ABSTRACT

The Improvement Course in Management of Basic Health Units, Clinical and Care Management is offered in the context of qualifying primary care management, through partnership between the Ministry of Health and the Fluminense Federal University. Its purpose is to present tools with use value to the daily life of managers. In this context, one of the proposals to work on daily relationships is the Circular Process. This article aimed to evaluate the acceptance and application of this tool by managers of Basic Health Units. It is a qualitative, exploratory, and descriptive research, with analysis of secondary database, which contained 376 forms completed by graduates of the course. The object of analysis was the answers to the non-compulsory open question (n=321), which asked the student to identify a positive effect that could be attributed to the Course. A textual search for the words ‘circular’ and/or ‘conflict’ was carried out, and 62 answers containing at least one of these words were identified, constituting the final corpus of the analysis. The analysis allowed us to recognize that the Circular Process tool enhances the formation of a mediating manager profile and facilitates the work process, supporting the actions of managers of Basic Health Units.

KEYWORDS
Health management; Primary Health Care; Conflict

Introduction

The Improvement Course in Management of Basic Health Units, Clinical and Care Management, coordinated by the Fluminense Federal University from the initial demand of the Department of Primary Care of the Ministry of Health, has presented and problematized tools capable of enabling new arrangements in the facing the micropolitical challenges of daily life of Basic Health Units (BHU).

The management of health services remains a challenge for the consolidation of the Unified Health System (SUS) in Brazil. Despite the expansion of the actions and services offered, the need persists to build a continuous network of integral care, in order to integrate the different points of attention, optimize the application of SUS resources and consolidate its legitimacy with users¹1 Baduy RS, Feuerwerker LCM, Zucoli M, et al. A regulação assistencial e a produção do cuidado: um arranjo potente para qualificar a atenção. Cad. Saúde Pública [internet]. 2011. [acesso em 2019 out 6]; 27(2):295-304. Disponível em: http://dx.doi.org/10.1590/S0102-311X2011000200011.
http://dx.doi.org/10.1590/S0102-311X2011... .

In reality, there are several problems for health care, and these are not unique to the Brazilian health system. One of these problems is the fragmentation of services that hinders the production of comprehensive care for users²2 Giovanella L, Almeida PF, Vega RR, et al. Panorama de la Atención Primaria de Salud en Suramérica: concepciones, componentes y desafíos. Saúde debate [internet]. 2015 [acesso em 2019 out 6]; 39(105):300-322. Disponível em: http://dx.doi.org/10.1590/0103-110420151050002002.
http://dx.doi.org/10.1590/0103-110420151... . Many initiatives and models of organization of Primary Health Care have been implemented in response to the challenge of organizing health systems to respond to the mismatch between the health conditions of populations and the ability to cope with health systems³3 Giovanella L. A atenção primária à saúde nos países da União Européia: configurações e reformas organizacionais na década de 1990. Cad. Saúde Pública [internet]. 2006 [acesso em 2019 out 6]; 22(5):951-963. Disponível em: http://dx.doi.org/10.1590/S0102-311X2006000500008.
http://dx.doi.org/10.1590/S0102-311X2006... .

It is necessary for health services management to adopt active and differentiated policies in order to engage in actions capable of ensuring an equitable distribution of resources and the universality of access to health⁴4 Epping-Jordan JE, Pruitt SD, Bengoa R, et al. Improving the quality of health care for chronic conditions. Qual Saf Health Care. 2004; 13(4):299-305.. Health system reforms in the 1990s addressed problems from an economist perspective, reducing them to financial, scarcity, or misallocation issues⁵5 Iriart C, Merhy EE, Waitzkin H. La atención gerenciada en América Latina. Transnacionalización del sector salud en el contexto de la reforma. Cad. Saúde Pública [internet]. 2000 [acesso em 2017 maio 15]; 16(1):95-105. Disponível em: https://dx.doi.org/10.1590/S0102-311X2000000100010.
https://dx.doi.org/10.1590/S0102-311X200... . Thus, issues related to care and management users and workers were less important than the search for solutions linked to efficiency and the most cost-effective actions and services.

In this context, studies and experiments that could represent possibilities capable of improving the quality of the services offered began to be developed. Health care management can be defined as the provision or availability of health technologies, according to the unique needs of each person, at different times of their lives, aiming at their well-being, safety and autonomy to follow with a productive and happy life. It is important to highlight the porosity between micro and macropolitics in care production processes. To do so, ‘externality’ must be translated (administrators, researchers, managers) and ‘internality’ (the teams that provide care), allowing greater permeability between these spheres. However, the richness of the micropolitical level is emphasized for the adoption of differentiated health management practices, since care management takes place in multiple dimensions⁶6 Cecilio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado em saúde. Interface - Comunicação, Saúde, Educação [internet]. 2011 [acesso em 2017 maio 15]; 15(37):589-599. Disponível em: https://dx.doi.org/10.1590/S1414-32832011000200021.
https://dx.doi.org/10.1590/S1414-3283201... .

In this text, we intend to address especially one of these: the organizational dimension of care in the sphere of primary health care. It is worth mentioning that the centrality of health management is the organization of the work process, the definition of care flows and the adoption of devices shared by professionals, such as: agendas, protocols, team meetings, planning activities, evaluation, among others⁶6 Cecilio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado em saúde. Interface - Comunicação, Saúde, Educação [internet]. 2011 [acesso em 2017 maio 15]; 15(37):589-599. Disponível em: https://dx.doi.org/10.1590/S1414-32832011000200021.
https://dx.doi.org/10.1590/S1414-3283201... .

Several authors, however, emphasize that this dimension is present in health services marked by the technical and social division of work, the difficulty of teamwork and the lack of coordination and communication activities between people⁶6 Cecilio LCO. Apontamentos teórico-conceituais sobre processos avaliativos considerando as múltiplas dimensões da gestão do cuidado em saúde. Interface - Comunicação, Saúde, Educação [internet]. 2011 [acesso em 2017 maio 15]; 15(37):589-599. Disponível em: https://dx.doi.org/10.1590/S1414-32832011000200021.
https://dx.doi.org/10.1590/S1414-3283201...

7. Peduzzi M. Equipe multiprofissional de saúde: conceito e tipologia. Rev Saúde Pública [internet]. 2001 [acesso em 2019 jun 12]; 35(1):103-109. Disponível em http://dx.doi.org/10.1590/S0034-89102001000100016.
http://dx.doi.org/10.1590/S0034-89102001...

8. Leite RFBV, Grisi TM. Trabalho em equipe: representações sociais de profissionais do PSF. Psic Ciênc Profissão [internet]. 2008 [acesso em 2019 jul 5]; 28(2):374-389. Disponível em: https://dx.doi.org/10.1590/S1414-98932008000200012.
https://dx.doi.org/10.1590/S1414-9893200... ^-99 Brown J, Lewis L, Ellis K, et al. Conflicton interprofissional primary health careteams - can it beresolved? J Interprof Care [internet]. 2011 [acesso em 2017 maio 15]; 25(1):4-10. Disponível em: https://doi.org/10.3109/13561820.2010.497750.
https://doi.org/10.3109/13561820.2010.49... . In this sense, different conceptions and typologies of conflicts between workers and managers are recognized, which are related to the lack of collaboration at work; with the disrespect arising from asymmetrical relations between workers; with problem employee behavior; with personal problems; asymmetry with other management levels and the poor infrastructure of services¹⁰10 Carvalho BG, Peduzzi MA, Ayres JRCM. Concepções e tipologia de conflitos entre trabalhadores e gerentes no contexto da atenção básica no Sistema Único de Saúde (SUS). Cad. Saúde Pública [internet]. 2014 [acesso em 2019 out 6]; 30(7):1453-1462. Disponível em: http://dx.doi.org/10.1590/0102-311X00134613.
http://dx.doi.org/10.1590/0102-311X00134... .

Conflict is always conscious, and its outbreak and development occur both by the different positions the actors involved occupy in the structures and by their opposing intentionalities. These are phenomena, facts, behaviors that, in organizational life, constitute ‘noises’ and can be observed or hidden. Conflicts that require action from the manager or covert those that circulate in the ‘backstage’ and that, in the more traditional management systems, do not occupy the agenda of the board¹¹11 Oliveira CLC. É possível trabalhar o conflito como matéria-prima da gestão em saúde? Cad. Saúde Pública [internet]. 2005 [acesso em 2019 out 6]; 21(2):508-516. Disponível em: http://dx.doi.org/10.1590/S0102-311X2005000200017.
http://dx.doi.org/10.1590/S0102-311X2005... , are observed.

The Improvement Course in Management of Basic Health Units, Clinical and Care Management is offered in the context of qualifying primary care management in the public agenda and presents tools aimed at addressing conflicts through the so-called Restorative Practices. Peace circles are recognized as a restorative practice inscribed within strategies adopted by Restorative Justice, based on knowledge of indigenous communities, mainly from Southeast Asia and Canada¹²12 Pranis K. Processos Circulares. São Paulo: Palas Athena; 2010.. They are recommended by the United Nations and are gaining recognition for their conflict management capabilities and their application in various fields of social life.

Restorative practices are those in which one person assumes the role of facilitator and assists others (directly and indirectly involved) in carrying 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 ties between people¹²12 Pranis K. Processos Circulares. São Paulo: Palas Athena; 2010.. The application of restorative practices in justice and education is already known¹³13 Balaguer G. As práticas restaurativas e suas possibilidades na escola: primeiras aproximações. Subjetividades. 2014; 14(2):266-275.

14 Patino DMM, Gutierrez AMR. A justiça restaurativa: Um modelo comunitarista de resolução de conflitos. Rev Fac Derecho Cienc Polit - Univ Pontif Bolivar [online]. 2015 [acesso em 2019 jun 2]; 45(122):213-255. Disponível em: http://www.scielo.org.co/pdf/rfdcp/v45n122/v45n122a10.pdf.
http://www.scielo.org.co/pdf/rfdcp/v45n1... ^-1515. Secco ML, Elivânia P. Justiça restaurativa - problemas e perspectivas. Direito Práxis [internet]. 2018 [acesso em 2017 maio 15]; 19(1):443-460. Disponível em: https://dx.doi.org/10.1590/2179-8966/2018/32715.
https://dx.doi.org/10.1590/2179-8966/201... . However, there are few theoretically grounded experiences in the health field.

The Improvement Course in Management of Basic Health Units, Clinical and Care Management was designed to address the problems of daily life of BHU, and conflict management is one of the most frequent issues faced by managers. On the other hand, often, conflict management is one of the issues in which health management focuses less on, studies and incorporates into daily activities¹¹11 Oliveira CLC. É possível trabalhar o conflito como matéria-prima da gestão em saúde? Cad. Saúde Pública [internet]. 2005 [acesso em 2019 out 6]; 21(2):508-516. Disponível em: http://dx.doi.org/10.1590/S0102-311X2005000200017.
http://dx.doi.org/10.1590/S0102-311X2005... .

In the movement of prospecting and selection of tools for addressing conflicts in primary care, it was considered that the incorporation of the Circular Process (CP) would be interesting because of its power to respond to several objectives, such as: working on core human values (participation, respect, responsibility, honesty, interconnection, empowerment and solidarity); restore relationships affected by conflict; build relationships and strengthen the uniqueness of each other.

Thus, this article aimed to evaluate the acceptance and application of the CP tool in BHU management from the proposition of the Improvement Course in Management of Basic Health Units, Clinical and Care Management.

Methods

Exploratory and descriptive research was developed. The study was exploratory and qualitative in nature, in order to discover ideas and intuitions, in an attempt to gain greater familiarity with the researched phenomenon. In this sense, exploratory studies make it possible to increase researchers’ knowledge of the facts, allowing for a more precise formulation of problems; and they are useful for diagnosing situations, exploring alternatives or discovering new ideas¹⁶16 Zikmund W. Business research methods. 5. ed. Dryden: Fort Worth, TX; 2000.^,1717 Gil AC. Como elaborar projetos de pesquisa. 4. ed. São Paulo: Atlas; 2008.. This research aimed to investigate the application of a conflict approach tool, in order to contribute to the construction of knowledge in the area. On the other hand, the study was descriptive insofar as it sought to describe characteristics of a given population or phenomenon, without making a commitment to explain the phenomena described, although its results may be the basis for such an explanation¹⁸18 Gil AC. Métodos e técnicas de pesquisa social. 5. ed. São Paulo: Atlas; 1999.^,1919 Vergara SC. Projetos e relatórios de pesquisa em administração. 3. ed. São Paulo: Atlas; 2000..

The secondary database belonging to the Improvement Course in Management of Basic Health Units, Clinical and Care Management, which gathered the evaluations of graduating students, carried out from July 1st to 31st, 2018, was used. The questionnaire was designed and made available by the course coordinator, via the learning environment, using Google Forms. It contained closed questions focused on the evaluation of the contents proposed by the Units of Learning and a non-compulsory open question – which asked the student to identify a positive effect that could be attributed to the Course.

The link was directed to the 504 graduates of the Improvement Course in Management of Basic Health Units, Clinical and Care Management, all professionals with higher education degree in health and responsible for the management of BHU in municipalities of all states of the Country. In the database, 376 records were found for the compulsory questions and 321 for the non-compulsory open question.

In a preliminary analysis, it was possible to identify that, among the manager support tools presented by the course, the CP was particularly well evaluated. On a scale where 1 was the minimum value and 4 the maximum value, the maximum score reached 82.4% of the answers. Comparing with the analysis of the other tools offered by the course (decay flowchart, singular therapeutic project and Kanban/materials management), the CP obtained the highest percentage in the maximum score (4) and in the sum of the scores (4 and 3).

The object of analysis was defined by 321 answers to the open question, seeking to explore the presence of citation about the tool ‘circular process’. For this stage, all open responses were aggregated into a single file, where each respondent corresponded to one line and the textual search for the words ‘circular’ and/or ‘conflict’ was performed. 62 (19.3%) answers containing at least one of these words were identified, constituting the final corpus of analysis.

The answers to the open question of the 62 respondents were analyzed according to the principles of thematic content analysis that allow us to highlight the information obtained, propose inferences and perform interpretations according to a theoretical framework. Bardin points out that thematic analysis consists in discovering the ‘nuclei of meaning’ that make up communication and whose presence or frequency of appearance may mean something to the analytical objective chosen²⁰20 Bardin L. Análise de Conteúdo. São Paulo: Edições 70; 2016.

Responses were read collectively among the researchers; and, from this procedure, an analysis grid was elaborated, in which the units of analysis were defined based on the repetition of the content common to most respondents.

Results and discussion

The identified central aspects formed two units of analysis of greater relevance for discussion: Circular Process as a tool for forming a manager profile; and Circular Process as a tool that facilitates the work process.

Circular Process as a tool for forming a manager profile

The graduates of the course are professionals with health education who perform the function of manager of basic units or intermediate management in primary care, within the exclusive scope of SUS. They recognize the fragility of their university education to deal with the team: “despite college, I was not fully prepared [...], there was a lot of insecurity and little didactics to deal with the multidisciplinary team” (C16).

The ability to build healthy and collaborative interprofessional relationships is poorly addressed in university education. Brazilian undergraduate courses devote little time to issues outside the traditional biomedical training model. This is based on a Cartesian view of separation between body and mind, which disqualifies psychological, social and environmental aspects involved in the process of illness of the individual, reduced to a biological organism²¹21 Perez EP. A propósito da educação médica. Rev Bras Saúde Mater Infantil [internet]. 2004 [acesso em 2019 out 6]; 4(1):9-11. Disponível em: http://dx.doi.org/10.1590/S1519-38292004000100001.
http://dx.doi.org/10.1590/S1519-38292004... . In this model, the unpreparedness of workers to perform their professional functions, the high cost of health services based on specializations and the inability to meet the real needs of the population coexist.

In addition, curriculum contents give higher priority to individual health problems than to collective health problems and disregard the psychic, affective, historical and cultural factors of human illness. In this model, cognitive aspects are valued over other possibilities, such as the development of the capacity for analysis, criticism and personal elaboration, and the adequacy of training to reality is also hampered by the fact that the academy prioritizes what was legitimized by traditional science rather than the knowledge that comes from the challenges of work. There is little incentive to think critically about reality in order to produce answers to everyday questions, and learning from the situations experienced in services is often disregarded²²22 Saippa-Oliveira G, Koifman L, Pinheiro R. Seleção de conteúdo, ensino aprendizagem e currículo na formação em saúde. In: Pinheiro R, Ceccim RB, Mattos RA. Ensinar saúde: a integralidade e o SUS nos cursos de graduação na área de saúde. Rio de Janeiro: IMS/ UERJ; Cepesc; Abrasco; 2006. p. 205-27..

Criticisms of the hegemonic model of health professions formation led to movements that culminated in the publication of the National Curriculum Guidelines (DCN), directed to undergraduate courses in health. DCN represent an attempt to break with this traditional reductionist model of biologicist formation and have influenced curricula in health education²³23 Feuerwerker L, Almeida M. Diretrizes curriculares e projetos pedagógicos: é o tempo de ação! Rev bras enferm [internet]. 2003 [acesso em 2019 out 6]; 56(4):351-352. Disponível em: http://dx.doi.org/10.1590/S0034-71672003000400006.
http://dx.doi.org/10.1590/S0034-71672003... .

A formation proposal needs to consider meeting with the other. Thus, possibilities are created for new self-arrangements, for the construction of new looks and for questioning certainty. However, this meeting also reveals tensions and conflicts²⁴24 Chagas MS. Chamei a morte para roda ela quis dançar ciranda, mudança: estudo descritivo sobre o processo de cuidar diante da finitude. Rio de Janeiro: Faculdade de Medicina; 2016. 287 p.^,2525 Chagas MS, Abrahão AL. Care production in health team focused on living work: the existence of life on death territory. Interface (Botucatu). 2017; 21(63):857-67.. Acting as a BHU manager means being in dialogue at the same time with both the care and management team of professionals and the set of users who demand and have multiple and unique care needs, each of which is a multitude. All have opinions and participate in the constructions and criticisms related to health, the organization of the service and the way they feel in life²⁶26 Nunes EFPA, Carvalho BG, Nicoletto SCS, et al. Trabalho gerencial em Unidades Básicas de Saúde de municípios de pequeno porte no Paraná, Brasil. Interface (Botucatu) [internet]. 2016 [acesso em 2019 out 06]; 20(58):573-584. Disponível em: http://dx.doi.org/10.1590/1807-57622015.0065.
http://dx.doi.org/10.1590/1807-57622015.... ^,2727 Feuerwerker LCM. Micropolítica e saúde: produção do cuidado, gestão e formação. Porto Alegre: Rede Unida; 2014.. Therefore, being a manager is not a trivial task, it is important to have knowledge and skills that allow you to play this role based on a welcoming reference and mediator of daily conflicts.

From the revision of the guidelines of the National Policy of Primary Care (PNAB), through Ordinance nº 2.436, of September 21, 2017, we observed changes about the organization and operation of BHU, and the inclusion of the figure of the primary care manager aiming at

It is up to the professional in this role, therefore, to ensure planning according to local needs, as well as to manage and organize the work process, integrating BHU actions with other services.

In this sense, the work of managers has the potential to make positive changes in the organization of health services, and it is worth highlighting the importance of such a movement being inscribed in the concept of Permanent Health Education (PHE). This presupposes revealing, in the work processes, the complexity and articulation of the different problems and makes evident the need for multiple strategies, which, in order to be proposed and implemented, need to be articulated with the management of the health system in an intersectoral, interdisciplinary, multidisciplinary and interprofessional. In this sense, it is also presented as a management strategy, so that the resources needed to organize work processes can be mobilized to face health challenges from the perspective of the integrated network²⁹29 Ceccim RB. Educação Permanente em Saúde: descentralização e disseminação de capacidade pedagógica na saúde. Ciênc. Saúde Colet. [internet]. 2005 [acesso em 2019 out 6]; 10(4):975-986. Disponível em: http://dx.doi.org/10.1590/S1413-81232005000400020.
http://dx.doi.org/10.1590/S1413-81232005... ^,3030 Silva JAM, Peduzzi M. Educação no trabalho na atenção primária à saúde: interfaces entre a educação permanente em saúde e o agir comunicativo. Saude Soc [internet]. 2011 [acesso em 2019 out 6]; 20(4):1018-1032. Disponível em: http://dx.doi.org/10.1590/S0104-12902011000400018.
http://dx.doi.org/10.1590/S0104-12902011... .

To broaden listening, promote accountability and cooperative relationships within health units, it is necessary to mobilize devices for work analysis³¹31 Feuerwerker LCM. Micropolítica e saúde: produção do cuidado, gestão e formação. Porto Alegre: Rede Unida; 2014. Coleção Micropolítica do Trabalho e o Cuidado em Saúde.. The management of continuing education enables the production of new pacts and new collective bargaining agreements in the SUS. The focus is on work processes, involving management, training, attention and social control, their target is the teams, their place of intervention is the collective, favoring innovations and changes in health conceptions and practices, as an indispensable strategy for the consolidation of SUS.

Workers need to learn to mentally represent their work process, to organize information and to plan its execution. In particular, the managerial position must develop key competencies such as motivation, teamwork, good communication, interpersonal relationships, emotional balance, systemic vision, ability to manage conflict, know how to work under pressure, predict and provide resources, be creative and flexible and know how to listen. In turn, these skills become essential for a possible transformation in work processes³²32 Antunes R. Os Sentidos do Trabalho. 6. ed. São Paulo: Boitempo Editorial; 2002. Coleção Mundo do Trabalho..

In this context, the good evaluation and adherence to the tool, identified both in the question that values the value attributed to the tools offered by the course and in the reports contained in the answers to the open question, show how communication and conflict mediation are at the center of the exercise of health teams management.

CP or peacemaking circles are grounded in the field of Restorative Justice³³33 Boyes-Watson C, Pranis K. Círculos de justiça restaurativa e de construção de paz: guia do facilitador. Porto Alegre: Escola Superior da Magistratura da Ajuris; 2011.

34 Zehr H. Justiça restaurativa. São Paulo: Palas Athena; 2010.^-3535 Zehr H. Justiça restaurativa. São Paulo: Palas Athena, 2012. and have been applied in different countries. It is noteworthy that the Improvement Course in Management of Basic Health Units, Clinical and Care Management made a proposition adapted to the context of primary care in Brazil since the circles have clear basic rules, but allow some flexibility. There are several types of circles, and these can be adopted as diverse restorative practices, such as reintegration, loss, healing, team conflict, school conflict, and others¹²12 Pranis K. Processos Circulares. São Paulo: Palas Athena; 2010.^,3333 Boyes-Watson C, Pranis K. Círculos de justiça restaurativa e de construção de paz: guia do facilitador. Porto Alegre: Escola Superior da Magistratura da Ajuris; 2011..

The reference to ‘peace’ building holds important questions as defined by C8: “Circular Processes! The tool taught us to make a conversation respecting the other’s idea”. In this case, the word peace is understood as the ability to deal well with otherness and conflicts in everyday social interaction, and therefore with the quality of their relationships and (dis)agreements with themselves, others and the environment¹²12 Pranis K. Processos Circulares. São Paulo: Palas Athena; 2010.^,3333 Boyes-Watson C, Pranis K. Círculos de justiça restaurativa e de construção de paz: guia do facilitador. Porto Alegre: Escola Superior da Magistratura da Ajuris; 2011..

In this context, it is essential to understand that, in general, people have difficulties opening up to the new. The moment something different is coming into being, the tendency is to shape it based on what is already known and familiar. Thus, it is noteworthy that the PC, or peace-building circles, do not intend to (re)invent the wheel meetings already adopted in the health field, but seek to make these wheels spin with greater power. Thus, in the Improvement Course in Management of Basic Health Units, Clinical Management and Care, we chose to present the CP as a management tool, and not as a method in the social area³⁶36 Pelizzoli ML. Círculos de Diálogo: Base Restaurativa para a Justiça e os Direitos Humanos. In: Silva EF, Gediel JAP. Direitos humanos e políticas públicas. Curitiba: Universidade Positivo; 2014. p. 131-151.. In fact, as a tool for this manager’s action, it is about opening the range of possibilities, changing the focus with which we perceive conflicts, in a perspective of recovering the meaning of the restoration of human relationships.

Thus, the course presents the CP as a conflict approach tool, and argues that the power of circular practices cannot be understood without their experience. Thus, students try it with their tutor and class during one of the classroom meetings and later propose its application in their BHU from a PHE perspective. Thus, having felt the kind of force/energy and restoration that circulates, in the form of diverse feelings and motivations, reconnections of sociability, rebalancing encounter between discomfort and affection, healing potential of relationships, human support and related elements, prepares for the confrontation of questions proper to its collective³⁶36 Pelizzoli ML. Círculos de Diálogo: Base Restaurativa para a Justiça e os Direitos Humanos. In: Silva EF, Gediel JAP. Direitos humanos e políticas públicas. Curitiba: Universidade Positivo; 2014. p. 131-151..

For managers, the CP tool contributed to improved interpersonal relationships and helped them better deal with teams, especially in conflict management. In this sense, one of the nuclei of meaning produced by learning from the knowledge of the CP tool was the displacement of the classic managerial profile for the exercise of a more sensitive and communicative management.

Circular Process as a tool to facilitate the work process

In the performance of health management and management processes, “social skills are more valued today than techniques”³⁷37 Fernandes MC, Barros AS, Sales SLM, et al. Análise da atuação do enfermeiro na gerência de unidades básicas de saúde. Rev Bras. Enfer. 2010; 63(1):11-15.⁽¹³⁾, because they are the ones that will support management activities related to the team and users. One dimension of managerial work is ‘relational’, but “the results point to management’s weaknesses in dealing with everyday issues of managerial work, especially with conflicting relationships”²⁶26 Nunes EFPA, Carvalho BG, Nicoletto SCS, et al. Trabalho gerencial em Unidades Básicas de Saúde de municípios de pequeno porte no Paraná, Brasil. Interface (Botucatu) [internet]. 2016 [acesso em 2019 out 06]; 20(58):573-584. Disponível em: http://dx.doi.org/10.1590/1807-57622015.0065.
http://dx.doi.org/10.1590/1807-57622015.... ⁽⁵⁷⁹⁾.

In this sense, another core of meaning indicates that one of the main effects of applying the CP tool is directly related to the perspective of changes in the work process.

Articles on management in BHU published from 2011 to 2016 point to the majority assumption of management functions informally by professionals with higher education in nursing. In these publications, managerial work is configured as a little recognized bureaucratic activity, performed by people with little experience, with low remuneration, despite the recognition of its importance for the organization of work. The main difficulties mentioned are: lack of autonomy, partisan political influence in the decision-making process, lack of material resources, little use of management tools, presence of conflicts and disputes between those involved as well as disarticulation between care and management practices. The studies indicate as possible solutions the professionalization and officialization of management, as well as the elaboration of policies aimed at work, the sharing of decisions and responsibility among those involved, the development of permanent education activities and the articulation between universities and managers to rethink the formation of management³⁸38 Jesus MA. Processo de trabalho de gerentes de unidades de saúde da atenção primária de um município do estado da Bahia [dissertação]. Universidade Estadual de Feira de Santana: 2018. 182 p..

These indications suggest the lack of instruments that help in the process of labor micro-politics, revealing, to some extent, the technical fragility of managers and the lack of support networks and exchanges in the management process³⁹39 Oliveira N. Micropolítica do trabalho na Estratégia Saúde da Família: quem cuida também precisa de cuidados? Rev bras med fam comunidade. 2011; 6(21):239-48.. Students wrote that the CP contributed to the improvement of these processes:

It is observed that the work of health unit managers, in addition to the relational context that includes the subjectivity of the subjects, is influenced by the political context and presupposes articulations with different instances of power. In this sense, a commitment to build relationships even before addressing core issues is an important and extremely intentional strategy of the process. Participants find out how their human journeys, as different as they may be, include experiences, fears, expectations, dreams and hopes that are similar.

The circle building stages generate greater awareness among participants. The opening movements of the circle introduce participants to each other in unexpected ways, challenging assumptions they may have made about each other. Creating the guidelines together gives the group an opportunity to experience affinities despite the differences.

Intentionally, many times, a circle does not seek objectivity and takes time to create shared experiences, so that group connection increases the level of emotional security. This process allows deeper truths to be verbalized, encourages self-analysis and offers the opportunity for collective learning.

Final considerations

Despite their ancestral origin, PC or Peacemaking Circles are a very interesting health innovation, especially because they are easily appropriated and capable of producing immediate concrete results. Circles have unique characteristics that distinguish them from other conflict resolution processes, but they can be associated with different dynamics and have wide application. Having experienced an initial workshop, participants overcome barriers between theory and practice and announce the realization of their first circles.

However, as powerful tools in addressing conflicts in the daily routine of health facilities, circles can not only restore interpersonal relationships, but, mainly, promote dialogic experiences as well as awareness of the humanity of participants, whether in institutions or communities.

Finally, the experience of the managers who graduated from the Improvement Course in Management of Basic Health Units, Clinical Management and Care showed that the CP was a tool that had great adherence, being widely used and well evaluated. However, despite the ease of management and the results achieved in the work process of managers, it should be considered that it does not respond to all dimensions of management work.

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