RESEARCH ARTICLES
Mental health commission: strategies for creation of interface in primary care
Luciane Silva RamosI; Carmem Lúcia Colomé BeckII; Natiellen Quatrin FreitasIII; Caliandra Marta DissenIV; Marcelo Nunes da Silva FernandesV; Isabel Cristina dos Santos ColoméVI
INurse. Master degree in Nursing. Member of the Work, Health, Education and Nursing Research Group of the Federal University of Santa Maria. Rio Grande do Sul, Brazil. E-mail: luciane_silva_ramos@yahoo.com.br
IIDoctorate in Nursing. Associate Professor of the Nursing Department of the Federal University of Santa Maria. Member of the Work, Health, Education and Nursing Research Group. Santa Maria, Rio Grande do Sul, Brazil. E-mail: carmembeck@gmail.com
IIINurse. Member of the Work, Health, Education and Nursing Research Group of the Federal University of Santa Maria. Santa Maria, RS, Brasil. E-mail: natiellen.freitas@yahoo.com.br
IVNurse. Member of the Work, Health, Education and Nursing Research Group of the Federal University of Santa Maria. Rio Grande do Sul, Brazil. E-mail: kalidissen@yahoo.com.br
VNurse. Master degree student of the Postgraduate Program in Nursing of the Federal University of Santa Maria. Member of the Work, Health, Education and Nursing Research Group of the Federal University of Santa Maria. Rio Grande do Sul, Brazil. E-mail: marcelonsf@gmail.com
VINurse. Doctorate student of the Postgraduate Program in Nursing of the Federal University of Rio Grande do Sul. Assistant Professor of the Nursing Graduation Course of the Federal University of Santa Maria. Rio Grande do Sul, Brazil. E-mail: enfbel@yahoo.com.br
ABSTRACT: This research aimed at identifying strategies used by the Mental Health Commission to create interfaces with the municipal Primary Health Care management. Case study research with qualitative approach. Data was collected through document analysis, observation, and focus group, with 11 participants, in the city of Santa Maria, Rio Grande do Sul, Brazil, 2009. Data was treated on the basis of content analysis. Four strategies were identified for creation of interface by the Commission, namely, survey of reality; engagement in discussions on mental health with local authorities; formalization of the commission; and organization of an event on mental health. The use of strategies in pursuit of democratic spaces, social control, and continuing health education stand out as relevant aspects for participative management. The commission is configured as a dialogue locus between mental health services and health units, in particular.
Keywords: Mental health; primary health care; health management; nursing.
INTRODUCTION
The Brazilian Psychiatric Reform was a movement that revolutionized the actions in mental health, since it proposes the creation of new alternatives in assisting and it aims to rescue the citizenship rights of people with mental disorders1.
The field of mental health is a field of knowledge and complex performance, plural, intersectoral and with a lot of transversality of knowledge2. In this context, we highlight the importance of the role of mental health workers, because they are constantly living with the challenges and contradictions of this area of activity and of the health policies in vigor.
Thus, based on the possibility of completion of the psychiatric reform based on a performance together with workers a space for discussion was created into a city in the State of Rio Grande do Sul/Brazil, among workers who work in mental health, organization designated as Mental Health Commission (MHC).
This Commission was created with the purpose of reflecting about the psychiatric reform in the city and, from that, to re-direct the assistance of reality of mental health services and the need to redesign the city network of mental health care.
Thus, it is proposed in this study to report how was the implantation of the MHC and its trajectory in search of consolidation as essential intercessor space in the management of city´s health services. We use the term space intercessor to designate the space of relationship that produce the intersection of subjects3,4.
In this line, this study is justified in order to contribute with other realities, so that initiatives like this can boost the search for new technologies in management in health and to contribute to the socialization of new knowledge on mental health.
Thus, the objective of this study was to identify strategies for building spaces of the MHC with the city administration of primary health care.
LITERATURE REVIEW
The Brazilian Psychiatric Reform process is characterized by its own history, entered in an international context of changes, as the overcoming of the model asylum, demarcated by reports of violence and mistreatment to long-stay mental patients in public hospitals made mainly by mental health workers1. It is highlighted, in this regard, the need for professionals in the health services entered into this context of changes, able to ensure a human and resolutive care, enabling the construction of a link between the subjects involved in this process5.
In this perspective, the Psychiatric Reform movement set up an innovative process, original and prolific, permeated by a series of practical initiatives of transformation, with the consequent emergence of the new actors and protagonists, and an emerging theoretical production, in which new questions arise in the field of mental health6.
This process is about a democratic and participative project, in which the protagonists are the managers of the Unique Health System (UHS/SUS), the health workers, as well as users and their families, being characterized by an irreplaceable role7.
In this context, it can be seen that the construction of a mental health care system, consisting of a cultural imagery and a network of social bonds based on the principles of the Psychiatric Reform, requires that the creativity and critical thinking are present and find ways of outlining the challenges that this transformation faces, under the conditions of the reality experienced8.
It is understandable, therefore, that there are difficulties to commit mental healthcare policies that are based on horizontality and which respect the principles of the Psychiatric Reform, making necessary a connection work with the collective, with social movements and with concrete everyday practices of health services, for implementing these policies9.
From that legacy, the process of the Psychiatric Reform enhances the realization of successive conferences on mental health, in order to build another way of thinking about the person with psychic disorders, not just identifying their diagnosis, but noting their existence and their suffering. Thus, it is contextualized the health process and the psychic disease, linking the concept of health to the exercise of citizenship. This differentiated perception promoted the social debate, very emphasized in the legal, legislative media and on issues related to the care model of the time1.
In this sense, it is evidenced that new forms of organization, the intersectoral and interdisciplinary work, the relationship between clinical and political aspects of psychosocial care, the interlace between strategies of care and accountability strategies or notification of the subject, are configure as aspects relevant to performance of workers able to carry forward the transformation process defended by reformist ideals7.
Thus, it is urgent to new ways of thinking and management work in mental health, pointing to a constant articulation between the different sectors of society, the inclusion of mental health in primary care, among other aspects, seeking to enlarge the spaces of discussion to implement the Brazilian Psychiatric Reform. In this way, the process can move forward, being marked by an impasse, challenges and conflicts, in the everyday life of the institutions, services and interpersonal relations between those involved.
METHODOLOGY
This is a study with a qualitative approach of case study type. It is justified considering that proposes to develop an empirical research that focuses on a phenomenon within its real-life context, especially when the boundaries between phenomenon and context are not clearly defined10.
The survey was developed by the MHC of a city in the State of Rio Grande do Sul/Brazil, located in the center of the State, which relies on its network of Basic Health Carewith 31 services [18 basic health units (BHU) and 13 family health units (FHU)], distributed in health regions1.
This study was composed of all participants of the MHC, that is, 11 members of the MHC, among them: mental health services workers and other health care services of the city; Professor of the health and academic courses, which knew the reality of mental health of the said city.
The documentary analysis methodology, observational technique and the focal group were used. Referring to the documentary analysis, all the records relating to the period of August 2006 to September 2008 were examined, i.e. since the opening of the book until the last record of 2008, totaling 72 records, which were released by the Coordinator of Mental Health Policy. As the documentary analysis, the aim was to identify issues such as: dates and lists of meetings, participants and the result from each meeting, which favored the understanding of the dynamics of functioning of MHC.
In relation to the observational technique, it was used an itinerary and an observer in the meetings of the MHC, in order to capture data, considering that the manifestations of the participants were of verbal and non-verbal manner and the record was done in a field journal. The observations were scheduled in advance with the group and they occurred in the period from March to April 2009, during meetings of the MHC, with approximate duration of two hours.
The focal group was constituted in a technique performed with small groups and homogeneous of participants, being held two sessions in the course of the research. The first session was held at the headquarters of a Psychosocial Care Center (PSCC) of that city (site of the weekly meetings of the MHC) and eight participants were participating. The second session was held in a meeting room of the Municipal Health Secretary, with the participation of six members, some of whom had already participated in the first session. These sessions have been scheduled in advance and agreed with members of the MHC, where each of them it last one hour and thirty minutes.
The material collected was analyzed, from the content analysis11. For the data treatment process, the following steps were used: pre-analysis; analytic description and choice of the themes and the data were grouped in thematic axes. The participants in this study were identified by the letter A, meaning actor, followed by Arabic number related to the order of the lines in the focal group, presented some fragments that illustrate the findings of the study.
It should be noted that the guidelines were followed from Resolution No. 466/2012 of the National Health Council12 and the participants were told to read the Free and Clarified Consent Statement and sign it in case of agreement.
The project received approval by the Research Ethics Committee of the Federal University of Santa Maria (UFSM), under the number of the Certificate of Introduction to Ethics Assessment (CAEE) 0283.0.243.000-08.
RESULTS AND DISCUSSION
The search for spaces of the MHC with the management of the primary health care in the city took place through a trajectory that had four main strategies (thematic axes): survey of reality; participation in discussions on mental health with the management of the city; formalization of the MHC; and organization of an event on mental health.
Survey of reality
In relation to the survey of reality, based on observational techniques, it can be understood that it was valuable for the members of the MHC could set goals and work plans, with understanding of the real situation of mental health of the city. This understanding of what was going on was being built from discussions in the group from where emerged some findings.
In the field journals, the records highlighted the relevance of the political context of that city for the performance of MHC. The city followed the standards and guidelines of the Ministry of Health, undergoing, strictly, to its policies and care model. Such a situation was understood by members of the MHC as an obstacle to the construction of alternative processes of care to mental health.
Later on, based on the survey of reality and transparent hierarchy of everyday actions, it was supported that the management in health field should not constitute a territory well demarcated and must be traversed by multiple and transversal lines1. It is believed that the management should not be restricted to a single organ, on the contrary, all actors involved must take responsibility for an autonomy exercise of the employees, either individually or in teams, expanding the possibilities of care13.
Given this scenario, it appears that the reality experienced by the city consisted in the hierarchy from government actions with public policies that sometimes become generalists and downstream operations in the sense of not meeting the unique needs of the subject and the generalities, leaving yet undefined the direction of mental health policy and revealing local management difficulties in acting on this reality.
In one of the focus groups, a member of the MHC reports:
[...] There is a disregard from the management in relation to mental health, which comes from a long time ago[...] the management runs over and ignore the reality of mental health services [...] there is no dialogue. (A5)
In this context, the MHC appears to get resize this reality and assist the coordination of mental health of the city in this construction, based on the precepts of the Psychiatric Reform.
To this end, sequentially, in an attempt to get the overcoming of difficulties, attention is drawn to the participation in discussions on mental health with the management of the city, which sometimes was led by the MHC.
In order to sensitize municipal sphere of Government about the situation faced by mental health services, the MHC sought to establish contact with the management. This was through a document containing the description of the difficulties experienced in mental health and it was built with the participation of employees included in the MHC, with the purpose to emphasize that mental health as the discussion with the management, thereby increasing its visibility.
Then, the MHC participated in meetings supporting the coordination of mental health in the city by social control, with some moments of resistance records, including for meetings.
Faced with these challenges, it is believed that the production processes in health, as well as the democratic management of the policies, they should be in a question at all times in discussion groups and that even running circles of tensions in the general context, they are enriching14. In this way and based on this precept, the MHC figured as a facilitator and even a moving of discussion spaces, bringing benefits and giving emphasis on mental health.
During the course of the MHC, it was evidenced that there was progress in the relationship between management and coordination of mental health of the city, by members of the Commission visualized aspect who commented on the evolution of dialogue with the management, as illustrated in the following speech:
[...] I found the General Director available, because he was interested in receiving monthly services reports on the number of attendances and the difficulties. (A3)
Therefore, it is assumed that the management is fundamental to the development of alternatives and modification of any situation. Analyzing the power relations, the discussion on the process of the psychiatric reform and mental health is focused mainly on the administrative character, being technical, ethical and policies issues contemplated by a small portion of workers15.
Considering the fragility in recognition of the space occupied by the MHC in the management and understanding the delimitation of this aspect as fundamental to the evolution of the actions performed, it was necessary to identify how it was constructed, as well as register how was seen by the workers. It is in this context that it is established the strategy of formalization of this space.
In this context, we analyzed the records of the discussions motivated by the need to formalize the MHC, not only of the difficulty of communication, but also depending on the difficulty of the members because to see the authorship of the documents of the MHC, which contained the decisions taken at the meetings, the agendas established with other services, among other important guidelines.
Formalization of the committee
In this line, we decided to formalize the MHC as a Board Manager. This plural composition space was characterized as an organizational arrangement made to stimulate the production/construction of the subjects and the collectives organized. Thus, these groups could take the form of work teams, co-management boards, assemblies, management committees, among others16.
The formation of micro-networks within the organization is effective for the conduct of projects, putting in the background the functioning on the basis of structural formations of the organization17. So structured and formalized, the MHC would have greater visibility and autonomy in the decision-making and implementation of mental health activities in the city.
In this perspective, it can be said that MHC is a collective organized, a group pleading for an end, having as purpose the production of health acts. This object is that it promotes the articulation and interaction between the members of the Committee18.
In agreement and giving meaning to the MHC, its components were, in one of the focus groups, about the meaning and function of this space:
A place that allows trading of content and which allowed me mainly to visualize the set of workers, without my participation here, this would not be possible [...]. (A1)
[...] I see the space of the MHC as a great agglutinating by going far beyond the field of mental health [...] A space like this always encourages learning. (A7)
In this sense, the intention of detracts formalization of this space as part of an organizational structure was deprive of characteristics. On the other hand, it is a space where it does not fit the organization chart and no overly plan ruled, but rather, a tangle of lines that are organized and disorganized to ensure its productivity19.
Thus, the process of formalization of MHC took place in the sphere of the Municipal Health Secretary, seeking to expand their actions, as well as disclose them and put mental health on evidence in the cty.
Organization of an event
From the analysis of the records, it appears that the MHC thought in organizing an event in mental health. However, it was the complexity of the organization of the event that drew attention, as the results of this study.
The analysis of the findings identified as a proposal of event conducting a Municipal Conference on Mental Health, which would act as a strengthening device of Municipal Policy for Mental Health and also it would contribute to the management approach.
Such a suggestion was justified by the conferences also to constitute spaces of discussion regarding the demands in health, as well as spaces for definitions of political priorities and decisions to consolidate them20.
In this scenario, different concerns emerged as regards the organization of a possible conference, as can be observed in the following lines:
The MHC does not have that role to call and take a Mental Health Conference, because this is not regulated, there is a whole issue of financing, organization of a pre-Conference [...]. (A11)
[...] We do not know the procedures, but we can work on local infrastructure, to conduct, disclosure, the themes that we found important, and then to communicate to the management regarding the intention to carry out a Municipal Conference on Mental health. (A2)
In front of these testimonials, it is realized that, although there are some notion about the process of organizing a conference by the members of the MHC, weaknesses in this subject are highlighted.
So, it is figured the need for clarification on the definition of roles, among other aspects, in order to make possible the consolidation of conference. It is worth noting that this requirement entailed the involvement of a management representative, acting in search of materials and theoretical references that could meet the need identified.
In this context, as the most of this class represents the segment of workers, it is reflected on the importance of making explicit, make public the debate of values that permeate and base decisions by the management, thus enabling clarity to actions and their repercussions on daily life for all segments of the population1,21-23.
We agree that the democratization of the system and of public policy will be effective when they institutional relations are resized allowing men to coexist as political subjects21-23.
However, even not recognizing the appropriation by the health workers, of the political issues, it is possible to infer their knowledge in relation to the implications of this dimension, in the realization of a conference.
Thus, it can be said that the creation of a mental health event was positive for empowering the members of the MHC about the complexity of organizing a conference and its impact, as well as to enhance reflections about the practices of management and the best way to do them.
CONCLUSION
It was observed that the trajectory of the MHC have gone beyond what was expected from a hierarchical administration, bypassing the difficulty of communication with managers and the challenge of formalization of this committee by the participation and initiative to organize an event on mental health.
As a consequence of this, it had expanded its visibility as well as won the right to participate in the discussions on mental health, having justified the reason to exist.
Thus, it can be highlighted the trajectory of the MHC as a search process for democratic spaces, social control and permanent education in health, relevant aspects to co-management, i.e. to a participatory management.
Soon, the MHC configured as an important space of constant interaction among mental health services and, especially, health units. It should be noted that it was from the MHC that started the joint actions between mental health and primary health care, thus demonstrating that the MHC was settled as an important intercessor space in managing the municipal health service.
It is noted that there is a need for the conformation of more collective spaces, such as the MHC, which allow the critical reflection, the production of subjectivity and, consequently, the integration of subjects.
It was observed that, to act in the field of mental health, the mental health act reflected from the everyday meetings and from the relations to spaces intercessors.
So, it is bet in collective spaces, such as those from MHC, to be configured as specific spaces, places and time, intended for communication, listening, the circulation of information about wishes, interests and aspects of reality, as well as elaboration and decision-making, seeking new paths institutor significations.
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