STUDY OF COMMUNICATIVE RELATIONS IN THE MANAGEMENT PROCESS OF A HEALTH INSTITUTION Estudo das relações comunicativas no processo de gestão de uma instituição de saúde

Conflict of interest: non-existent state Departments of Health, had to reformulate the health management practices1. Management is understood as administration, optimization of productivity and decision making that contributes to the effectiveness/efficiency of the organisation2. For the application of these concepts to health management, it is necessary, in addition to ensure the compliance with the universal principles of the SUS, to enable the professional and popular participation in the decisions about the health services and ensure high productivity of the implemented actions2. However, to achieve these objectives, the management within the public health agencies must follow certain stages that organize the implementation of internal actions in the institution. The management can be divided into three stages: planning, implementation and evaluation of actions. The planning should establish a coordinated set of actions to achieve a certain objective3; ABSTRACT


INTRODUCTION
With the implementation of the Single Health System (SUS) in the 90s, not only the direct health care has been changed, but also the way to manage the resources and health policies.To adapt the management to this new logic, the public bodies responsible for that, such as the municipal and the implementation is related to the management of the proposed actions 4 ; and the evaluation is related to the follow-up, accountability on the achieved results 5 .However, in order to perform these three stages in the proposed way, it is necessary to establish an effective communication process between all spheres of power within the organization, so that the final actions become known by all involved.
In the field of administration, the School of Human Relations 6 introduces communication as an element that integrates workers that occupy different positions in the organization.This theory addresses the importance of "communication between the positions" and the "participation in decision making".This means that all levels of employees in an organization must actively participate and access all the actions performed.For this to happen, it is important that the departmentalization of the activities is not exaggerated and that the information is decentralized.In the field of health in Brazil, the communicative management proposed by Rivera 5 presents a counterpoint between the Theory of Communicative Action of Habermas 7 and the Situational Strategic Planning of Carlos Matus 8 , emphasizing the importance of communication as a strategy for the pursuit of radical democracy.In this context, the communication within the health management model becomes a work tool and management component.
As the communicative management is the ideal model of the SUS management 5 , it becomes important to study how to establish communicative relations within a health manager agency.These relations can determine the final set of health policies formulated by the institution.Thus, the objective of this study is to relate the strategies of communication used in three phases of the management with the perception of communication of employees of an institution that manages the Single Health System.

METHODS
The descriptive-comparative and cross-sectional study with a sample defined by type was conducted in a health institution in the State of Minas Gerais.Six sectors of a total of 18 sectors of the institution were randomly selected and included in this study, whereby 56 subjects were drawn by lot and interviewed (30% per sector).The data were collected from September 2008 to April 2010.
It used a questionnaire with closed questions on the communication resources, on the planning dynamics, on the implementation and evaluation of health actions and on the perception of the subjects of the research about communication in their work.After the drawing, each participant was invited by email and/or phone, and upon the acceptance the term of consent was signed and clarified.
The interviews were based on a structured questionnaire, developed by the researchers (Figure 1).In this study, only the issues concerning the three stages of the management and the perception of the subjects of the research about communication in their work were considered.
This research was approved by the Research Ethics Committee of the Federal University of Minas Gerais (Opinion No. ETIC 74/08) and received funding from FAPEMIG.
The entry, processing and quantitative analysis of the data were performed using the SPSS program (version 16).For the statistical analysis, the Kappa Index was used, which is a measure of agreement used in nominal scales.This index provides an idea of how much the observations deviate from the expected, due to chance, indicating the legitimacy of the interpretations.In order to verify the agreement between the responses of the subjects related to the three stages of management and perception of communication, the Kappa Index was applied, considering the classification of degrees of agreement suggested by Landis and Koch 9 .
The tests were considered statistically significant when p-value ≤ 0.05.The kappa value from 0.80 to 1.00 was classified as excellent agreement, from 0.61 to 0.80 as good agreement, from 0.41 to 0.60 as moderate agreement, from 0.21 to 0, 40 as reasonable agreement and from 0.20 to -1.00 as poor agreement.The absolute and relative frequencies were used for descriptive analysis.

RESULTS
Of the 56 participants of the study, 82.1% had a complete higher education, most of them were approved employees (have passed the civil service examination) of the institution (85.7%) and 58.9% had never worked in the public service previously.Regarding the job position, 14% had a position of high school level, 58% of higher education level, 10.7% of coordination and 16.1% had another type of job, which mostly relate to coordination or advisory positions in sectors that do not exist in the formal organizational structure.This is often due to the complexity of the actions performed by the formal sectors, which often generates the need for the creation of informal departments also with informal leadership in the institution.Each sector included in the study was identified by a letter, for data analysis and presentation of results.The sample distribution in the sectors was as follows: 6 subjects in the sectors A and C, 8 in the sector D, 10 in sectors B and E, and 16 in sector F. Instruction: Now I will make four open questions and your answers will be recorded.

Which problems you have to pass and receive information from other sectors?
17.
Which information is missing for improving performance at work?

18.
List the positive aspects of communication in the SES/MG.

19.
List the negative aspects of communication in the SES/MG.With regard to the stage of implementation of the planned actions (Table 2), all sectors showed that generally each staff member assumes a particular activity, although everybody is also responsible for all executed actions.The six groups revealed that the information on activities are shared among all staff members on a frequent basis ("sometimes/ always").
In the analysis of how the communicative process in the planning stage occurs (Table 1), it was observed that all the sectors mentioned low frequency ("never or rarely") of its realization through meetings with pre-determined agenda.Even so, in 5 of the 6 groups analyzed, most subjects stated that planning is done through periodic meetings "sometimes or always".Periodic meeting is understood as a pre-scheduled meeting, which is part of a schedule and happens with certain frequency.In all groups, the planning is predominantly conducted in an unsystematic way, following guidelines external to the sector (except group E).Regarding the participation at the time of planning, in most of the sectors, the entire team participates "sometimes or always".It is observed that almost 100% of the respondents in all groups consider that the direct leadership is present with great frequency in this management stage, whereby the same does not apply to the indirect leadership.In the stage of evaluation of the actions (Table 3), only 2 groups reported their occurrence predominantly through meetings with a pre-determined agenda.The evaluation process mostly occurs in an unsystematic way four 5 groups and through periodic meeting only for 2 groups.The direct leadership participates of this stage in all sectors, whereby the participation of the indirect leadership predominantly occurs only for 2 groups.The evaluation of the actions occurs systematically Never/Rarely 0 0,0% 3 30,0% 3 50,0% 3 37,5% 1 10,0% 3 18,8% Sometimes/Always 5 83,3% 6 60,0% 3 50,0% 5 62,5% 8 80,0% 12 75,0%
Regarding the perception of the subjects in relation to the communicative process, to internal communication and with other sectors or superintendence, as well as with the senior management and other institutions, it was considered satisfactory by most of the participants.There was also positive self-assessment by 92.9% of the respondents (Figure 2).

DISCUSSION
The analysis of the results concerning the planning stage showed a contrast between the low frequency of meetings with pre-determined agenda and the high frequency of regular meetings.This data may suggest the occurrence of a "planning without planning," i.e., meetings with a predetermined agenda would indicate the existence of a space/ time reserved for planning.So, as recommended in the literature, such actions would demonstrate that planning should be considered as a fundamental stage in the work process, in the perspective of a communication organization 10 .It seems to happen, according to the respondents, periodic meetings in the sector to discuss planning and other topics.Thus, the time for planning is shared with other activities, not occupying a relevant role in the agenda of the sector.
Another important data found in the planning stage was the higher participation of the direct leadership in relation to the indirect leadership at that work time.This may suggest autonomy and decentralization of power because the headed staff members are the most active subjects in the stage of implementation.However, it can also lead to think about a fragmentation of the institutional planning, assuming that the indirect leadership is involved with actions of other complexity levels.This reality contradicts the principles of the communicative planning [11][12][13] that values the diversity of actors involved in the act of planning.Thus, the presence and actuation of leadership of different levels is important in the planning process 14 .
Regarding the stage of implementation, the data show that, in most cases, each staff member undertakes the performance of a certain activity, although, also in most cases, everybody undertakes all activities of the sector in general.This suggests the establishment of effective communicative relationships within the sectors during the implementation of the projects, supporting the integrated performance of the actions.Once the implementation process is the time when the planned actions are performed, it is natural that the use of communication in the process as a work tool becomes more evident.
In these circumstances the implementation stage experienced by the respondents presents characteristics of participatory management or co-management, highlighting features such as: autonomy, collective co-responsibility and participation in the decision processes 15 .
In the analysis regarding the moment of evaluation, a relationship between the low frequency of meetings with pre-determined agenda and the occurrence of unsystematic evaluations was observed.As the planning stage, the evaluation stage is also not performed on a scheduled basis, with space/time exclusive for that.Especially in this case, most of the respondents reported that the evaluation is informally done without systematic recording (in minutes of meetings, for example).In this context, it can be understood that the evaluation is not seen as an important tool in the work process  or as a steering mechanism for the creation of a new intervention strategy as described by the literature 16,17 .The principle of responsibility 5 establishes that within an institution all actors are subject to require and account for the planned appointments.The connection between these two moments, planning and evaluation, form a cycle 5 , in which all the actions proposed and implemented by the institution are interconnected.It must be considered that the non-valuation of the assessment breaks this cycle and that the effectiveness of the management could be reduced.
It is worth remembering that the degree of democratization of the internal environment of the institutions 18 must be considered in the analysis of the participative management.
Thus, in this study, the management of the work process and the configuration of the management adopted by the sectors of the institution must be included in the discussion about the relationships between staff and leadership.
The low level of agreement obtained in relation to the answers given by the respondents may reflect the communicative profile of the institution.There is disagreement between the responses of interviewees belonging to the same sector, as well as between the various sectors surveyed.So, it can be understood that the management stages that should be followed to perform the work process are not standardized by the institution or are not even respected by the sectors.
The literature shows that the organization of the work, when delimiting the skills and relationships between the subjects involved in the process, produces a model about what individuals understand and think about themselves 19 .
It is possible to relate the responses related to the perception and self-perception of the subjects about the communication process with data related to the management process.The perception of the respondents regarding the communication established with the various spheres of power within the institution and with external bodies was mostly satisfactory.The self-evaluative question was the one that obtained the highest level of satisfaction.These results indicate that the respondents do not establish a direct relationship between communication and work processes within view of the contradiction between the positive perception of the communicative relationships and the low level of agreement between the responses of other issues, besides the prevalence of responses unfavorable to what is expected from a communicative management 20 .Therefore, it can be said that the respondents do not see the management and communication as two interconnected actions.Thus, they do not identify, in situ, the problem or even are aware of its existence.
When analyzing the results obtained during the conduction of the present study, it is observed that they approach with the data found in the literature.Several authors emphasize the importance of communication as a tool for the support of the management process 5,10,11 .The present study shows that the management of SUS, as it occurs in the surveyed institution, is not yet adapted to the communicative management model 5 .
The literature also emphasizes that communication can be understood as a process that is influenced by the context in which the interlocutors are inserted and also by the management concept 15 .
The survey was supported by a small sample compared to the total number of employees of the institution, since the sample used here involved only the inclusion of six of the fourteen sectors of the institution.An analysis with a higher number of individuals, covering all sectors of the organization, will allow a more precise understanding of the surveyed issue and greater robustness in the descriptive and statistical analysis of the data.

CONCLUSION
The data obtained in the study showed to be significant within the field of Public Health.Through the results, it was possible to identify management strategies adopted by the surveyed institution and the role of communication in this management system.
The analysis of the answers showed that the respondents do not establish a direct relationship between the management process and the perception and self-perception of communication.This may suggest the need to use management devices in the surveyed institutions that emphasize the dialogical and intersubjective character, which will contribute to a more participatory management.

Figure 1 -
Figure 1 -Structured script used as an instrument for data collection.Belo Horizonte, MG, 2011.

Figure 2 -
Figure 2 -Relative frequency of the categories of perception of the subjects about the communication process in the organization.Belo Horizonte, MG, 2011.(n=56)

In the implementation of the planned actions and/or activities of the sector in which you work
InstructionsThis questionnaire requires only 25 minutes to be completed.It is divided in 3 parts: the first is identification, the second with closed questions and the third with 4 open questions.Please answer the questions based on your professional experience in the Department of Health of the State of Minas Gerais.Thank you for your participation.

of your individual evaluation (performance evaluation) is discussed with the direct leadership
First read all the items, and then ask the respondents if there is any other item they wish to add.If yes, add it to the list.Finally, number only the items that are used by the interviewee.
Sort the communication resources in ascending order of use (first= higher use, last= less use):Instruction: Order, according to their priority, your routine of reading reports ( first=highest priority , last=lowest priority):Instruction: First read all the items, and then ask the respondents if there is any other item they wish to add.If yes, add it to the list.Finally, number only the items that are used by the interviewee.