the processes experienced by students in the daily management of primary health care¹¹11 Universidade Federal Fluminense. Coordenação de Educação a distância. Curso de Aperfeiçoamento Gerencia de Unidade de Saúde, Gestão da Clínica e do Cuidado. [internet]. Niterói; 2019. [acesso em 2019 fev 16]. Disponível em: http://epubs.cead.uff.br/site/#info_curso.
http://epubs.cead.uff.br/site/#info_curs... ^,1212 Brasil. Ministério da Saúde, Departamento de Atenção Básica. Notícias [internet]. Brasília, DF: 2018. [acesso em 2019 fev 13]. Disponível em: http://dab.saude.gov.br/portaldab/noticias.php?conteudo=_&cod=4173.
http://dab.saude.gov.br/portaldab/notici... .

One of the tools presented by the course is the CP. The practice originates from traditional peoples of the American continent and Oceania, and brings together ancient community wisdom and contemporary values of respect for individual differences and needs in a process that values everyone’s contributions and respects each participant’s presence and history, ensuring equal voice to all. Circular processes have been adopted in various contexts¹³13 Pranis K. Processos Circulares: teoria e pra´tica. Sa~o Paulo: Palas Athenas; 2010. Se´rie Da reflexa~o a` ac¸a~o.. In the FHS they can be used, for example, in warm-up activities, calming discord, repelling misconceptions, building and restoring relationships, minimizing conflicts, reflecting and evaluating work processes¹⁴14 Franco CM, Klitzke DD, Moreira LCH, et al. Unidade I: Gestão do Processo de Trabalho em Saúde In: Abrahão AL. Curso de Aperfeiçoamento em Gerência de Unidades Básicas de Saúde, Gestão da Clínica e do Cuidado - Niterói: CEAD-UFF; 2016. p. 49-53.

To materialize the circular processes it is necessary to consider some fundamental elements: i) the construction of the ‘mood’ for the accomplishment of the activity, based on an invitation with characteristics of seriousness and commitment, but lightly and lovingly to address a theme. An opening ceremony welcomes participants and explains the step by step dynamics; ii) presentation of the speech stick, a symbolic and significant object for the group, with the purpose of organizing and ordering the group’s speech and, at the same time, providing all participants with respectful listening and speech; iii) presence of a guardian or facilitator, person who coordinates the debate, provokes and problematizes the group, but keeps the focus on the theme and dialogue with respectful and non-violent; iv) closing of the moment with a closing ceremony, which aims at celebrating the group process. The ceremonies can be concluded with circles, wheels, simple conversations, reading poems, verses and other possible playful-reflective resources contextualized with the products of the moment¹³13 Pranis K. Processos Circulares: teoria e pra´tica. Sa~o Paulo: Palas Athenas; 2010. Se´rie Da reflexa~o a` ac¸a~o.^,1414 Franco CM, Klitzke DD, Moreira LCH, et al. Unidade I: Gestão do Processo de Trabalho em Saúde In: Abrahão AL. Curso de Aperfeiçoamento em Gerência de Unidades Básicas de Saúde, Gestão da Clínica e do Cuidado - Niterói: CEAD-UFF; 2016. p. 49-53.

In order to provide the managers-students of the course with a closer approach and the appropriation of the tool, the tutors perform, at the first on-site meeting of the course, a CP wheel aiming to exercise and favor the knowledge of the power of the tool, considering the various situations and themes experienced by managers in the work context.

For Franco¹⁴14 Franco CM, Klitzke DD, Moreira LCH, et al. Unidade I: Gestão do Processo de Trabalho em Saúde In: Abrahão AL. Curso de Aperfeiçoamento em Gerência de Unidades Básicas de Saúde, Gestão da Clínica e do Cuidado - Niterói: CEAD-UFF; 2016. p. 49-53, circular processes may have different loyalties, however with the same objective of addressing or preventing conflicts in the BHU environment. Possibilities may be circles of dialogue or evaluation, support, integration and celebration.

During the workshop dynamics proposed at the physical meeting of the course, the tutors play the role of guardians of the moment, highlighting the importance of the organization for the materialization of the CP and emphasizing that at the moment of the workshop, the proposed type of CP is aimed at promoting reception, inclusion and acceptance in the group.

At the end of this on-site meeting, the tutors guide the students to perform a CP in return to their work contexts, in order to evaluate the power of the tool with the work group of these managers.

This whole process is oriented through the didactic material of the course, which presents the theorization about the tool, as well as an organizational instrument to operationalize the CP in its work environment. Added to this, in VLE, there is the support of the tutor and classmates, through a discussion forum and, whenever necessary, communications through private messages to the tutor.

The work environment is invariably more complex and difficult than the simulated classroom environment. Therefore, the students reported difficulty in selecting a theme to perform the CP in their BHU. Even though they were aware that the choice of the theme should start from a concrete situation, whether it was a problem or not, most students/managers chose to approach themes considered recurring problems.

The students/managers mentioned some strategies that contributed to the practice, such as holding the CP on a meeting date already established in the BHU work schedule; the investment in personal invitations, confirming the importance of the participation of all professionals of the unit and the snacking. Such strategies contributed to the participation of the unit’s workers and could subsequently be instigated by the CP itself. The students/managers reported that the experience of the CP tool was able to generate evaluations by the professionals of the BHU and also a self-assessment by the managers. The evaluation of participants involved the following aspects: duration of meetings/team meetings, choice of theme, participation and motivation in discussing the issue by professionals and referrals of moments, with perspectives of deliberations and accountability by team members. These points had different weights, with greater emphasis on time duration and referrals.

In most cases, it was the students/managers who previously defined what would be the theme addressed in the CP. In this sense, the participants evaluated that the process of choosing the theme could have been done collectively, even if there was no consensus, but the democratic process prevailed in the selection. Although the orientation of the course is so that the choice of the theme starts from a situation or context of the work process in the unit, many students/managers chose to select problem situations from their own perspective, which brought consequences to the moment of the CP, as many of the participants did not see the topic as relevant to a group discussion.

Probably due to this little shared definition of the theme, students/managers stated that they expected greater participation and motivation of professionals in the application of the tool, and on several occasions it was the guardian who had to provoke such participation. Some students/managers reported that the process resembled more an opinion poll than a moment of presenting the perception and feelings on the subject. Some managers stated that at some point during the performance of the CP, they had to intervene with questions obtaining short answers and little connected with the speech author’s positioning.

The students/managers who assumed the role of guardians on the CP wheels in a self-assessment movement revealed excessive concern to fully follow the steps of the script proposed in the course material, which produced some stress in the group due to mechanization of the dynamics.

Therefore, there was no participation motivated by the opinions and experiences of the participants on the theme. Although in the CP proposal, speech needs to circulate among all members of the group, and it was stressed that this speech was not always laden with meaning and truth.

Participants evaluated that the CP tool has the potential to define referrals from the individual speeches produced, which facilitates the agreements (dates of execution and responsible actors).

However, students/managers realized that the construction of this agenda of commitments and monitoring of pacts was again centered on the manager or nurse, although participating professionals recognized the need to agree dates and responsibility for actions.

Even in the face of the challenges faced by students/managers during the realization of the CP, it was consensus its power to tense the work process of the BHU manager. The possibility of having a tool capable of ensuring the presentation of different perspectives, as well as promoting collaborative and nonviolent dialogue when dealing with sensitive topics in the team and, thus, promoting debates, reflections on diverse topics pertinent to primary care was understood as very positive by the managers.

Another aspect highlighted by the students/managers was the power of the tool to promote the interface between the dimensions of people and input management and health care management. Students/managers emphasize the importance of recognizing the inseparability between these dimensions to address the health needs of the population covered by the health unit.

References

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