ABSTRACT

This paper discusses the findings of a research that tried to elucidate the experience lived by managers of Basic Health Units (BHU) with a perspective to contribute with health managerial development. The methodology used in the research was phenomenology and hermeneutic and the history collections were held through a deep interview. When they became managers, they faced an intense, varied and fragmented routine and they were astonished by institutional priorities that prevented their agenda implementations. Highly dependent on other sectors, they needed to organize a wide relationship network inside and outside the institution. Standing tensions, solving problems, and overcoming challenges, they reviewed their concepts and passed through a conscious changing process that made them think and act as managers. Being a BHU manager meant, for each of them, being a changing agent, working under a high pressure environment and with low autonomy, leading transformation processes in his/her unit, due to the community where he/she is inserted.

KEYWORDS
Health services administration; Primary Health Care; Learning

Introduction

On a daily basis, many professionals are appointed as managers of Basic Health Units (BHU), most of whom are technicians in the field (nurses, dentists, doctors, psychologists and others), without any training to perform the new function.

The specialized literature points out that the management of the first level of organizations is usually the most difficult, because the demands of users, employees and superiors fall upon it¹1 Hill L. Novos gerentes. Rio de Janeiro: Makron Books; 1993.. The work processes of a BHU are complex, highly intangible, involving multiprofessional teams, with a scope of actions ranging from health promotion to patient rehabilitation. Demand is often diversified and not scheduled.

BHU management is considered difficult and with high stress level, due to high population demand, scheduling overload, interference from the most central levels of management and team management difficulties, leaving the manager with little time for planning²2 Barbieri AR, Hortale VA. Desempenho gerencial em serviços públicos de saúde: estudo de caso em Mato Grosso do Sul, Brasil. Cad. Saúde Pública. 2005; 21(5):1349-56.

3 Cubas MR. Planejamento local: a fala do gerente de Unidade Básica de Saúde. Rev Bras de Enferm. 2005; 58(3):278-283.^-44 Raupp B. Estudo da cultura organizacional como estratégia na sistematização de uma metodologia gerencial com enfoque na aprendizagem em situação de trabalho. Relatório de pesquisa. Porto Alegre: Grupo Hospitalar Conceição; 2006..

These observations correspond to researches in the area of administration, where the image of the manager who systematically plans, coordinates and controls is considered pure folklore. On the contrary, their activities are characterized by brevity, variety and fragmentation. Planning is precarious, with frequent reprogramming of their workday⁵5 Mintzberg H. The managers's job: folklore e facto. Harv. Bus. Rev. 1990; 53(4):163-78..

Despite the complexity of the function and the high turnover observed in the position of managers of BHU, little is done to support this professional, beyond the skills guided by outdated methods, which respond only to institutional interests.

This article is based on a thesis research⁶6 Loch S. Tornar-se gerente: a experiência vivida por médicos de família e comunidade ao assumirem a gerência de Unidades Básicas de Saúde [teste]. Florianópolis: Universidade Federal de Santa Catarina; 2009. 295 p., which sought to understand the experience lived by family and community physicians when taking over the management of BHU, with the perspective of supporting the development of managers in the area. This research was part of a larger set of initiatives and was funded by the Department of Primary Care of the Ministry of Health.

Methodology

The methodology used in the research that feeds this article was based on the interpretative paradigm. It was based on the view that reality is the product of the subjective and intersubjective experience of individuals, understood from the participant’s point of view rather than from the observer’s point of view⁷7 Morgan G. Paradigms, Metaphors, and Puzzle Solving in Organization Theory. Adm. Science Quarterly. 1980; (5):605-22..

The methodological approach was hermeneutical phenomenology, as presented by Max van Manen in his book ‘Researching lived experience’⁸8 Manen VM. Researching lived experience. New York: State University of New York Press; 1990.. To obtain the reports, Seidman’s in-depth, or three-time interview technique was used, which allows a progressive approach to the essence of the experience lived by the research subjects⁹9 Seidman I. Interviewing as qualitative research. New York: Teachers College Press; 1998..

The inclusion criteria of the research subjects were guided by the literature of the area, according to which the first experience as a manager is usually the most remarkable and the process of transformation from individual contributor to manager is greater in the first year of activity¹1 Hill L. Novos gerentes. Rio de Janeiro: Makron Books; 1993.. In this sense, family and community doctors, managers of BHU, who had their first experiences as managers in the last five years prior to the survey, were interviewed, with at least one year of experience, without specific training for the function and who were working in municipalities of the Greater Florianópolis Region (SC). Only six doctors met these inclusion criteria. To preserve their identities, respondents chose the codenames by which they are identified. The report and the article follow the phenomenological descriptive orientation and dialogued with literature.

The subjects agreed with the Informed Consent Form (ICF), in accordance with the determinations of Resolution nº 196 of the National Health Council¹⁰10 Brasil. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 196 de 10 de outubro de 1996. Normas regulamentadoras de pesquisas envolvendo seres humanos. Brasília, DF. Diário Oficial da União. 11 Out 1996.. The research was authorized by the Human Research Ethics Committee (Conep) of the Federal University of Santa Catarina through certificate nº 131, on May 25, 2009.

Results and discussion

The first experience as a manager is often remarkable in the lives of professionals, regardless of the size of their organization. During this period, the biggest discoveries and transformations in their behavior happen and that will mark them for a lifetime.

The new managers

When invited to be managers, the professionals interpreted the invitation as a recognition of their dedication and work. Knowing the problems of the unit where they worked, they saw in the invitation an opportunity to make changes in the unit and the possibility of interfering in the decisions of the secretary.

Initially, they had a comprehensive, motivational and inclusive stance. Its priorities were directed towards solving the unit’s structural and functional problems, supplying inputs, involving the team in local decision-making processes, and their personal strategic objectives.

However, the new managers were surprised by a huge bureaucratic workload, lack of autonomy to solve problems and a routine for which they were not prepared:

The manager of a BHU acts as a respondent, in real time, to the numerous problems and demands that emerge from moment to moment on all sides, leaving him little time for planning. This observation corresponds to Mintzberg’s findings, in his study of top executives, in which he observed that his routines were intense, varied, and fragmented, and that the image of the manager planning, executing, monitoring, and evaluating was pure folklore⁵5 Mintzberg H. The managers's job: folklore e facto. Harv. Bus. Rev. 1990; 53(4):163-78..

Similarly, the new managers could not get rid of their technician agenda and acted as wildcards, replacing missing professionals, meeting demand and renewing revenues, which made their daily lives even more chaotic. To be able to do their work, they had to master their time and set a priority agenda.

The manager’s agenda

A manager’s agenda represents his/her priorities. It is usually tacit, with goals and strategies built on the secretariat’s plans, the information gained from its contacts, and its experiences and personal impressions on health¹¹11 Kooter JP. What effective general managers really do. Harv Bus Rev. 1999; March/April: 145-60..

Initially focused on the unit’s functional problems, the agenda was soon dominated by the demands of the health department. Bureaucratic routine, emergency reporting, interference with local work, last-minute meetings, the need to attend institutional events, and other unanticipated demands prevented their priorities from being implemented. The reaction to the central interference was intense, a factor of revolt and great psychological distress:

While the managers were focused on their priorities, the expectation of the superiors with their appointment was that they would give way to the institutional agenda. They soon discovered that institutional demands were the most important and that, in addition to their agenda, there were others: those of their superiors, their employees/employees and the community. To implement their priorities, they would need to meet different expectations and, above all, negotiate a lot.

Managers’ performance is the result of the balance struck between the things they are required to do, the things they cannot do and, ultimately, their choices¹²12 Stewart R. A model for understanding managerial jobs and behavior. Acad. Manag. Rev. 1982; 7(1):7-13.. Over time, they realized the importance of bureaucratic activities and that meetings were opportunities to establish contacts, to know institutional priorities and to identify opportunities to implement their already completely reconfigured agenda.

The political agenda of managers was the most difficult to absorb. Although they had lived with politics early on, as unit officials, now as managers, these issues began to tangible their lives. The initial tension was great, but they learned and developed strategies to interfere with campaigns, making contacts, publicizing proposals for the unit, and making movements to accommodate electoral promises without major interference in local work.

The relationships network

Highly dependent on other sectors of the health department to implement their agenda, managers had the support of their employees and countless people outside the unit. Strategic sectors of the secretariat, such as people management, warehouse and information technology, were quickly articulated, as well as outsiders, such as teachers and even politicians.

Studying the trajectories of these professionals showed that, the broader their network of relationships, the more efficient and effective their performance in terms of schedule implementation and tenure has become. It was through this formal and informal network, that managers obtained information, monitored the environment, were able to influence decisions that they considered important to their unit and identified opportunities:

Studies show that newcomer managers tend to take longer to formulate and implement their agenda because they do not yet have a good structured network of contacts¹¹11 Kooter JP. What effective general managers really do. Harv Bus Rev. 1999; March/April: 145-60.. Relationship was a critical resource for success. Contrary to expectations¹1 Hill L. Novos gerentes. Rio de Janeiro: Makron Books; 1993., BHU managers supported each other little, giving preference to relationships with superiors in the technical areas (family health strategy and program areas) and with the unit’s employees. The relationship with the community, although sometimes conflicting, due to the pent-up demand and the difficulties of access to exams and specialized consultations, was the most peaceful and linear.

The relationship with superiors of the highest hierarchical level was the most conflicting of the entire relationship network. Managers responded to their agendas, unit interventions, lack of inputs and information, and policy decisions. In some cases, it was possible to evolve into discussion and mutual learning processes; in others there were direct confrontations and burnouts, in which the manager and his unit lost the most.

It is interesting to note that most managers referred to their superiors as ‘secretariat staff’, ‘secretariat’, ‘central level’, as if they belonged to another institution of which they were not part.

The interface with employees was the agenda that most occupied the time of managers. Consumed between bureaucracy and management priorities, they had to rely heavily on their collaboration. Knowing how to listen, negotiate conflicts, motivate, technically support, have credibility and articulate the team was fundamental to local management.

Being able to structure a good team was essential. As they had no autonomy to hire and did not participate in selection processes, it was through the network of contacts that they were able to influence the selection and deployment of personnel for their unit.

The strategy most used by BHU managers to mobilize and commit staff to the implementation of agendas was participatory management. This management style provides several benefits, such as improving decision quality, increasing decision acceptance, developing members’ skills to analyze problems, and facilitating conflict resolution. It is related to high satisfaction, low stress, low absenteeism and better response to managerial initiatives¹³13 Yukl G. Leadership in organizations. New Jersey: Prentice Hall; 1998.. It contributes to the rescue of health technical subjects, to accountability, motivation, empowerment, learning and as a mechanism for changing institutional culture³3 Cubas MR. Planejamento local: a fala do gerente de Unidade Básica de Saúde. Rev Bras de Enferm. 2005; 58(3):278-283.^,1414 Merhy EE. O SUS e um dos seus dilemas: mudar a gestão e a lógica do processo de trabalho em saúde (um ensaio sobre a micropolítica do trabalho vivo). In: Teixeira SF. Democracia e Saúde. São Paulo: Cebes; 1998.^,1515 Rivera FJU, Artmann E. Planejamento e gestão em saúde: flexibilidade metodológica e agir comunicativo. Ciênc. Saúde Colet. 1999; 4(2):355-365..

BHU can be considered Knowledge-Intensive Organizations (OIC). These organizations are characterized by having their work processes based on the knowledge and intellectual ability of their teams; teams have a high degree of autonomy in service development; often have horizontal operating structures based on teams that work in a flexible and integrated way and use communication intensively for coordination and problem solving; work is user-centered and requires articulation of solutions; there is a power asymmetry, making users rely on workers’ skills to solve their problems; and quality of service assessment is difficult due to the degree of complexity of the problems and the high participation of users in work processes¹⁶16 Cunha CJCA. O processo de criação do conhecimento em Unidades Básicas de Saúde. In: Anais do 16 Simpósio de Engenharia de Produção; 2009 Nov 9-10; Bauru. Bauru: SIMPEP; 2009..

These units need specific management processes, that facilitate and motivate the process of knowledge exchange and creation, both tacit and explicit¹⁶16 Cunha CJCA. O processo de criação do conhecimento em Unidades Básicas de Saúde. In: Anais do 16 Simpósio de Engenharia de Produção; 2009 Nov 9-10; Bauru. Bauru: SIMPEP; 2009.. In this type of organization, where the production process depends on the knowledge of each team member and there is little technology support, local management models generate high levels of dissatisfaction and are often unproductive, as workers need to be motivated to mobilize their knowledge and contribute positively to the production of services.

Knowing of the alternation of governments and the likelihood of becoming individual employees in their units again, concerned about the possibility of retaliation in the future, BHU managers had a hard time assessing their employees and taking often unpopular attitudes:

Researches indicate that the ability to monitor and evaluate subordinates is associated with the maturity and performance of managers¹1 Hill L. Novos gerentes. Rio de Janeiro: Makron Books; 1993.^,1313 Yukl G. Leadership in organizations. New Jersey: Prentice Hall; 1998.. Different strategies were used: some visited all sectors daily, others were part of the different work processes, and others in meetings supported by information about the work in the unit.

Making an employment ‘contract’, even informal, was an important strategy used to facilitate evaluation. Discussing and negotiating with employees expectations, standards of living and work processes facilitate future crisis assessment and management, as there is an established pact, a starting point for evaluations.

In order to be respected, managers had to gain credibility and trust from their teams. They were observed and evaluated all the time by their collaborators. It was necessary to set a good example, to provide technical support and to guarantee backing for the agreed behaviors:

The manager role requires new attitudes and behaviors, different from those performed as unit technicians. A balance must be struck between support and recovery, between protection and exposure, between distance and proximity; you need to position yourself as a manager¹1 Hill L. Novos gerentes. Rio de Janeiro: Makron Books; 1993..

Keeping superiors informed about work at BHU was a preventive measure used, as some employees resort to them in situations of conflict, which may trigger contradictory actions and interference in the unit.

Staff shortages were the most constant problem managers faced. To deal with it, they had mainly the support of the unit staff:

Since replacement or substitution of staff is often time consuming in the public service, working hours and negotiating time off were the only resource managers relied on to absorb demand and overcome problems arising from staff shortages.

To assist them in managing the unit, managers relied on the support of their staff and, most precisely, a few people who could do their work. Although reluctant to transfer their work, managers had to learn to delegate.

The level of delegation varies according to the magnitude of the responsibilities, the level of freedom to decide, the authority received, the nature of the decisions, and the access to information. In general, it results in greater commitment from subordinates, decreases manager overload and contributes to the formation of new leaders¹³13 Yukl G. Leadership in organizations. New Jersey: Prentice Hall; 1998..

Another important learning observed was living with old and new servers. BHU managers, mostly young, tended to regard former employees as poorly committed, outdated, and resistant to change. However, if it was difficult to engage them in the processes of change, they were also the oldest who sustained the units in times of crisis (due to lack of employees, inputs or support from superiors), as they already had their strategies to live with the chronic problems of the institution.

Shortcomings in the training of new staff and the secretariat’s delay in responding to training needs were overcome by local training initiatives involving the entire staff of the unit. The inexperience in the relationship with the community, especially in regions with high violence, was overcome with initiatives that facilitated the sharing of experiences with veterans.

According to the literature in the area, the insertion of newcomers in an organization usually has a frequent path, represented by a set of trials that are submitted until they are inserted in the communities of practice, the groups that influence the decisions of the organization. Knowledge of this pathway can guide initiatives aimed at facilitating this journey, reducing individual stress and speeding up their contribution to the institution¹⁷17 Gherardi S, Nicole D, Odella FS, et al. Toward a social understanding of how people learn in organizations. Manag. Learning. 1998; 29(3):273-97..

The intensity of professional work in a BHU, the high participation and proximity of users imply continuous possibility of review and creation of innovative opportunities¹⁸18 Almeida HAC, Bianco MF. A estratégia de saúde da família: uma contribuição da análise ergológica à administração. In: Anais do Encontro Nacional de Pós-Graduação e Pesquisa em Administração; 2007; Rio de Janeiro. Rio de Janeiro: Enampad; 2007., in which the performance of a leader/manager can have an important impact on the unit’s performance.

The learning path

The managers of the BHU surveyed had experienced an intense work routine, low autonomy and high dependence on other sectors, conflicts with superiors and difficulties in dealing with their employees. To survive on the job, they had to quickly review their agenda, build a broad network of contacts, and motivate the team.

In this journey, the tension was great, and their conceptual reference system no longer gave them any insight into the new reality. Rejection, anxiety, clashes and questions began to be part of your daily life:

In order to gain some autonomy and make the unit work, managers had to learn to take risks and develop their activities despite core orientations and likely later retaliations:

Fear in management is a recurring theme. Executives experience different feelings of fear (of rejection, of making mistakes, of incompetence and of impaired image), usually accompanied by physical and mental signs, such as fatigue, anxiety and tachycardia¹⁹19 Meinicke D. O medo na gerência [dissertação]. Florianópolis: Universidade Federal de Santa Catarina; 2003. 105 p., as also observed in this research.

Setting their ethical boundaries and learning to handle power were also important learning. Although the first-level manager has little autonomy, he/she has a lot of power: the power over local decisions as well as directing facts and situations to superiors, and vice versa. It is the bridge between the organization and employees and can amplify or diminish local problems, intervene in work processes, and other relevant decisions.

Every conflict, every difficulty faced, managers were thrown into deep questioning, a process of action-reflection-action that provoked changes in their behaviors and ways of interpreting reality. It is the transformational learning discussed by Mezzirow¹1 Hill L. Novos gerentes. Rio de Janeiro: Makron Books; 1993.^,2020 Mezirow J. Transformative learning as discurse. J Transfor Educac. 2003; (1):58.^,2121 Mezirow J. Contemporary paradigms of learning. Adult Education Quarterly. 1996; 46(3):158-73.. This process led them to a true process of identity change²⁰20 Mezirow J. Transformative learning as discurse. J Transfor Educac. 2003; (1):58.^,2121 Mezirow J. Contemporary paradigms of learning. Adult Education Quarterly. 1996; 46(3):158-73., which led them to act and think as managers. They, then, became part of another community of practice: that of managers¹1 Hill L. Novos gerentes. Rio de Janeiro: Makron Books; 1993..

These changes were felt not only in the workplace, but also in personal life. They have become more agile, more active, more communicative.

Facing problems, overcoming difficulties and reflecting on their experiences, managers learned, as predicted in the literature, in practice¹1 Hill L. Novos gerentes. Rio de Janeiro: Makron Books; 1993..

In this learning process, they mainly used four resources²²22 2Mccauley CD. Developmental experiences in managerial work: a literature review. Greensboro: Center for Creative Leadership; 1986.: experience as an individual contributor, networking, formal training, and assessments.

The individual contributor experience of the unit employee prior to promotion served as the basis for structuring the initial agenda, composing the list of interpersonal relationships, interface with the population, and employee support¹1 Hill L. Novos gerentes. Rio de Janeiro: Makron Books; 1993..

The network of relationships has become an important source of teachings through the numerous contacts and information exchange they have made. People who admired, who marked their lives, also served as a model²¹21 Mezirow J. Contemporary paradigms of learning. Adult Education Quarterly. 1996; 46(3):158-73.. They analyzed their behaviors and acquired not only skills, but also values, attitudes, and even emotional support¹1 Hill L. Novos gerentes. Rio de Janeiro: Makron Books; 1993..

The specialized literature on managerial learning credits formal and academic training with a reduced impact on managers’ performance compared to learning in practice¹1 Hill L. Novos gerentes. Rio de Janeiro: Makron Books; 1993.^,2323 Clarck KE, Clarck MB. Choosing to lead. 2nd. Greensboro: Center for Criative Leadership; 1996.^,2424 Fox S. From management education and development to the study of management learning. In: Burgoyone J, Reynolds M, editors. Management learning: Integrating perspectives in theory and practice. [London]: Sage; 1999.. The training was cited, but referred to a training conducted by the health department addressing practical and conceptual aspects related to the management of BHU: planning, territorialization, performance evaluation, administrative flows, forms, computerized systems, among others.

Evaluations, both formal and informal, were important for managers to analyze their performance and correct possible failures. These assessments came mainly from subordinates and public feedback mechanisms, such as the ombudsman service. From the superiors, they did not receive evaluation or, at most, it was restricted.

Survey managers rated their experience as positive based on perceived professional growth. However, they made observations about the difficulties encountered.

The biggest complaint was the impossibility of planning a BHU. Consumed by the demands, those who were able to plan something did it through the delegation, or working after hours, but always partially and unsatisfactorily:

The meaning of being a PHC manager was, in the experience of these managers, defined as: being coordinator, organizer, articulator, mediator, catalyst, negotiator, pawn, strategist, negotiator and being leader:

Being a BHU manager meant, in the experience of the managers analyzed, being an agent of changes in a high pressure and low autonomy environment, organizing transformation processes in their unit, depending on the community in which it operates.

Final considerations

The study allowed to know the routine, the challenges and the strategies used by the managers of BHU. The research findings correspond to recent studies and research in the area of administration.

The work routine of managers is intense, varied and fragmented, with little time for planning. They are under pressure from users, employees, and their superiors to accomplish their agenda priorities.

To survive and keep the unit running, they reshaped their initial agendas, taking into account the institutional interests and those of their employees, and organized a large network of relationships. The network of relationships was composed of people from inside and outside the unit, involving strategic sectors of the secretariat, users, personal and even political reference persons. Through this network, managers sought information to evaluate the environment and identify opportunities to implement their priorities. The larger and more diversified the network of relationships, the more successful the managers were and the longer they remained in office.

Resources such as listening, empathy, knowing employees’ needs and expectations, being flexible, and living with imperfect solutions were critical to motivate their teams and implement their agenda. Participatory management style was an effective strategy used to motivate and commit teams to the unit’s work. Facing challenges and pressures, managers underwent a process of reflection and overhaul of concepts and values that resulted in a change of identity from individual contributor to manager. Being a BHU manager meant being a change agent in a high pressure and low-autonomy environment, leading transformation processes in their unit, according to the community where he/she was inserted.

The finding that management work is complex and tense and that learning takes place mainly from practice brings new perspectives to training and managerial development in health services. Such perspectives include the mobilization of the subjects for reflection through action, which stimulate self-knowledge, the exchange of experiences and make possible to diversify the network of contacts.

References

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