ORIGINAL ARTICLE
DOI: 10.11606/issn.1806-6976.v13i3p140-147

 

Conception of multiprofessional residents on the management of mental health services

 

Las concepciones de los residentes multiprofesionales en la gestión de servicios de salud men

 

 

Zaira Letícia Tisott^I; Leila Mariza Hildebrandt^II; Luiz Anildo Anacleto da Silva^II; Fernanda Beheregaray Cabral^II; Marinês Tambara Leite^II

^IMaster’s student, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil. Scholarship holder at Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil
^IIPhD, Adjunct Professor, Universidade Federal de Santa Maria, Palmeira das Missões, RS, Brazil

 

 

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ABSTRACT

OBJETIVE: to obtain the conception of professionals of health, residents of Multiprofessional Residence in Health Program, about the process of Public Management of Mental Health Services and to comprehend theinfluence of process of management in the education of resident professionals.
METHOD: Qualitative and descriptive research, produced with 13 resident professionals. The data was collected through a semistructured interview and analyzed by thematic area.
RESULTS: It was observed the importance of the manager in health has some knowledge about mental health and the politics that rule them. Still, the participation of residents in management contributes in professional education.
CONCLUSION: It was concluded that the management implicates directly in the process of teamwork and in professional qualification of residents, through lived experiences.

Descriptors: Mental health; Communitarian Services of Health; Management in Health.

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RESUMEN

OBJETIVO: comprender el concepto de los profesionales de la salud, los residentes de la Residencia Multiprofesional en Salud, acerca del proceso de Gestión Pública de los Servicios de Salud Mental y comprender la influencia del proceso de gestión en la formación de los profesionales residentes.
MÉTODO: investigación cualitativa y descriptiva, realizada con 13 profesionales residentes. Los datos fueron recolectados por medio de entrevistas y analizados por medio del análisis temático.
RESULTADOS: Se señaló la importancia del gerente en la salud tener los conocimientos relativos a la salud mental y las políticas que lo rigen. Aun así, la participación de los residentes en la gestión contribuye en la formación profesional.
CONCLUSIÓN: Se concluye que la gestión implica directamente en los procesos del trabajo en equipo y en la cualificación profesional de los residentes, de las experiencias vividas.

Descriptores: Salud Mental; Servicios de Salud Mental de la Comunidad; La Gestión de la Salud.

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Introduction

The beginning of the Psychiatric Reform in Brazil favored the changing the care models and management in mental health practices^(1-2). In this context, Federal Law N^o 10.216, enacted in 2001, listed the rights of people with mental disorders and the end of asylum practices in the country⁽³⁾. Based on this legislation, several services were structured to meet the demands of users with mental disorders and their families. Ordinance Nº 3,088 of 2011 established the Psychosocial Care Network (PSCN), including several services, among them the Psychosocial Care Centers (PSCC) and the General Hospital (GH)⁽⁴⁾.

Although several changes have been proposed by the Psychiatric Reform, the Ministry of Health has developed strategies aimed at the training and qualification of health workers based on the principles of the Unified Health System (SUS), among them the Multiprofessional Health Residency by Ordinance N^o 2.117/05⁽⁵⁾. This strategy is organized and developed in partnership with managers, workers and users of health services, aiming at teaching-service-community integration⁽⁶⁾. The National Policy for Humanization of Care and Management in the Unified Health System -HumanizaSUS (NPH), whose policy proposes the promotion of health management and health care practices⁽⁷⁾, is inserted in this context. Health management is sometimes based on the assessment and achievement of goals. However, in order to face this logic, it is necessary to create proposals and offers of reorganization of services such as the co-management model, which provides for collective decisions, through the constitution of collective spaces and communicative action, in order to think about action⁽⁸⁾. In this sense, this study aims to apprehend the conception of health professionals, residents of the Multiprofessional Health Residency Program, about the process of Public Management of Mental Health services and to understand the influence of the management process of mental health services in the training of resident professionals.

 

Methodology

Qualitative and descriptive research carried out with all residents of the second year of a Multiprofessional Residency Program Integrated in the Public Health System (MRPIPHS) with emphasis on mental health, in the central region of Rio Grande do Sul. There was a total of 13 professionals. The study participants were enrolled in a psychiatric inpatient unit of a general hospital and three PSCC, including a PSCC II a PSCC II i (juvenile infant care), and a PSCC II ad (alcohol and other drugs). From the 13 participants, there were three Nurses, five Psychologists, four Social Workers and one Occupational Therapist; all were women.

Age ranged from 25 to 36 years. As for professional experience, eight participants were newly graduated, three had work experience in other municipalities in their respective training areas, previous to the Residency, two participants had previously done a Residency, one of which has a Master’s degree and two specializations in Public Management.

Data collection was performed in the months of August and September 2015, through semi-structured interviews. The interviews were recorded in digital audio and transcribed verbatim, and were performed in health institutions where the resident professionals developed their activities, at a previously agreed time.

The technique chosen for analyzing the data was the Thematic Analysis⁽⁹⁾, which consists in discovering the nuclei of senses that make up a communication, whose presence or frequency has some meaning for the targeted analytic object. The thematic analysis unfolds into three stages: pre-analysis, which includes the choice of the documents to be analyzed and the resumption of hypotheses and objectives of the research; the second stage involves the exploration of the material and its classification, in order to reach the core of understanding of the text; and the third step consists in the treatment and interpretation of the results obtained, in which the researcher proposes inferences and performs interpretations, interrelating them with the theoretical framework that sets the aims of the study.

Ethical principles were observed in the research, according to Resolution N^o 466/12 of the National Health Council, in order to protect the rights of the participants⁽¹⁰⁾. The research project was approved by the Research Ethics Committee of the Federal University of Santa Maria/UFSM, by means of Collaborated Opinion Nº 1,182,777.

 

Results

From the exhaustive reading of information from the empirical field of research, two themes of analysis emerged, based on the similarity of information. The first one deals with the perception of the resident professionals on the Public Management of the Mental Health services where they are inserted and its influence in the work process; and the second theme deals with the process of training resident professionals in the experiences of public management in mental health services.

Theme 1: Perception of resident professionals on the public management of mental health services where they are inserted and its influence on the work process.

The speeches of the resident professionals pointed out some difficulties in the management of mental health services due to the frequent change in both the coordinating board of health in the municipality, that is, the Health Secretariat, and the coordinating board of mental health in the municipality: This year, the coordination of mental health has already changed three times in a year, this is a lot, and with these changes, the work processes also changes (R6). It delays everything, as coordinator, you know the whole network, you start to organize yourself as a manager, and when this happens, you have already to move and another manager comes in. And then, she has to get familiar with the whole network again to start organizing herself, this delays everything, it is a snowball (R9).

The participants of this study brought up the importance of the manager being a health professional. And also, that this professional knows the Health Policies, Mental Health Policies and the management process, in order to better manage the service to which he is linked. He would need to have a specialization, some knowledge or some training on mental health, knowledge of laws and ordinances; this would contribute to a more qualified management. The PSCC coordinating staff often claim something for coordination of mental health and they do not even know that these things they are claiming exist, and that it is in the Law (R2).

The research shows, based on the speech of the participants, the importance of managers having knowledge of the demands and needs of the service in order to avoid excessive financial expenses. Lack of communication in the workspace often results in unnecessary monetary expenses. Also, it was mentioned that managers have paid little attention to service workers and make decisions without previous collective discussions. We ask for a type of food and they provide other types that we do not use here, so what’s the point in liters and liters of oil if we do not cook here, lunch comes packed, it would be more useful to do snacks, but there is not even sugar, so we would buy what we think it is necessary, then the product expire and then is thrown away; this results in more expenses (R4). What we know of management is what is told us in team meetings, a little of the management here of the PSCC, that would be the reports that the PSCC staff does and the rest is all an issue that comes from top to bottom, so we know very little about what is happening (R2).

The speeches pointed to the lack of support for the team from the management, and dissatisfaction with unfulfilled promises. There were periods when we had to close the PSCC for unhealthy work conditions and the management instead of supporting services, ended up creating a more distressing situation, either because of a lack of communication or because of the difficulty of understanding the situation of the PSCC, to come here, to walk along with services (R6). We realize that the agreements that were made, nothing was materialized.; first, there was the story that the PSCC ad would become a PSCC III, that we were going to have to the issue of the night shift, then the story of the therapeutic residential that the municipality would have, and that did not happen either, and then the story of a new PSCCII, after dismembering the clinic in health areas in the FHSs, nothing materialized; the plans changed always, but nothing was effectively done (R5).

On the other hand, a participant spoke about the existence of dialogue between the team and the manager in times of crisis and overcrowding of the service, as a positive aspect. The hosting has been closed since last year, the management is close in this case; we agreed with the management because the team was sick and the management saw that we were not able to put more users in here without providing at least medical care, psychological care, groups; it would be useless to have this user with us, because we were unable to provide the assistance, that was a positive factor, that is what happens when the management hear this worker (R6).

Resident professionals reinforced that it is important that the mental health manager monitors the work processes, as well as participate in team meetings in order to understand the dynamics of the team and to listen to the professionals. The manager is new; I think she is trying to get inserted in the services, I think it is very good for her to participate in order to know how it is, because you have to be there experiencing everything to know how it works, so that she is going to the PSCC and this is good because the PSCC will request something and she will be able to see that it is really necessary (R11).

The participants of the research listed co-management in health services as an important tool for management. It is in these spaces that the resident professional has a voice and actively participates in the management processes in the places where they are inserted. Here in the PSCC, there is a shared management, it is well organized, they share; a manager is responsible for one thing, another for another, even in the meetings they decide who can go (R4). There is a co-management now, the staff of the secretariat said that management and co-management were both necessary, the team made the adjustments and created a co-management, they are three people, they ask us for help sometimes for many things (R2).

The interviewees also reported that the lack of financial resources implies in the fragility of the development of some therapeutic activities provided directly to users and their families. Scheduling a home visit with a user, you do not know when you will be able to go, you will not be able to program things, you have to wait to get there on Tuesday and see if there will be anything more important, if the car will not come again. Now we have little money, mainly for vegetable garden, we have almost nothing and this is affecting a lot the group (R2).

Theme 2: The process of training resident professionals in experiences of public management in mental health services

The participants listed the influences and learning related to management in the mental health services of the municipality in which they are inserted. It is worth mentioning that resident professionals have learned to overcome frustrations and deal with difficult situations. We need materials that are not provided, we do what we have, we have to be creative, we have to invent some ways of keeping the groups, we replace one activity for another, somehow we have to make the group go on. Many people do not want the conversation group, and so you have to think about other possibilities. I learned how to work in the public service, these problems that we face and have to try to find a solution, work without much material, I think it was good, I do not know if it will be different elsewhere, I think it strengthened me to work, to accept frustration, I think I feel more prepared (R5).

The respondents highlighted the personal growth after the becoming part of the team as a learning result, with respect to knowing how to listen, make plans, and to unite the workers. However, this is a slow process that must be built together with the staff in the services. We have to be able to listen to professionals who work in the whole network (R4). You learn to also plan, not only do what the management wants, but to plan, it is also an exchange, we not only accept, we need to talk, the manager comes here, speaks with us, we are trying to see if it can work a little of that, of unity, of the sense of belonging. Our team meets once a month, only the professionals, this was something that the residency brought to them (R3).

Resident professionals must be involved with the management processes to try to gain knowledge and to be protagonists of their own training. There are some who never speak up, who spend the whole meeting as a present body, I think this has a lot of implications, there are people or they are just doing residency just for doing it, or because it represents a very good economic possibility (R6).

The participants also mentioned that they gained a lot of knowledge about the management process and that they feel prepared to manage a PSCC. They pointed out the Nucleus of Continuing Education in Health and the Nucleus of Support to Mental Health as spaces to make management. I feel ready to take on a PSCC management. I learned a lot on how to manage and how it should not be done; the participation of all the professionals who work at the front is necessary (R4). I think we end up doing a little of management, extrapolating the PSCC, when we are able to participate in the Nucleus of Permanent Education in Health, I think that there, when we are in the training, when we call the professionals, I think this is part of management, I think this is management (R6).

Other study participants reported that they had little knowledge about the management of the services and had not participated in any meeting with managers of the municipality during the period of their training as residents. I did not gain knowledge on management, of better ways to do it, because I have very little access to that (R8). I do not attend any meetings, there is nothing that I can put my point of view, to say what I think it should be done; I think residents never share on that (R9).

One participant pointed out the importance of participation of users in the management process. This could encourage them to claim their rights with the managers. They get indignant; we even try to empower them, because that is a right they have, that the service has to receive these materials, to try to mobilize them as well (R4).

 

Discussion

In the context of health management, the coordinator assumes an important role in the work process. However, management is not limited to a single actor, but it includes a team that can reconcile projects and values ​​with the management practice. Managers need to be aware that their attitudes are not limited to ruling, managing and organizing, but their central element is the human being⁽¹¹⁾.

It is also worth mentioning that changes in health management can cause losses due to interruption of services, but on the other hand, they may be beneficial to the work process because it allows the inclusion of new and promising ideas. Every organization has some turnover, but when it involves the loss of strategic people, it is a factor of disruption and impairs organizational efficiency.

In order for mental health care to be qualified, it is necessary that health services be articulated through the Psychosocial Care Networks (PSCN), as described by Ordinance 3,088 of 2011⁽⁴⁾. Moreover, it is relevant that managers, health workers and the population be aware of the advances related to the Psychiatric Reform, including legislation, so as to offer to users appropriate treatment, aligned with the policies that govern them. Research performed with nurses shows that professionals who study their own work reality and through the updating of knowledge and skills apply the results produced in the organization of the service are able to improve the quality of care⁽¹²⁾.

The qualification of professionals as managers is indispensable for a more effective management. However, depending on the reality of many municipalities, sometimes the management positions have a political-partisan character, with little qualification for the exercise of managerial function. This can negatively affect the progress of work processes.

Qualified management is possible when the manager has a comprehensive view, ethical orientation, sensitivity and ability to communicate and articulate⁽¹³⁾. We understand that, through listening practices, management can learn the needs of the substitutive services in mental health and, thus, provide them support to the issues related to these aspects.

Building trust in management processes implies the ability to count on one another for problem solving, sharing positive outcomes and adopting collective decision-making. For a relationship of trust to be established, it is essential to value the knowledge of all members of the team, as well as dialogue and respect for the different opinions. Through qualified listening, social management in health enables people to interact and collectivity becomes present⁽¹³⁾.

In moments of crisis, the close presence of managers is important to promote emotional support, strengthen confidence, discuss new directions to the service and avoid the disruption of the team. The support received from management at these moments reassures the staff and also users and can promote the offer of quality service, which is fundamental in the treatment of people with mental disorders.

Team meetings are important working tools to enable the exchange of experiences and knowledge between employees and management. Horizontal meetings strengthen interrelations in the team and the work developed by it; they provide support to face the challenges of daily life, generate motivations for work, and provide the creation of open spaces to share anguish and suffering. Moreover, horizontal relationships can contribute to the co-responsibility of team members in making necessary decisions and referrals⁽¹⁴⁾. These moments of exchange between manager and professionals of mental health services through team meetings are important devices, with positive repercussions on the activities developed and, consequently, attention to users and their families.

In the same sense, co-management can be a strategy that contributes to the management of mental health services, since it constitutes a shared exercise of a program, a service, a system or a social policy, with the participation of different subjects, with different interests and diverse social insertions. Shared management implies the participation of all in all stages of the management process: definition of objectives and guidelines, diagnosis, interpretation of information, decision making and evaluation of results⁽¹⁵⁾. Co-management is a form of participation of the professional residents in the mental health service that has direct implications in their training.

In the context of mental health, the responsibility for implementing the proposals of the Psychiatric Reform, with changes in health practices, sometimes with asylum characteristics, falls on the health professionals who make up the teams of substitutive mental health services. In this scenario, the training of professionals through their insertion in the Multiprofessional Residency in Health, can positively influence the quality of the assistance provided to users. Training of human resources is important in the context of the structuring the health care networks, since it allows the consolidation of integrated health systems that favor the access with continuity of care, integral attention and the consistent use of the existing resources. Human resources are essential elements for achieving a satisfactory performance in the context of Health Care Networks⁽¹⁷⁾. The involvement of resident professionals in the service, with potentialities and fragilities, offer a meaningful experience that contributes to their training, contextualized and convergent to the reality of the work environment.

The dialogue and the approach among workers are important in the construction of a new way of working in the health area, centered in the users, with quality, resolubility and equity. The training strategies for the SUS, through the Multiprofessional Residency, present pedagogical and political potentialities for transforming the care model and health care practices based on the learning experienced in the work context of the health services⁽¹⁸⁾.

A study shows that the Multiprofessional Residency in Health tends to see the users in an integral way, in their biopsychosocial aspects, a fact that makes possible the interlocution between the professionals of different areas, emphasizing the teamwork⁽¹⁹⁾. Resident professionals perceive that, although the work is done in a team, each one has his individuality, in the sense of not interfering with the other’s performance, but contributing to the development of a multiprofessional practice aimed at the benefit of the patients⁽²⁰⁾.

It is noticed that residents play an important role in the health team of the service, instigating debates and bringing theoretical references to the daily practice. Otherwise, the professional maturation of the residents results from the experiences that the health services offer, in this case, mental health.

The Multiprofessional Residency seeks the professional growth of the residents and the transformation of the health services where they are inserted, by encouraging a reflection on the practices developed there. However, it is necessary to establish a competence profile geared to the world of work, addressing the health needs of the population and contributing to the consolidation of the SUS⁽¹⁸⁾. In this sense, residents have an important role in the course of their training that is to promote changes in the service. For this, it is necessary that they get involved in their work environment.

Research carried out with residents shows that the Multiprofessional Residency Program was understood as an opportunity for learning and contact with workers from different areas. This enabled them to adopt a new behavior in the daily practice in which the assistance to users acquired a more humanized and comprehensive character as a result of an effective sharing of specific knowledge of each area and participation in health activities⁽²⁰⁾. The management of services can be included in this scenario, constituting an area to be strengthened, based on the experiences and daily discussions of the resident professionals. Residents who participate in these spaces contribute to the construction of management in the health services and, on the other hand, strengthen their professional training.

Training professionals to work in the health system is a great challenge. The knowledge, skills and attitudes demanded of SUS workers change rapidly; thus, learning to learn is indispensable⁽²¹⁾. In this way, resident professionals need to be in the services, experience the demands related to the management, reflect on this work process and be able to learn and to contribute in the discussions about the dynamics of the services. In this context, we highlight the involvement of the resident professionals in this theme. There are some theoretical gaps in the learning process of a multiprofessional resident, including Public Health Management, which may lead resident professionals not to be involved or to consider the issue of management as important.

The Multiprofessional Residency in Mental Health promotes professional growth within the services, in the work logic articulated in networks, in work processes and in personal relationships between team and users. It plays an important role in the training of professionals within SUS. Health management is part of this training and provides a critical and reflective view of the work processes in the mental health services where resident professionals were inserted, as well as a critical and reflective view of their role in that context.

Also, the importance of participation of users in the management process is emphasized. Ordinance N° 2,488/2011 focuses on the participation of users as a way to increase their autonomy and capacity to build the care for their own health, both in facing the determinants and conditioning factors of their health, and in the organization and orientation of health services, based on user-centered practices and the exercise of social control⁽²²⁾. The empowered users become instruments of change for themselves and for the community in the promotion of health. By doing so, they participate in the management process in the municipality where they are inserted.

 

Final considerations

The research contemplated the objectives of the study. Management was understood to directly influence the work processes in mental health, since the understanding of management before Mental Health Policies up to the knowledge of the needs and demands of the services. The management process sometimes makes it impossible for resident professionals to act in a network and in activities directed to the treatment of users. In the same context, management also has repercussions on workers, producing suffering and demotivation, both in the collective and individual sense, due to the lack of support or promises of changes which are not fulfilled by managers.

Listening and dialogue between managers and mental health workers are essential for the collective construction of work processes. In this sense, co-management among service teams, where residents have a voice in the construction of these spaces, is fundamental to empower professionals to participate in decisions regarding the mental health network and work processes in these spaces.

The Multiprofessional Residency is an instrument that provides to resident professionals a greater approximation and knowledge regarding Public Health Management processes, since it allows them to learn the dynamics of the service and, together with the team, build work strategies that benefit the population assisted. The Multiprofessional Residency has provided learning and professional growth for the majority of the interviewees regarding the experiences in Health Management, as well as the need of them to seek to be involved with the processes of management of the municipality and of the services and to empower users in the same perspective.

 

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Received: Aug. 22^nd 2016
Accepted: Sep. 19^th 2017

Corresponding Author:
Zaira Letícia Tisott
Universidade Federal de Santa Maria
Av Roraima, 1000, prédio 26, sala 1445
CEP: 97105-970, Santa Maria, RS, Brasil.
E-mail: zairatisott10@gmail.com