versão impressa ISSN 0104-1169
Rev. Latino-Am. Enfermagem v.15 n.1 Ribeirão Preto jan./fev. 2007
Perceptions about the coordination and functioning of general group meetings at a psychiatric day hospital1
Edson Arthur SchererI; Zeyne Alves Pires SchererII; Maria Auxiliadora CamposIII
IPsychiatrist, Doctoral Student in Pathology, University of São Paulo at Ribeirão Preto Medical School, e-mail: firstname.lastname@example.org
IIRN, PhD, Professor, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development
IIIPsychoanalyst, PhD, Retired Professor, University of São Paulo at Ribeirão Preto
This study aimed to examine the activity of coordinating general team meetings at a psychiatric day hospital, its functioning and the feelings these meetings aroused in the researchers. The method adopted to carry out this research was the observation and registration of two observers' perceptions. Twenty-one meetings were studied. The findings and discussion indicate that it would be ideal to diagnose the coordinator's performance, the organizational dynamics and structure, and then manage the malfunction. In that sense, the intervention of an institutional supervisor is suggested. The researchers' feelings were similar to their perceptions about the proceeding of the meeting and about the coordination.
Descriptors: patient care team; day care; psychiatry; mental health
Psychiatric day hospitals are modality for care delivery to mentally ill patients. In general, this form of care follows the guidelines for the functioning of the "therapeutic community", which ideally involves a care team with professionals from different areas, who interact in an integrated and complementary way, with a view to offering users with more humanitarian care.
However, in studies about mental health teamwork, researchers alert to some of the difficulties that can be met in this practice. One of these is exactly the team's heterogeneous composition, that is, the contact among professionals from different areas and with different kinds of training, entailing possible disagreements and knowledge shocks. These differences and their developments derive from the division of human sciences, which tend to seek refuge into their small intellectual feuds(1-5).
Team practice presupposes the distribution and articulation of tasks among its members. Therefore, professionals are expected to have a clear view of their role, limit and responsibility, besides acknowledging these aspects in their colleagues. However, this is not always what is found when a research is performed or team work is assessed. Frequently, roles are mixed up and members face difficulties to divide and acknowledge each professional's limits and responsibilities. Physicians, for example, tend to believe that, due to their attributions related to clients' admission, diagnostic investigation, therapeutic plan implementation and discharge, they play a more important role in the group and, hence, should be the leader (head). Moreover, for some medical professionals, teamwork generates dissatisfaction because they perceive it as distancing from their traditional task(6-8). On the other hand, this is not about questioning this professional's functions, but about sharing the patient's care with other technicians, exchanging information, discussing procedures and distributing tasks with a view to offering more integral care to clients.
The different professional categories that may be part of interdisciplinary teamwork bring knowledge and ways of approaching the health problem, based on various theoretical frameworks, ranging from those centered on symptoms to theories that recommend valuing the humanization of interpersonal relations. Each technician is trained to deal with the aspects inherent in the care population's suffering using an apparatus that is specific to his/her function. In general, training institutions do not yet prepare their students for teamwork, in which the "my patient" view makes room for "our patient". Nevertheless, recent tendencies have trained professionals with a more critical and reflexive attitude(9).
In view of the appointed difficulties, strategies are needed to try to mitigate these difficulties. Specialized literature agrees that, for the functioning of interdisciplinary teams, there is a need to create a space to reflect on direct practice involving users, as well as to seek the cohesion of the technical group. In this case, cohesion is understood as offering support and establishing significant relationships (bonds), thus favoring the integration and constructive maintenance of confrontation and conflicts present in the team. Systematic meetings between team professionals emerge as a resource to integrated different ways of thinking and acting. During these meetings, discussions are implemented to reconsider concepts, postures, attitudes, conducts; to provide for innovations in practice, to process emerging conflicts and to facilitate interpersonal team-team and team-patient relationships. Hence, in contrast with verticalized hierarchical decisions, these team meetings facilitate the democratic distribution of authority for tasks that need to be performed(10).
This understanding about the importance and consequent need for professionals in this kind of services to meet aroused our interest in getting a better understanding of these meetings. Thus, we studied "general team meetings" (GTM) at a Psychiatric Day Hospital affiliated with a university, with a view to characterizing meeting themes and how participants used time during a given period. These results were presented in a master's thesis(11). This research complements the quantitative analysis of the GTM analyzed in the above mentioned thesis and aims to examine how the coordination of the GTM was conducted, how these meetings functioned and the feelings they mobilized in the researchers.
This study was carried out at a university day hospital (DH), which delivers care to patients in mental suffering and performs teaching and research activities. At this institution, in-service training is offered to professionals graduated in areas related to mental health. Hence, two groups exist, one fixed and one floating. During the research period, the former consisted of the technicians who constitute the permanent work team (psychiatrist, nurse, social worker, occupational therapist, recreation professional, nursing auxiliary and administrative assistant), while the latter included trainees who had graduated in medicine, psychology, social service and occupational therapy. This team composition has participated in GTM since 1974, during which subjects are discussed that relate to administrative issues, interpersonal relations and conduct involving patients(12).
This study was carried out through a naturalistic research(13) by means of observation. The importance of observational skills(14), which are systematically trained, is the fact that the researcher is not a mere spectator who aims to obtain valuable data to understand group processes and improve his/her own participation as a group member. In this study, realized with the help of an observation script, we could focus on aspects related to the members' functional roles (constructive and non-constructive task and maintenance behaviors) and group metabolism (energy level, activity rhythm, socioemotional climate).
Thus, using observation, the observers apprehended the team's global behavior during meetings, that is, phenomena were registered according to their occurrence, and data were appropriately written down for further study. They were interested in the GTM participants' discourse style and psychological and formal alterations. Moreover, they paid attention to movements, such as the interposition of silent moments, voice inflections, affective changes in voice tones, laughs, cries, etc. Other aspects taken into account were self-observation procedures, understood as phenomena that happen to the researcher in response to the observed subjects' manifestations(15).
For this research, 21 meetings were observed during six months. The GTM were held every week, took one hour each and were coordinating by fixed and floating team members, according to a predetermined scale. The coordinator was responsible for maintaining GTM structure and functioning, delimiting time and mediating discussions, democratically facilitating interested persons' participation.
At the end of each meeting, the observers individually registered aspects related to the meetings in fluent writing, according to a script that had been established in the pilot study. This script included: 1. opinions about the meeting; 2. perceptions about how the coordination was conducted; 3. feelings mobilized during the observation. To analyze these data, a minimum agreement level of 80% among the records was established. These were called "observers' perceptions".
Data obtained from the observers' perceptions were submitted to content analysis(16). The categories of the coordinator's participation were defined as follows: Participative - besides providing structure to the meeting, the coordinator opined during discussions; Did not maintain structure - without participating in discussions and without control of time dedicated to each theme; Manifested anxiety - revealed anxiety and insecurity in his/her role as coordinator, without participating actively and facing difficulties to maintain the meeting structure; Little participation - remained limited to maintaining the GTM structure, without intervening in debates; Alert to structure - only maintained the structure and was concerned about time; Partial - led the meeting towards his/her own interests.
The following categories were used to assess GTM functioning: Productive - meetings where feelings were expressed, as well as affective manifestations, participants' interests, polemic discussions in a calm climate followed by the conclusion of the theme, or feelings of well-being were verbally expressed during the meeting or perceived by the observers; Not very Productive - meetings with superficial discussions; it could be perceived that participants were tired; meetings became empty as participants left; or irritability was clearly expressed.
During data collection, the following feelings were mobilized in the observers: identification; anger; tiredness; tranquility; interest; irritation.
The theoretical frameworks of individual, group and organizational psychodynamics were used for analysis(10,14,17).
The research project was approved by the hospital's Ethics Committee (responsible at that time for assessing research involving human beings). DH team members gave their informed consent during one GTM, as registered in the meeting proceedings.
Data related to coordination are presented in Table 1.
According to Table 1, 14 of the 21 meetings were coordinated by fixed team members and seven by trainees. The GTM were transcribed by the coordinators themselves, except for the first and the eleventh, whose transcriptions were made by another team member.
What the coordinator's participation is concerned, on five occasions, observers considered the coordinator participative, with little participation during five other GTM and alert to structure during three. On three occasions, the coordinator did not maintain the meeting structure, (s)he manifested anxiety during two GTM and was partial during two other meetings.
About the functioning of meetings
Table 2 shows how the researchers perceived GTM functioning.
Eleven out of 21 GTM were considered productive, while the remainder was considered as not very productive.
A comparison between Tables 1 and 2 also evidences correspondence between the meetings' and the coordinators' characteristics. Thus, productive GTM had a coordinator who was participative or alert to structure. Not very productive meetings, on the other hand, coincide with a coordinator who did not maintain the meeting structure, manifested anxiety or performed his/her task with partiality. Two of the five meetings whose coordinator showed little participation were considered as not very productive and three as productive. Half of the meetings coordinated by fixed team members were assessed positively. The same is true for coordinators from the floating team. The two meetings transcribed with the help of a participant were considered productive.
As to feelings mobilized during the recording
Table 3 presents results about what feelings were mobilized in the observers during data collection.
Results in Table 3 show that observations aroused feelings of tranquility in the observers during seven meetings. Eight GTM mobilized anger associated with tiredness or irritation. Observers identified with the affective manifestations expressed or perceived in participants on three occasions, one of which associated with interest. During two meetings, observers felt tired and, during one, interest.
A comparison between Tables 2 and 3 shows that productive meetings mobilized feelings of identification, tranquility and interest in the researchers. Feelings of anger, irritation and tiredness, on the other hand, coincide with not very productive GTM.
Silent group observation is a task loaded with peculiar aspects. The observer listens and, in some way, records the participants' statements. Sometimes, he/she ends up receiving the contents that emerge in the group. As he/she can feel but needs to contain him-/herself during the observation process, he/she can function as a depository of the emotions and fears that flourish from the group relation. This can give rise to expectations for the observer to make a more independent and precise analysis of what happens during the meeting(18). Hence, observing is neither easy nor free from some kind of involvement between the observer and what he/she is studying.
In this research, the comparison between the feelings mobilized in the observers during data collection and the way they perceived GTM functioning (Tables 2 and 3) allows for a number of considerations. During the meetings assessed as productive, feelings of identification, tranquility and interests emerged in the observers, while feelings of anger, irritation and tiredness coincided with not very productive GTM. These results seem to evidence the silent observers' involvement with the study situation.
The meeting coordinator is responsible for its structure and functioning, delimiting time, mediating discussions and stimulating interested persons' democratic participation. Therefore, he/she needs to overcome the obstacles of communication. Hence, to manage to play this role, the coordinator needs to be alert, concentrated on how discussions are moving ahead and on the other participants' movements or (verbal or non-verbal) manifestations. It is important for the coordinator to be available, capable of listening and understanding, of moving beyond his/her reference framework, asking questions to help whoever is talking to clarify their thoughts and meeting their needs. Comprehensive listener provoke less desire to strengthen their position(19) in people who feel listened to and understood, thus decreasing the risk of conflicts. Thus, coordination is a task that demands skills.
Transcription, in turn, requires not only the ability to synthesize, but also to fix one's attention on the contents of discourse, extracting important meanings, besides aptitude to write rapidly. In the study situation, whoever is transcribing needs to double attention, as this task is performed concomitantly, verbatim and by the GTM coordinator. Hence, the coordinator's role would be facilitated by the availability of another person to transcribe the meetings, which could possibly improve his/her participation and the way meetings evolve.
The GTM coordinator act as the group or team leader. Thus, starting from the premise that he/she holds power during meetings, group movements can be understood from the perspective of coordination, specifically in terms of authority(17).
During the study situations, the team in general seemed to correspond to the behaviors presented by different GTM coordinators. Participants manifested united behaviors towards calm and participative coordinators. When the coordinator wanted to conduct the meeting with partiality, on the other hand, team members manifested their emotional reactions in a free and democratic way, which could be observed during one GTM. The coordinator was interrupted by the other participants, who asked him to return to the normally used discussion structure, evidencing aggressive and evasive behaviors. This type of coordination can be compared with the tyranic, seductive and aggressive leader(14,17). Sometimes, according to the observers, the group seemed to depend on the coordinator.
On the other hand, group members' emotional needs can motivate a leader who is initially task-oriented to assume complementary attitudes. The expectation of primitive leadership, exercised by an omnipotent and generous figure, configures a dependent group, while a powerful and controlling authority configures struggle and flight in the group. This favors the leader's regression to adapt to this role(10). These aspects give rise to questions about knowledge and power relations and their influences on group behavior when confronted with different kinds of coordinators in this type of meetings.
When the coordinator is capable of assuming and sharing his/her responsibilities, being sensitive to group climate, which he/she considers as transcending individual participants, he/she can be compared with a democratic leader(14,17). He/she perceives his/her function as an actual coordination task, that is, his/her goal is to create conditions for the group to participate in the elaboration and execution of decisions under his/her responsibility. In this study, a coordinator considered as participative or alert to time can thus be equaled with actual leaders, organizers and identification models. Therefore, it would be adequate for a person with this leadership profile to become the GTM coordinator.
However, correcting a leadership dysfunction may not be restricted to the attribution of the leadership role to someone with a specific profile. Besides diagnosing the coordinator's functioning, the organizational dynamics and structure he/she is inserted in needs to be examined and his/her malfunctioning needs to be managed(10,20). Leadership problems can be the first symptoms of a service functioning failure. In this sense, an institutional supervisor should intervene(8,10).
Coordination of the GTM under study varied, which is justified as a teaching-learning activity. It is known, for example, that organizations can be divided in two types: demand and paranogenic. Demand organizations have a functional administrative structure, that is, authority and responsibility match. Paranogenic organizations, on the other hand, end up molding behaviors that give rise to mistrust, envy, rivalry, anxiety and hostilities, which turn relationships more difficult, even when individual good will is present(10). The DH's characteristics and the GTM's functioning seem to favor paranogenesis.
Technical differences between the specialties that make up a team and the inequality attributed to them allow for the emergence of tensions among team members (each of whom has his/her own knowledge and autonomy), characterizing a grouping team (juxtaposition of actions and grouping of agents) or an integration team (articulation of actions and interaction among agents). Hence, communication among professionals is essential for teamwork, that is, reciprocity between work and interaction is needed(3-5,9,20).
Based on literature and on our findings about GTM assessments, the DH team seemed to correspond to an integration team, as participants sought communicative interaction during meetings. Eleven meetings contained expressions of feelings, affective manifestations, participants' interest, polemic discussions in a calm climate with conclusion of the themes, or feelings of well-being were verbally expressed or perceived by the observers. During the other ten meetings, discussions were superficial, participants revealed tiredness, meetings tended to empty as participants left or irritability was clearly expressed. The observers perceived the feelings manifested by participants in a similar way. Thus, by facilitating the professionals' free expression and manifestation of positive (or considered productive) as well as negative aspects (or considered as not very productive), GTM offer the DH team with space for interaction.
Health professionals increasingly need and seek more humanized ways of approaching patients, independently of the type of disorder they suffer. Interdisciplinary teamwork has attracted new followers with a view to care delivery to a wide range of diseases, especially chronic conditions like cancer, painful syndromes, acquired immunodeficiency syndrome, diabetes, hypertension and psychosomatic and mental illnesses.
Developing research in health teams is a hard task, as this involves many questions and many particularities in the interaction process among team members themselves and between these and the care population and their relatives, with the institution and with the community the care practice is inserted in. Hence, there are many variables and it is difficult to control them. In this study, it could be perceived that even the researchers who observed the team end up getting involved with the situation they are studying.
This research did not look at the communication process during these meetings. The contents of discourse, who was talking, discourse quantification and decision making were not taken into consideration. To address these aspects, we suggest that a research procedure be implemented to focus on health work and communicative actions(3).
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Recebido em: 25.8.2005
Aprovado em: 18.4.2006
1 Study presented at the World Assembly for Mental Health/The 26th Congress of the World Federation for Mental Health