ABSTRACT

This article is an experience report, which contextualizes the importance of restorative practices as management tools of conflicts in the Family Health Strategy, carried out in a southwestern municipality of Paraná, between 2017 and 2018. The objective was to report the experience of applying Non Violent Communication (CNV) and circular process techniques to handle conflicts and promote collaborative work at the Alvorada Health Unit, in Pato Branco, Paraná. For the report, it was decided to articulate the literature review on restorative practices to the experience. The results include greater integration and accountability between the health team, promotion of meetings with collective reflection, use of CNV techniques and circular process in work management and the return of walking groups for hypertensive and diabetic patients. It is emphasized the importance of studies in this area, as well as the introduction of topics related to restorative practices during the training periods, in order to provide management and assistance professionals with tools to deal with conflicts that may occur in their future professional activities.

KEYWORDS
Organization and administration; Leadership; Interpersonal relations; Family Health Strategy

Introduction

The Family Health Strategy (FHS) emerged with the objective of changing the health care model to a user-centered system, in which the care of this individual is the ethical-political imperative for the organization of care. Teamwork in the context of the FHS gains a new dimension towards the division of care responsibilities among group members, in which all participate with their specificities contributing to the quality of health actions¹1 Figueiredo WM, Camargo AM, Ribeiro LG. Estratégia da saúde da família: avaliação da percepção da comunidade / Family health strategy: assessment of community perception. Braz. J. of Develop. [internet]. 2018 [acesso em 2019 jan 21]; 4(6):3579-96. Disponível em: http://www.brjd.com.br/index.php/BRJD/article/view/364.
http://www.brjd.com.br/index.php/BRJD/ar... .

In teamwork, it is essential to approach interpersonal relationships as processes that have as a premise mutuality, conviviality, exchanges between individuals. These are intensely mediated by the feelings of those involved, and to avoid interference in relationships, frank dialogue and exposure of their perceptions is necessary to avoid distancing, superficiality and incommunicability²2 Pinho LB, Santos SMA. O relacionamento interpessoal como instrumento de cuidado no hospital geral. Cogitare Enferm. [internet]. 2007 [acesso em 2019 jan 19]; 12(3). Disponível em: https://revistas.ufpr.br/cogitare/article/view/10038.
https://revistas.ufpr.br/cogitare/articl... . In the process of interpersonal relations, communication has become an essential instrument, as it can be used to stimulate, motivate and even resolve conflicts, which are routinely present in the daily life of managers of health organizations³3 Cecílio LCO. Can conflict be used as the "raw material" for health services management? Cad. Saúde Pública [internet]. 2005 [acesso em 2019 jan 21]; 21(2):508-16. Disponível em: http://www.scielo.br/scielo.php?script=sci_abstract&pid=S0102-311X2005000200017&lng=en&nrm=iso&tlng=pt.
http://www.scielo.br/scielo.php?script=s... .

Restorative practices are forms of conflicts management widely adopted in Restorative Justice. In the context of the Basic Health Units (BHU), Nonviolent Communication (CNV) and the Circular Process can, for example, be used. Nevertheless, the literature shows us that these tools are still incipient in the Brazilian scenario⁴4 Ferrão IS, Santos SS, Dias ACG. Psicologia e Práticas Restaurativas na Socioeducação: Relato de Experiência. Psicol cienc Prof [internet]. 2016 [acesso em 2019 set 16]; 36(2):354-363. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1414-98932016000200354&lng=en&nrm.
http://www.scielo.br/scielo.php?script=s... .

In approaching these tools, the facilitator, a role that should preferably be occupied by the manager of the BHU, helps the parties, directly or indirectly involved, to carry out a dialogical process aimed at transforming a relationship of resistance and opposition into a relationship of cooperation and collaboration. In this process, the parties collectively decide how to deal with circumstances arising from the conflicting act. The idea is to promote reflection, restoration and accountability, allowing the strengthening of relationships and bonds between people. They also help people deal with conflict differently, because by challenging traditional patterns, they enable the perception of conflict as opportunities for change and learning, emphasizing the values of inclusion, belonging, active listening and solidarity.

In this sense, the following question was asked: how could the use of nonviolent communication techniques and the circular process help in the management of conflicts in basic health units? Thus, this report aims to contribute to the understanding of how the techniques of CNV and the Circular Process can assist in conflict management in BHU.

Methodology

This is an experience report, that seeks to describe the conflict management strategies used by the nurse of the FHS 2 team at Alvorada BHU, in Pato Branco, Paraná, held during the Improvement Course in Basic Health Unit Management, Clinical and Care Management promoted by the Fluminense Federal University (UFF), in the years 2017 to 2018.

For the accomplishment of this report, literature review about restorative practices was used, focusing on the CNV and the Circular Process, articulating it to the experience report.

Case study: application of CNV tools and Circular Process in Pato Branco, PR

The report was built in three moments related to the use of restorative practices in the management of the FHS. The first one reveals the initial perception of the team about the weaknesses and challenges in the work process of the FHS of the municipality of Pato Branco. The second one reveals the ‘meeting movements’ that management and workers carried out to solve problems, finally, the third one deals with the strategy of using CNV and the Circular Process in the teamwork process.

FIRST MOMENT

The Alvorada Health Unit is one of the oldest in the municipality of Pato Branco and assists about 6.000 people, divided between two teams (FHS 1 and FHS 2), with assigned territories. Each team consists of a doctor, a nurse, a dental surgeon, an oral health assistant, two nursing technicians, and six Community Health Workers (CHW). The team that received the intervention was the FHS 2, which at the time had around 3.200 people registered. The team experienced difficulties in interpersonal relationships between professionals, distance between them and frequent conflicts. There was an imminent need for greater attention from managers and team members regarding the development of mechanisms that would reinforce interaction and integration among their members. There was no clear definition of team management; and intuitively, the nurse eventually assumed the leadership role, organizing team meetings every Friday afternoon to plan activities and expose needs.

The meetings were conflicting and generally no clear conclusions were drawn about what was causing the disagreements. Some points were recurrent in these meetings, such as the high demand of the population for physician-centered care, which distanced users from other team professionals and the low adherence of the population to education and prevention groups offered by professionals, especially the walking group for hypertensive and diabetic patients. This group emerged in 2013, with the implementation of the Family Health Support Center (Nasf) in Pato Branco, and was entitled ‘Hiperdia for walking’. At the time of its implementation, there was a change in the concept of health education of team professionals, previously focused on drug delivery and lectures with little variation in theme.

The main goal of ‘Hiperdia for walking’ was to stimulate the creation of walking groups for hypertensive and diabetic patients in the municipal health units. At the beginning of the group, the participation of professionals and the population was significant, Nasf professionals participated supporting the team on pre-established days, usually twice a week. Over time, it became apparent that the FHS team was no longer responsible for this activity as before. They came to realize that, as the group was designed by Nasf, only its professionals should lead it. At this point, the nurse realized that the flaws in the work process were worrying and that the internal conflicts did not favor so that they could be found and corrected.

SECOND MOMENT

Through team meetings and the perception of conflicts, the FHS 2 nurse saw the possibility of applying restorative practices as a possible tool for improving failed processes. Knowledge about the existence of these practices by the professional occurred between 2017 and 2018, when she participated in the Improvement Course in Basic Health Unit Management, Clinical and Care Management. The first activity performed was based on the Circular Process using the speech stick with the participants. During the activity, the nurse also used CNV strategies, which is an effective form of communication that involves, among others, empathic listening and the reformulation of the message that consists of paraphrasing some speeches, without including a judgment. Self-messages and restorative questions were also used to stimulate reflection and listening to feelings and needs, always seeking different points of view of the situation⁵5 Abrahão AL, Franco CM. Curso de Aperfeiçoamento em Gerência de Unidades Básicas de Saúde, Gestão da Clínica e do Cuidado. Niterói: CEAD-UFF; 2016..

The Circular Process or Peacemaking Circle comes directly from the traditional Circles of Dialogue common to the indigenous peoples of North America. Circular space ensures more autonomy for participants, leads to team empowerment, generates horizontal relationships, improves the sense of belonging to the group and is a powerful tool for dialogue. The author points out that there are several types of Peacemaking Circles, related to different purposes and motivations⁶6 Pranis K. Processos Circulares. São Paulo: Palas Athena; 2010..

At BHU, circular processes can be used for warm-up activities, to calm down possible disagreements or discords; to ward off misconceptions, disagreements and potential violence or to build and restore relationships; for conflict resolution and other problems; to discuss collective responsibility, among other functions. They also allow shy people who rarely speak to express themselves, generating inclusion, and enabling those who often dominate collective spaces to learn to listen and respect other opinions.

Following the characteristics of the Circular Process, the participants sat in the chairs arranged in a circle, without a table in the center. Some object that has special meaning for the group, such as inspiration, should be placed in the center, something that evokes in the participants common values and bases⁶6 Pranis K. Processos Circulares. São Paulo: Palas Athena; 2010.; and in the reported process, the object was a hiking shoe.

This meeting was attended by the Nasf team, who started the conversation, emphasizing the project ‘Hyper day for walking’. Subsequently, the team designated the nurse, as the speech guardian or facilitator, who should be a group person and properly trained to ensure a fair and impartial process⁷7 Amstutz LS, Mullet JH. Disciplina restaurativa para escolas: responsabilidade e ambientes de cuidado mútuo. São Paulo: Palas Athena; 2012.. The facilitator is the person who ensures that the group remains firm in their willingness to listen and focus on the theme that motivated the circle. In addition, the facilitator is not neutral, as he/she participates in the process and contributes to his/her perceptions⁵5 Abrahão AL, Franco CM. Curso de Aperfeiçoamento em Gerência de Unidades Básicas de Saúde, Gestão da Clínica e do Cuidado. Niterói: CEAD-UFF; 2016..

The speech guardian explained the methodology of the Circular Process, in which the word is made available to those present, in a sequential and rotational manner⁸8 Brancher L, Kozen A, Aguinsky B. Justiça Restaurativa. Brasília, DF: CEAG; 2011. [acesso em 2019 dez 20]. Disponível em: http://www8.tjmg.jus.br/jij/apostila_ceag/MODULO_IX.pdf.
http://www8.tjmg.jus.br/jij/apostila_cea... . A speech stick is used, which is a focal object accepted and used by the group, and has special meaning for the group; and, at the meeting in question, a bottle of water was chosen. The stick provides an opportunity to listen and reflect before speaking, as everyone must wait their turn to speak when they receive the speech stick⁷7 Amstutz LS, Mullet JH. Disciplina restaurativa para escolas: responsabilidade e ambientes de cuidado mútuo. São Paulo: Palas Athena; 2012.. In the report in question, the guardian presented the guiding question of the circle: what are the main weaknesses and challenges in the work process to carry out the project ‘Hiperdia for walking’ at BHU? Beginning the passage of the speech stick and informing that only those who had the object in hand have the ability to speak.

Through this process, participants tend to listen carefully to what people are saying rather than thinking about preparing an immediate response. The circle also reinforces equality, as it provides an opportunity for everyone to participate, and encourages those who speak little to express themselves and provides an opportunity for listening to those who speak a lot⁷7 Amstutz LS, Mullet JH. Disciplina restaurativa para escolas: responsabilidade e ambientes de cuidado mútuo. São Paulo: Palas Athena; 2012..

During the Circular Process, the nurse had to interfere in noticing some exchanges of accusations, which cannot be admitted in the Circular Process, since each participant needs to answer the question according to their own reference. In the process, the facilitator was able to identify both the points most resilient and opposed to the project and discover potential for collaboration. After everyone put their speeches, the nurse was able to realize that the main weakness in the conception of the team would be the issue of the departure time of the walking group. In principle, this departure would happen early in the morning, but the unit’s technical staff cannot follow due to the flow of attendances at this time. Later on, the closing ceremony was held with a video on collaborative work. In the days following the application of the Circular Process in the team meeting, the nurse felt the need to talk to some professionals. First, she sought out the CHW who are closest to the community, so that, during that week, before there was another team meeting, they would check the community for other possibilities of schedules for the group to take place, in order to facilitate the participation of the population. They were supportive of the activity, because they knew the patients and their needs. The relevance has to do with the commitment of the team, when the members feel that, in fact, they belong to it and work for the objectives and goals set by the team⁵5 Abrahão AL, Franco CM. Curso de Aperfeiçoamento em Gerência de Unidades Básicas de Saúde, Gestão da Clínica e do Cuidado. Niterói: CEAD-UFF; 2016.. The CHW felt appreciated at the request of the nurse and talked with several people of the community with interest in the group and evidenced that, because it is hot periods of the year, the first hour of the morning would be more pleasant to walk.

The nurse then sought out the nursing technicians, as they had shown concern during the speech stick activity feeling overwhelmed early in the morning, as this is the moment with the largest flow of patients in the unit. In these conversations, she used principles of CNV, adopting the strategy of restorative questions that aim to trigger collaborative dialogues, as they facilitate the reflection and listening of feelings and needs and help to restore broken relationships, and bring greater clarity of what is happening, leading also the verification of different points of view⁵5 Abrahão AL, Franco CM. Curso de Aperfeiçoamento em Gerência de Unidades Básicas de Saúde, Gestão da Clínica e do Cuidado. Niterói: CEAD-UFF; 2016.. The nurse asked some questions and noted that technicians were more collaborative in participating in the activity on certain days of the week when patient flow was not so intense early in the morning and that, then, a technician could check the vital signs of the participants.

The conversation with these workers sought to follow the four components of CNV: observation, recognize the feelings involved with the observed facts, recognize the needs and requests, proving extremely important for the nurse to schedule the next team meeting, entering this way in a third moment of change. Adopting CNV in the routine of the manager’s activities means to hear in essence the observations, feelings, needs and requests expressed by the team, without judgment of what motivates each expression. It is important to highlight that the way of speaking with calm and the pleasant tone of voice, used in the meeting, made all the difference when the request was made to the team⁹9 Rosemberg MB. Comunicação Não-Violenta: técnicas para aprimorar relacionamentos pessoais e profissionais. São Paulo: Ágora; 2006..

CNV components have demonstrated that they are important tools and can make a difference in the success of the conflict approach if used by managers/team leaders.

If the Unit manager is unprepared and motivated to deal with the conflicts that routinely appear on the team, he/she turns his/her requests into demands and is interpreted as aggressive by others. Usually, professionals are not empowered by universities or their employers to manage conflict, and only after a series of misconceptions and enmities they end up seeking improvement to minimize the problems they face in everyday life.

THIRD MOMENT

The nurse gathered the information provided by the CHW and the nursing technicians and prepared a proposal to be assessed and discussed by the professionals about the format of the walking group. The meeting was prepared again according to the Circular Process conception, since the tool was well evaluated by the team.

After the speeches in the circle about the new proposal, the team was able to reflect and realize that they could think of other strategies to develop the group and not compromise the activities performed internally at the Unit and decided to support the structuring of the walking group, with co-responsibility for conducting the activities and scale of participation of professionals in the group.

Using the Circular Process and CNV to listen, motivate and encourage team cooperation was fundamental for the development of the group. The strategies used aroused in the team members the co-responsibility in caring for the hypertensive and diabetic population that resides in their area of coverage.

It was possible to observe the uniqueness of the team members, as human beings, some showing availability and flexibility, others some resistance to leaving their comfort zones.

The walking group at the Alvorada Health Unit started again with few participants, but as the days went by, with more people invited by the team, it was taking larger proportions. It is noticeable that there is rotation among its members, because they participate when they can, it is not a closed group, but the most assiduous are always present.

The participation of patients in the group showed greater rapport with the team; and in the most assiduous patients, after approximately one year of the group, it is possible to verify some improvement in the blood pressure and glycemic indexes. The CHW were once again important in the link between the community and the team, as they routinely follow the walks in the Unit, contributing to the group’s success.

Final considerations

The implementation of restorative practices through the use of CNV and the Circular Process produced positive results, such as the rescue of interpersonal relationships, greater integration and accountability of the health team, the production of meetings focused on listening that facilitated collective reflection, a qualification of work management and the return of walking groups for hypertensive and diabetic patients.

The logic of qualified listening and the use of the CNV components effectively contributed to the joint planning, stripping participants of judgments, allowing each member to contribute more assertively to the development of the proposed activities.

The professional who takes a leadership position in the team must not only have empathy and respect for other professionals, but also live with different opinions and try to know the limitations and potentialities of their team. Restorative practices help in this process, as they place the leader in a position similar to the others, generating equal participation opportunities, allowing team expression, without imposition. Thus, the group builds an environment of mutual accountability, minimizing possible crises and interpersonal conflicts.

The importance of conducting studies in this area is emphasized, as well as the introduction of the subject in disciplines during the training period, in order to present management and assistance professionals with tools to deal with conflicts that may occur in their future activities professionals.

References

Publication Dates

History