Organization of professional practices against intrafamily violence against children and adolescents in the institutional context 1

ABSTRACT Objective: to analyze based on the practitioners' discourse, the way they organize their practices confronting situations of intra-family violence against children and adolescents. Method: qualitative research carried out with 15 professionals who work in social and health services located in the southernmost of Brazil. Data were collected through semi-structured interviews, performed at the participants' workplace. We used a theoretical matrix to analyze the data, based on Institutional Ethnography and the technique of discursive textual analysis. Results: the practitioners' practices developed in situations of intra-family violence against children and adolescents are organized on the basis of: power relations that take place in services that respond to violence situations; routines instituted to meet the demands of care in services; and the interplay between the conception of violence as a public health problem and the conception of violence as a social problem. Conclusion: the way these practices are organized is reflected in actions that are not protective against situations of intra-family violence against children and adolescents.


Introduction
Strategies for intervention in situations of domestic violence against children and adolescents have been expressed in some official documents, among them the Statute of the Child and Adolescent (ECA) and the Primary Health Care Handbook -Intra-family violence against children and adolescents: guidelines for practice in service. The first document places Brazil in a prominent position in the world scenario for establishing a law considered one of the most advanced in terms of guaranteeing the rights of the child and youth population (1) ; The second aims to support states and municipalities in the implementation of actions that promote equality and the exercise of human rights (2) .
From what these documents propose, professionals have the responsibility to identify victims in an early stage, to notify suspected or confirmed cases of violence (1) , and, to promote actions to strengthen relations between institutions working in the areas of health, safety, justice, education, human rights and social movements, aiming to guarantee adequate protection and treatment for children and adolescents (2) .
Although these documents point out guidelines The literature suggests that the professional practices developed in the health services are based on power relations that hinder the integration between professions and professionals (4) . As a consequence, the practices developed in the context of these services tend to be fragmented and individualized, proving to be ineffective in the face of the complexity of the problem, which can not be understood by individual competence in a single professional area, but rather involving multidisciplinary and intersectoral actions (5) .
In addition, professionals rely on pre-established norms and routines that tend to situate them in certain spaces and to regulate their daily practices (6) . On the other hand, the lack of emotional support to deal with situations of intra-family violence against children and adolescents contributes to the failure of many professionals to assume their responsibilities, thus transferring the situations to other services (7) .
In order to understand how the organization of practices occurs in the face of situations of intra-family violence, it is fundamental to give voice to practitioners working in this context, understanding the phenomenon of violence based on their experiences and the problems they experience in the daily life of their work, and in the dominant institutional and social relationships that shape, limit and organize their practices.
In view of the above, this study aimed to analyze, based on the practitioners' discourse, how the organization of their practices confronting situations of intra-family violence against children and adolescents.

Method
This is a qualitative study carried out with 15 professionals, six nurses, two psychologists, two physicians, two community health agents, two guardianship counselors and a social worker, who met the following inclusion criteria: have had under their care children and adolescents attended as a result of intra-family violence, (being it presumed or confirmed) and to be linked to the service where they have been for at least 12 months. To preserve anonymity, the professionals were identified by the letter P, followed by the word "health" or "social", corresponding to the area of performance of each of the professionals interviewed. Example: (P health ),

(P social ) . This study was approved by the Research Ethics
Committee of the institution to which it is affiliated, with registration under the number 066/13.
For the organization, analysis and interpretation of the data, a theoretical matrix was built based on Institutional Ethnography (IE). The IE considers that the social relations and the ways work is established in institutional contexts are mediated by "texts", which are considered the main elements of coordination and regulation of the work activities (8) . In this study, the "texts" are represented by public policies, institutional routines, power relations and by some forms of discourse that permeate the institutional context.
During the process of analysis, the political and bureaucratic interests that "texts" can carry (8) , producing standardized methods of work that exclude the point of view of people and contribute to the production of automatic and non-reflexive practices in certain situations (9) .
The technique of analysis was the textual discourse (10) , following the steps: dismantling the interviews, identifying the institutional forces present in the discourse of professionals and forming the units of analysis; then build relations between these units, grouping their elements into a process that resulted in three categories: relations of power as mediators of professional practices; institutional routines and the need to meet the demands; family violence against children and adolescents: a social or health problem?  The professionals who work at CREAS testify that one of the main difficulties encountered in dealing with situations of intra-family violence against children and adolescents is the bureaucracy and the demands imposed by the judiciary. Among them is the production of medical reports and reports used in legal proceedings. These professionals recognize that they must act jointly before the courts, however, they affirm that the determinations of the judicial services impose changes in their routines that are directly reflected in the assistance provided to children and adolescents victims of intra-family violence.

Institutional routines and the need to meet the demands
In the professionals' discourse it was possible to identify concerns in terms of supply and demand in relation to social and health services. The municipality in which this study was developed is located in one of the main naval hubs of Brazil, which in recent years has caused intense migration to the region causing socioeconomic impact and causing changes in the organization of services, given the need to care for the entire population.
One of the interviewees stated that institutional routines are now determined by the supply and demand of services: The population of the municipality has increased greatly in recent years and violence has also increased. We From the perspective of some participants there is a lack of consensus regarding the responsibilities of each service that makes up the network of protection for children and adolescents. This contributes to make many families to go through a long journey in the search for care. In view of this, there is a need to further problematize the power relations that are established in the context of institutions, since they contribute to the fragmentation of care, compromising the assistance provided to users (12) . For some authors, work practices aimed at protecting children and adolescents should efficiently articulate the different sectors that make up the protection network, integrating them both in macrostructural (political) aspects and in internal aspects of services, seeking inter-institutional and interpersonal interactions (13) .

Discussion
The power relations identified in the scope of the Guardianship Council may be related to the social role of this institution, insofar as this Council is seen as a reference body, charged by society to ensure the fulfillment of the rights of children and adolescents, as described in the ECA (1) . However, it is necessary to question whether such power relations, reported by some professionals, do not constitute an alibi for a less participative action of the other professionals in the intervention processes.
In this sense, a study developed with tutorial advisers emphasized that social and health institutions do not monitor the protective measures taken in the scope of the Guardianship Council. As a result, many cases have ceased to be monitored and are eventually lost. Thus, the importance of better communication between the institutions, with a view to promoting collective actions, controlling workflows and monitoring these situations is evident. (13) .
For some authors, regardless of the different professions involved in the protection of children and adolescents, there is a need for professionals to establish and share responsibilities for situations dealt with in the daily work situation, providing a more accurate evaluation of the situation and a follow-up and treatment that addresses the needs of victims and families (14) . In addition, the authors pointed out that the sharing of responsibilities among professionals is an efficient way of reducing negative factors such as personal prejudices and subjectivity in decision making (15) .
It was also verified that the organization of minutes as minimum productivity standard (16) .  (17) .
Concerning the interplay that assigns the responsibility for the care of the victims of violence to a health service, or to a social service, it is necessary to question whether this is not a reflection of a true joint limitation of both social and health services, due to the multifaceted character of violence, which generates physical, psychological and social consequences (6) . Moreover, this interplay seems to be www.eerp.usp.br/rlae 6 Rev. Latino-Am. Enfermagem 2017;25:e2889.
a reflection of the professionals' difficulty in taking responsibility for their care service and for reporting violence. Researchers point out that in the field of nursing violence against children and adolescents is often understood as a problem whose resolution is not part of the competencies of this professional group (18) .
Faced with these aspects, it is up to professionals and institutions to strengthen shared actions, establishing an effective protection network that includes reference and counter-reference services capable of acting on the multiple demands for attention and care expressed by victims and families in situations of violence.

Conclusion
The In view of these aspects, it is important to emphasize the importance of analyzing the institutional contexts and practices of professionals confronted with intra-family violence, in order to understand the subjacent order, and then to formulate strategies that allow to re-adjust the care provided.