Analyzers of Support Practices in Humanization and Permanent Health Education

Analisadores de Práticas de Apoio em Humanização e Educação Permanente em Saúde

Analizadores de Prácticas de Apoyo en Humanización y Educación en Salud Permanente

Abstract

The National Policies of Humanization and Permanent Health Education (PHE) have shown advances and setbacks in their historical process. Some concepts from the theoretical framework of institutional analysis can contribute in these themes, such as the concept of analyzer. This article discusses the analyzers identified in an intervention research with professionals who work as supporters of humanization and/or articulators of PHE in municipalities of the state of São Paulo. The theoretical-methodological framework is the institutional analysis, socio-clinical line, focusing on the work of the analyzers. The intervention groups were composed of 30 participants. We highlight three analyzers: (1) the COVID-19 historical analyzer; (2) the time analyzer; (3) the silence analyzer. These analyzers evidence tensions such as: the peripheral place of primary care, discomfort in the face of “not knowing” and/or lethargy in the face of imposed non-doing, and the paradox of creating and interrupting both care actions and support for the teams.

Keywords:
institutional analysis; continuing education; single health system; action research; COVID-19

Resumo

As Políticas Nacionais de Humanização e Educação Permanente em Saúde têm mostrado em seu processo histórico avanços e retrocessos. Alguns conceitos do referencial teórico da análise institucional podem contribuir nesses temas, como o conceito de analisador. O objetivo do presente estudo foi discutir os analisadores identificados em uma pesquisa-intervenção, com profissionais que exercem a função de apoiadores de humanização e/ou de articuladores de educação permanente em saúde em municípios paulistas. O quadro teórico-metodológico é a análise institucional, linha sócio-clínica, sendo destacado, o trabalho dos analisadores. Participaram 30 pessoas dos grupos de intervenção. Destacamos três analisadores: (1) o analisador histórico Covid-19; (2) o analisador tempo; (3) o analisador silêncio. Esses analisadores iluminaram tensões como: o lugar periférico da atenção básica, o desconforto frente ao “não saber” e/ou a letargia ante o não-fazer imposto e o paradoxo de criar e interromper tanto ações de cuidado, como de suporte às equipes.

Palavras-chave:
análise institucional; educação permanente; sistema único de saúde; pesquisa-ação; COVID-19

Resumen

Las Políticas Nacionales de Humanización y Educación Permanente en Salud han mostrado avances y retrocesos en su proceso histórico. Algunos conceptos del marco teórico del análisis institucional pueden contribuir a estos temas, como el concepto de analizador. El objetivo de este artículo fue discutir los analizadores identificados en una investigación-intervención, con profesionales que actúan como apoyadores de la humanización y/o articuladores de la educación permanente en salud en municipios de São Paulo. El marco teórico-metodológico fue el del análisis institucional, línea socioclínica, destacándose el trabajo de los analizadores. Participaron 30 personas en los grupos de intervención. Se destacan tres analizadores: (1) el analizador histórico Covid-19; (2) el analizador de tiempo; (3) el analizador de silencio. Estos analizadores iluminan tensiones como: el lugar periférico de la atención primaria, el malestar ante el “no saber” y/o el letargo ante el no hacer impuesto y la paradoja de crear e interrumpir tanto las acciones asistenciales como de apoyo a los equipos.

Palabras clave:
análisis institucional; educación continua; sistema único de salud; investigación-acción; COVID-19

In March 2020, the World Health Organization (WHO) declared the infection by SARS-CoV-2, which causes Covid-19, to be a pandemic (Cucinotta & Vanelli, 2020). It is emphasized that Brazil is the second country in the world with the most people infected by the new coronavirus, and the State of São Paulo is the most affected, considering the number of cases and deaths in the national territory. Far beyond just a health crisis, the pandemic has also highlighted other crises involving politics, social, economic, management, education and health. The scenario requires a set of measures that go beyond the immediate containment of the virus transmission chain (Sarti, Lazarini, Fontenelle, & Almeida, 2020) and including facing the contradictions present in health systems, considering the local differences in each national territory (Araújo, Oliveira, & Freitas, 2020).

The Covid-19 pandemic and the strategies taken by health authorities in Brazil, especially the Ministry of Health, have made clear how the national health system has been facing challenges of, among other things, the effect of definancing caused by neoliberal economic policies. We have experienced situations such as hesitation and delay in investment to develop and purchase vaccines; adoption of unproven scientifically proven measures, such as “preventive and early treatment” with hydroxychloroquine; disincentive of measures to minimize outdoor aglomerations and of use of masks; and lack of planning and purchase of inputs such as oxygen and medications indicated for cases of intubation. In a global scale, the infodemic (WHO, 2020) created certain confusion in the dissemination of information both for health professionals and for the general population.

As such, investment in educational measures that allows professionals and users to make decisions based on critical analysis instead of ideology is of utmost importance. The National Policy of Permanent Health Education (PNEPS), a Brazilian strategy from the 2000s, attempts to enforce health practices that consider work as a locus of learning experiences and of social pacts of full healthcare (Santos & Ceccim, 2019). The way in which this public policy can be enacted upon can be showcased by the methodological theoretical framework of the institutionalist movement, whose presence in Brazil is enforced via the National Humanization Policy (PNH), created in the same period and with several intersections to the aforementioned policy.

Permanent health education here refers to the learning processes that lead to the denaturalization of that which is no longer perceived during the routine of healthcare services amidst the people involved (managers, workers, educators and users). The concept is not limited to organized learning processes such as group conversations, workshops or courses. Sometimes, such processes are not even involved, as they themselves can reproduce and normalize routines and practices. A permanent health education process pressuposes what some authors have named “routine destabilization” (Silva & Guanaes-Lorenzi, 2021), “listening to analysis noises” (Merhy, 2004) and “conscious surprise” (Thievenaz & Piot, 2017). These can occur in scheduled educational activities, but also in non-institutional spaces such as the kitchen, the hall, the office, the waiting room of healthcare units or in the spaces outside the walls of healthcare services, as this is institutionally allowed to question the work mode of production and question whether healthcare is performed, how it is done and who are the people being cared for. The pandemic could trigger many processes of permanent health education and it has shown to be an analyzer of institutional contradictions and of the instituted modes of functioning.

According to the theoretical-methodological framework of Institutional Analysis (IA), institutions have an abstract and immaterial dimension and an apparent dimension. The institution is a result of the movement between forms and forces between maintaining its visible side and attempts to rupture what is instituted performed by institutional movements (Kasper et al., 2019; Lourau, 2014).

The analyzer, another concept proposed by IA, consists in the exposition of contradictions present in institutions, namely “that which allows to reveal the structure of the organization, provoking it, forcing it to speak” (Lourau, 2014, p. 303). In a certain way, the analyzer deinstitutionalizes, revealing the institutional party hidden by what was instituted, thus deconstructing the order of that which was instituted (Lourau, 1978; Rodrigues, 2013). Analysts have identified a few types of analyzers: historical, natural and artificial. Historical analyzers correspond to facts that have happened in history, analyzing the modes of production of societies, such as the events of May 1968, the World Wars, the 8th National Health Conference in the case of Brazil’s health system, among others. Historical analyzers are thus “events that reveal contradictions at a given time and lead to a practical analysis where institutional knowledge is effectively improductive” (Lourau, 2014, p. 146). Natural analyzers are those that are expressed “spontaniously” during the process. Artificial analyzers, on the other hand, are created by the institutional analyst via devices put into practice with the groups with whom work with with the goal to make people analyze certain situations (Lourau, 2014).

In this paper, we make the following question: which analyzers were expressed during the initial period of the Covid-19 pandemic in relation to the primary healthcare services of the Unified Health System (SUS) and what contradictions are there? Our search through academic databases did not find any papers on the analyzers in permanent health education (EPS) or on institutional support. This study thus discusses the analyzers identified by means of a research-intervention involving professionals that act as humanization supporters and/or promoters of permanent health education in São Paulo municipalities.

Method

A part of a complete qualitative research of type research-intervention was analyzed via the theoretical-methodological framework of Institutional Analysis (Lourau, 2014), of the Socio-clinical variant (Monceau, 2013), to verify the effects of a research-intervention and study the professional practice of humanization supporters and promoters of permanent health education.

Participants

The participants were healthcare professionals that act as PNH supporters and promoters of PNEPS, who are selected by municipal managers to develop measures of institutional support and permanent health education together with the territory teams. Currently, this demographic consists of professionals with the following roles: company administrator, community health agent, social worker, nurse, physical therapist, speech therapist, geographer, historian, psychologist, chemist and occupational therapist.

The recruitment of participants occurred during a meeting in a municipality of São Paulo where the researchers presented their research, the role of the participants in it, and of the study goals. This meeting happened before the health crisis and 30 supporters and promoters accepted to participate in the research.

As such, we included the supporters and promoters of 24 municipalities of São Paulo who were active when data was collected. The exclusion criterion was people who were not currently active (be it via leave due to sickness reasons or any other reason), however no exclusion was necessary.

It should be noted that this demographic was instituted in the year 2007 with the aim of implementing the Permanent Health Education and Humanization Policies by the Center of Development and Qualification of SUS (CDQ-SUS) of a Regional Health Department (DRS).

Instruments

The technique known as intervention groups was performed in person and remotely in real time via software application. All meetings were recorded and transcribed for analysis.

Procedures

Data colection The device for data production was performed via monthly meetings in person up until the pandemic started. After March 2020, the meetings started being conducted through online meeting software on a monthly basis in two periods of the day in order to meet the needs of the participants since the context of the health crisis and the social distancing measures required it.

During the meetings preceding the pandemic, the group worked on questioning the work contexts of the supporters and promoters in their respective municipalities in order to identify issues in their practices deemed of higher priority for intervention. Starting with the pandemic, the focus of the meetings was Covid-19 and its consequences.

Devices were created to foment discussion, with triggering questions to continue the meetings while maintaining the focus in the study goals and in the emergence of contradictions. The researchers, supporters and promoters participated in the meetings, for a total of 45 people, and the meetings would average at around 25 participants. The data analyzed for this paper focused on 10 distance meetings performed in 2020.

The distance meetings changed the dynamics of how participants and researchers interacted, presenting many challenges, such as how to use the platforms and their tools. The creation of new work pacts was necessary, such as keeping the microfones disabled to minimize noise, keeping the webcams on whenever possible, and saying “passo a palavra” (I’m done talking now) after finishing their speech turns. The duration of the meetings became shorter since there was less attention overhead required. Another point observed was the difficulty of participants in identifying body language. We started interacting mostly with facial expressions and while wearing masks for personal protection, and some computers lacked webcams. Certain spoken lines were choppy due to internet constraints or replaced with chat conversations in cases where the participants would be in their workplace without a safe space. The meetings had an average length of two hours, being recorded and later transcribed for analysis.

Data analysis The analyzers identified are derived from the empyrical material and subjected to analysis performed with the theoretical-methodological framework. The research was finished in September 2021. The speech lines were encoded to preserve anonimicy and are represented by month and year, as observed in Table 1.

Table 1
Illustrates how the data was organized

Initial codes	Intermediate codes	Theme
		Contradictions acting in the institutions: analyzers
Emptying of the units	Healthcare model focused on medical diagnosis and therapy	The historical analyzer Covid-19
Distancing of the teams towards the local territory
(Dis)belief in science
Work organization
Suspension of Continuing Education in Health and Institutional Support practices
Carrying out other support practices and EPS
Time without work	Short time	Time analyzer
Clinical coping time without physical presence
No time for EPS practices and Institutional Support
Not speaking	Experience of uncertainty	Silence analyzer
Not knowing
Not welcoming the self-analysis

• Note.Source: research database.

Ethical Considerations

The project was approved by the Research Ethics Committee of the Nursing School of Ribeirão Preto of University of São Paulo, CAAE: 33638720.6.0000.5393.

Results and Discussion

Contradictions were found for the institutions Health, Politics, Science and Research during the process of research analysis. Three analyzers were identified in the context being analyzed: (1) the historical analyzer Covid-19; (2) the time analyzer; (3) the silence analyzer.

The historical analyzer Covid-19

The Covid-19 pandemic proved to be an important historical analyzer of the institutions, explaining the modes of operation instituted, leading to ruptures and malfunctions. This analyzer shows the social place of the Unified Health System (SUS) and at the same time questions the ways of providing healthcare.

In the territory studied, the pandemic revealed the primacy of the healthcare model centered on medical diagnosis and medical therapy, where the hospital began to occupy the central place in the healthcare networks instead of primary healthcare (PHC), which was initially placed in the background for its coping.

It is worth mentioning that this response concerning the reaffirmation of the hegemonic biomedical model focusing on individual actions, with measures focused on the biological body, pathophysiology and medicalization, is not a specificity of Brazil. This fact makes evident the dispute of logics in the socio-political-economic scenario and, in this case, the predominance of a logic more aligned with consumption and capitalism.

This shrinking of PHC in a pandemic context, in which the hospital gains visibility as the equipment required to fight it, because it saves lives according to the presence of beds for intensive care units (ICU) and respirators, is taking away the locus of PHC in public, journalistic and social media. As a consequence, we observe the emptying of the presence of users in these units: “We are asking patients to stay at home, but I think this period has made us more tired than before” (Meeting of April 2020). “The line of the emergency coordinator is not about seeking care without needing it, not going to the UPA [Emergency Care Unit] without needing it, I think this also emptied these spaces by a lot…” (Meeting April 2020).

However, after declaring state of calamity in Brazil (Legislative Decree No. 6, 2020), institutional supporters and education promoters made changes in the professional practices of the PHC teams. In the municipalities of the studied region, some were able to organize measures against Covid-19 based on primary healthcare and health surveillance, but focusing on distancing from physical contact, the team also got more distanced from the territories. This was shown by the initial retreat of Community Health Agents (CHA) when making their routine visits due to lack of Personal Protective Equipment (PPE) or fear of getting sick, as well as by the feeling of helplessness, a fact that sometimes led them to not acknowledge the situation of families with whom they had already built bonds of care. The work on the resumption of this bond has been a necessary investment and assumed by some instances of management and social control: “Some of our agents are contributing to the monitoring of cases, because a monitoring center has been set up. It improved the quality of the communication with patients and family members quite a lot” (Meeting of July 2020).

About the FHU [Family Health Units], we had the issue of CHA who were afraid to visit. Now it is coming back a little, so there are the guidelines on how to make the visit, the visit is peridomiciliary, but it is not inside the home. (Meeting of July 2020).

The manifestation of what was instituted linked to infectious and communicable diseases could be seen, translated into the need to eliminate the enemy, the other, the patient or the patient’s family. Hostility and blaming of the patient were identified in the reactions of the population studied. In one of the municipalities, certain residences where people with Covid-19 lived got stoned, in addition to respite in social networks.

There were expressions of supporters/promoters regarding the indignation of health professionals, with people’s disbelief regarding the pandemic:

[…] we’ve had cases of a health professional who had to almost fight with a girl from the community. She said that inside her church this was not going to happen, that they could continue to do the ritual normally and that she would eat her pizza on Saturday normally with her family and that these things were mere invention, that it was politics (Meeting of April 2020).

The disease is felt as it approaches, by hospitalization or loss of a nearby person. As the virus has spread over time, affecting the municipalities of São Paulo in different ways, the workers said in the meetings, “here in my city, it does not look like there is a pandemic, everyone on the streets and living normally” (Group of Abril 2020), especially in smaller cities.

Often, professionals, faced with the impotence in dealing with the lack of knowledge of the population, begin to hold them responsible for their non-collaboration in not complying with the recommendations of social distancing.

This perspective reiterates the individualization of the contradictions produced in social, economic and political relations, but learned as if they were personal. Simplified forms of understanding the problem are constituted as if only the adoption of protective measures were an individual option.

The pandemic revealed that even with the achievement of social control in the SUS, conferences, municipal and local health councils, intersectoral strategies, and proposals for changing the healthcare model, there are still challenges for the production of dialogue between professionals and people to be cared for. Is this one of the effects of infodemia or the way the media has portrayed SUS over the years? Is there a power struggle between professional councils and the advancement of private medicine? Is there a need for assistance whose logic derives from the maintenance of productive bodies? Certainly this study cannot and does not intend to answer these complex questions, but it is important to emphasize them.

What bets can be instituted in order to increase the production of bonds between the population and health professionals? Some scholars propose investing in micropolitics (Merhy, Feuerwerker, Santos, Bertussi, & Baduy, 2019). In this paper we wish to reaffirm the importance of investing in the production of meetings that by their inherent power can have strength to allow for the contestation of conservative and excludent institutions. The promotion of education and institutional support can be devices towards this goal.

Part of the challenge people face in standing up to the protective measures recommended for Covid-19 can also be explained by the incoherence of information and mechanisms triggered by science and how it mixes with the economic-political-partisan dimension. Authors point out that conservative movements and entrepreneurs act politically using denialism, conspiracies, false experts and the use of isolated articles that are outside the scientific consensus, among others (Camargo Júnior & Coeli, 2020), to justify the return to lost “normality.” In meetings with supporters and promoters this aspect was present: “The Trade Association met today, well not today, twice this week with the mayor and they are quite apprehensive and pressuring the mayor to return everything to normal as soon as possible…” (Meeting of April 2020).

The pandemic analyzer evidences the science institution occupying dichotomous places: the place of protector of life and the place of the one who discovers the easy, profitable and accessible measure, in the form of the drug and technologies that cure. The dispute of logics, discourses and contradictory attitudes can generate disbelief in science in people (Abreu, 2021), as exemplified by the resistance to the use of the face mask or its incorrect use in public places. This part of the population is taken as the one that does not collaborate, sometimes responsible for their own illness and that of others. The hospitals studied and the propaganda of drugs contribute to the intensification of the forces of dispute of a still hegemonic and biomedical model and others based on the recognition of multiple knowledge and in the living territories of existence, which PHC seeks to express, but is still fragile in this direction, despite the undeniable investment in strengthening the PHC in Brazil, especially from 2003 to 2015.

The Ministry of Health (MH), which historically brought guidelines to municipalities and states, continued to publish numerous protocols with guidelines for action in health services, but its manifestations conveyed through interviews and lives were contradictory and denialist of the pandemic. The large amount of communications, in a way, disrupted the functioning of the teams. Some municipalities were able to structure committees to fight against Covid-19 and establish guidelines for teams, including the participation of supporters and promoters, demonstrating the importance given to educational processes and reflection on which paths to take at this time. Other supporters and promoters reported the distance between managers and workers, which hindered the work process of the teams and their reorganization.

The pandemic has been questioning the established logic about how managers, supporters and workers have been operating. The distance perceived by some causes them to seek the tools in their own cases that they need to support their practices. The first place to turn is in vocational training, which adds power to work, but sometimes not. There is still a hegemonic context of formation where theory and practice follow disarticulated; there is little possibility of experiencing interprofessional and team work; formation is also centered on authoritarian and traditional models with asymmetric relations of power between educators and students, in short, a set of characteristics that offer few possibilities to supporters and promoters to produce new interpretations of the needs present in the context, innovating in the offer of support to these teams.

Many reports addressed the need for support to the workers in the frontline, in terms of the effects of the pandemic on them, such as feelings of fear, stress, anxiety and fear of contaminating the family. Some initiatives were created as strategies to meet this demand: psychological teleservice, small group conversation groups in the units, auriculotherapy and PPE supply. Although these practices are important to health work, we know little about the effects they produced and the analyses made by the teams, such that actions are planned and executed, but little evaluated in their power of meeting the needs that required them:

Here in (name of the municipality), we are on psychological duty for the team,(…) The psychology sessions are happening with the teams and for next week we thought of an action of going to the teams in person, taking candy, chocolate, ready sentences and blank papers to try to get people to put out what they are feeling (Meeting of April 2020).

In order to ensure access to users, supporters and promoters, they report that the municipalities organized flows and protocols to care for flu-like syndromes, restructured work processes, and connected with different network equipment, such as hospitals and specialty services.

We preferred not to focus on this service. The service happens divided in their territories. In all units we did the protocol to attend to flu-like syndromes, that is, everyone who arrives with any flu syndrome, runny nose, cough, sore throat, complaining of fever, we evaluate, we made a protocol. Depending on the vital signs of blood oxygenation, respiratory rate, we refer to the ER [Emergency Room], otherwise we ask the person to stay at home, quarantine for the next 15 days, and we monitor this person every day by call, asking if the person has improved or not (Meeting of April 2020).

There are reports of strengthening the partnership with civil society. Several initiatives were articulated, such as the donation of shoes to health workers by shoe companies, donation of fabrics for the manufacture of aprons and masks, as well as volunteers to carry out sewing work. It was necessary to intensify the partnership with the media to disseminate information and guidance of health care, that is, instituting processes were being jointly woven in health work. “We have a lot of donation of equipment here, the council is also involved, wanting to donate equipment, articulating to achieve this. A church in front of the UPA [Emergency Care Unit] has made its space available, a fantastic space to expand the number of beds” (Meeting of April 2020).

It was observed that the supporters and promoters who maintained their established modes of organization, based, for example, on waiting for the guidelines coming from authorities, had more issues with that period.

The time analyzer - Between chronos and kairós

The time analyzer is expressed in the speech of supporters and promoters in two ways, namely the lost time with prior planning and coping with the pandemic, which proves to be short for professionals to appropriate all the norms, bulletins and technical reports published with recommendations to to be followed and the opportunity to prepare oneself and act. The right time.

[…] organizing things, I did manage to organize things well, as soon as I left the surveillance meeting, they made an announcement, after the carnival it could arrive, we were able to buy PPE, train people, set up a respiratory unit wing, getting to learn with the hospital that is our reference for secondary/tertiary care” (Meeting of May 2020).

Of the already addressed aspects, the processes that gained more speed stood out, given that in the period before the pandemic they would have taken longer to analyze and incorporate into the institutionalization process.

[…] So, we have made some care provisions. And then we have been working on implementing auriculotherapy, as over here the Department has a professional that is going to offer a day a week for the workers. We also got an aromatherapy part, a partnership was even partially inspired by that intervention you made. So we’ve been making these offers, these small offers - even if just to reach a different tone, perhaps, in the course of things. We are talking about illness at work at this time of a pandemic” (Meeting of July 2020).

Time is also perceived as slow for understanding what is being experienced, or fast and insufficient due to countless events, new information and the amount of activities and responses to be crafted.

It is worth exploring the idea taught by the time analyzer chronos and kairós. This denomination is more present in the field of philosophy, mythology, the world of administration, explored in several references more common in the human sciences. We borrow the idea of an educator, psychologist and philosopher, Joel Martins, a precursor of gerontology in Brazil, who says: “We are not just Cronos, a determined time, but Kairós, energy accumulated by lived experiences” (J. Martins, 1998). The time analyzer has a connection with the health institution, because healthcare is a part of it and with it lives can be lost or saved.

Time in its relationship with the health institution, in general, is perceived as an executioner, always lacking. In their speeches, the supporters and promoters refer to the time it took to prepare themselves, the time it took to appropriate the knowledge, the time it took to take care of what is related to this work, the support of the teams, the meetings with management, elaborating reports, among other things. Thus, they always find themselves in debt for work not done and that is often done alone.

In the aforementioned fragment, the supporter/promoter seems to bring into play another possibility of understanding the time analyzer: time in its possibility of producing power and life through lived experiences. That is all the experiences tested, analyzed, studied, in short, the opportunity to perform in a different way due to the possibility of triggering the kairós time, a time out of time and with time.

We cannot fail to point out that the time analyzer is sometimes seen by the health institution through its less favorable perspective, in a dimension of the rationality of time, essentially activated by its chronos function. Time is saved from listening to the other, from collective and creative work, from being with the other in the possibility of producing care, all of this seen from the productivist and mercantilist logic, which today captures health work as a waste of time. This is a contradiction of the health institution, which has as its stake the ability to care for and protect the other.

Some authors analyze the metamorphosis of work and time, bringing contributions from Marx that enlighten us:

To him [Karl Marx], the emptying of work as an activity that shapes the subject is linked to the lack of meaning given to work. The author aligns this lack of meaning with the moment when the worker is so immersed and alienated in an infinite productive chain, that they can no longer recognize themselves in the final product of their work. They lack even the time for reflection (…) we could, at this point, align the self-managed time work (the work in Kairós) as a liberating and noble work of the human condition; and, conversely, that temporally controlled and rigidly determined work that removes from the subject the characteristic that most promotes ennoblement (J.C.O. Martins, Aquino, Sabóia, & Pinheiro, 2012, p. 225).

The institutional interferences show the blurring of the border between what seemed minimally agreed as the separation (even if just apparent) between the technical and the party-political. In the midst of the health crisis, Brazil was the only country in the world that, within a month (time analyzer), replaced the Minister of Health and the teams in charge of the department. The main divergences announced concern physical isolation and the use of hydroxychloroquine (representatives of the biomedical and medicalizing model), both agendas closely related to economic and political-partisan interests. The time analyzer helps to think about the research process and the need to cultivate spaces for reflection with supporters and promoters about how we use time. Whether in its chronos dimension, as determined and controlling, or kairós, as power.

The silence analyzer

Lastly, we address the silence analyzer. This was identified in remote meetings held between the researchers and the supporters and promoters. Silence is manifested by not speaking or by the unsaid moments during the meetings. As researchers, we ask ourselves if this refers to a non-doing of work (assuming work is doing), if it is not having anything to report when asked or if workers do not recognize themselves outside of their prescribed tasks (related to their roles) or, even, if those are doubts that deserve more reflection on doing.

Orlandi points to silence as the founder of meaning and ways of feeling, which perhaps justifies the importance of analyzing it, as he states that “silence permeates words, exists between them, or indicates that meaning can always be a different one, or even that what is most important is never said” (Orlandi, 2007, p. 14).

Silence is also related to “not knowing” and sustaining silence can mean sustaining “not knowing,” something fundamental for collective learning and opening gaps for other ways of thinking/acting/feeling. This “not knowing” perhaps represents what is usually rejected/excluded for not complying with the instituted order (Lourau, 2004). As such, the following sentence illustrates the place of not knowing and the proposal to assume this place, in order to build with the other:

[…] So, supporting us like so: people, we have to think about it together, but bring a voice to these people, because sometimes they also see us as if we had some sort of power - which we don’t actually have - and we get frustrated because we can’t give them the answer. I don’t have the power to answer, I don’t know everything, I’m not a strategist able to solve all problems. So I need to encourage, I don’t know, a more active stance on the part of these teams” (Meeting of July 2020).

The production of dialogues in the meetings is related to silence, which are carried out in a linear way, from one to the other instead of a conversation targetting all at the same time, having as main interlocutor the group coordinators (researchers who perform and take turns in this role), as if the triggering questions were intended to verify whether or not they are exercising their function during this period. This is evident in the report of the group of supporters and promoters, who most of the time address what they are doing, even if the question is “How are you feeling?

We were telling a little bit about our experiences, it was until… it was… [looks at the colleague next to them, seeking confirmation] it was the consignation… for us to start, adding it to the classroom and we can tell a little about the experience of the supporter and the organizer, what they were doing, the challenges… [looks at the colleague next to them again, as if seeking confirmation] (Meeting of August 2020).

While listening to the audios of the meetings from April and May, it was possible to notice that the short answers and the silence periods of the supporters and promoters were not studied in depth by the meeting’s coordination team. The anxiety manifested in the coordination of the meetings interrupted the silence when new questions were made, preventing the deepening of certain themes. “Researcher 1: (Name) are you finished speaking? Is that it? Participant: Yeah. Sorry. (Silence) Researcher 2: Would anyone else like to share? I’m finished speaking. Researcher 3: People, I also wanted to share […]” (Meeting of April 2020).

Researcher 1: The meeting we had that was virtual. (Name), were you there? (Name), (Name). I don’t remember much, because there were a lot of people. Are you listening? Researcher 2: Anyone else want to talk some more? Researcher 3: Right. (Name), (Name), do you want to talk some? (Meeting of May 2020).

Would not allowing self-analysis processes be a contradiction experienced by the researchers? Would the research institution be willing to take its place of knowledge management and, consequently, of the solutions to be pointed out, depriving institutional supporters and promoters of education of the “power” of reflection and production of new meanings about the challenges present in the current context?

It is possible that the resistance of the team of researchers who coordinate the meetings towards the analysis of what is instituted may be related to the fantasy of self-dissolution of the group’s research. To be clearer, because it is a funded research and a commitment was established between organizations (universities and municipalities), the researchers, fearing that the research will end when faced with their difficulties involving analysis, can operate with the activation of speeches that interrupt silences, producing exactly the opposite of the proposal, which is the collective analysis of the practices produced.

In a study that addresses EPS and action-research, the participants identified the inadequate management of silence in the groups, among other aspects, as a challenge in holding meetings with the health teams, which attests that this aspect deserves reflection on the part of the group coordinators (Nunes, Caixeta, Pinho, Souza, & Barbosa, 2019). The maxim that silence “is good for your health” can be applied to this context, with the understanding that the processes of change require analysis, reflection and, therefore, silence, as an important element for the functions of support and articulation.

The research team that proposes the production of change through the use of research-intervention, which is not produced only by action or participation, but also by the production of knowledge, ends up hindering the capacity of the group for this construction to the extent that the research institution wants to provide the production of knowledge, as a lever, from the outside in, for these changes.

This may be the contradiction of researchers who have bet on shared and interventional modes of research and knowledge production, who need, at times, to be silent, using an attentive listening. The investigation presents as contributions to social psychology the possibility of articulating concepts from institutional analysis to question public policies, including the field of health, since in Brazil, the area of psychology was primarily responsible for the dissemination of the theoretical-methodological framework. With regard to Permanent Education in Health and Institutional Support, interprofessional dialogue between psychology, collective health and the organizational area is recommended, as these are areas of knowledge respective to the professional categories that have been carrying out the work of monitoring teams in the health sector.

As a limitation, the analyses were carried out while the pandemic is still ongoing, crossing and exposing the contradictions of health and management practices, and it can still lead to over-implication, that is, the difficulty of analyzing our implications with all the institutions that we form and that form us. Thus, the contradictions highlighted by the analyzers show the polarization between social groups, on science, ideologies, the World Health Organization, hydroxychloroquine, the economy, social inequality, among many other topics. These polarizations can trigger processes of continuing education in health and institutional support, but, for that, they need collective reflection, a time of silence and not knowing, to produce more questions and new knowledge.

The results show that although several investments have been made, there is still a place of fragility of PHC within the SUS or of its importance to public management and in the public imagination, journalistic and social media, as well as the guidelines and provisions of national policies for permanent education in health and humanization.

It is also evident that some managers do not recognize the power of the work of institutional supporters and promoters of education and the lack of clarity of this work by themselves, due to the distance of some CHA from the territories and the distance of the teams towards users.

However, this moment also reveals movements that can become instituting, in that they “replace” the role of PHC as a coordinator and organizer of care, due to the ability that some teams demonstrated to reinvent their practices and the existence of supporters and promoters in the territories.

Time, in the context of the pandemic, can be understood as a hindrance, but it can also represent a time of opportunity for new learning and knowledge, chronos time and kairós time. Shall we be able to produce knowledge from listening to the silences of our time? Close to time, there is the silence analyzer, necessary to reflect on the possibilities of transformation.

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• Support:

  The study had financial support from the Research Program for the SUS, São Paulo Research Foundation (PPSUS/FAPESP) through Process 2019/03848-7, (CNPq, MS, Decit, SES-SP, FAPESP).

Edited by

Associate editor:

Marina Simões Flório Ferreira Bertagnoli

Publication Dates

• Publication in this collection
  28 Mar 2022
• Date of issue
  2022

History

• Received
  16 July 2021
• Reviewed
  17 Oct 2021
• Accepted
  05 Dec 2021