Study of communicative relations in the management process of a health institution

Ferreira, Marcela Cristina; Maciel, Fernanda Jorge; Castro, Leonardo Assis de; Lemos, Stela Maris Aguiar

doi:10.1590/S1516-18462013005000045

Abstracts

PURPOSE: to relate the communicative strategies adopted in the management of a health institution with the communication perception of the participants. METHOD: descriptive-comparative and cross-sectional study with a sample defined by type. 56 subjects from six sectors of the institution were interviewed with a closed questions questionnaire. For this study, we analyzed the questions related to stages of management and perception of communication at work. RESULTS: most of the respondents reported that the meetings in which planning occurs are not exclusive to this activity. The direct supervisors are always present, as opposed to the indirect ones. Regarding the implementation of actions, it was observed that all members of the sector take responsibility for the activities and share information during the process. It was reported that the evaluation occurs in an unsystematic way and the presence of direct and indirect leadership is similar to what occurs in the planning stage. It was found a low degree of correlation between the answers. The perception of the subjects about the communication was adequate, noting that no direct relationship is established between the communication and work process. CONCLUSION: it is considered that the data obtained in this study were relevant, so that led to discuss the role of communication in the system manager searched.

Health Management; Communication; Speech, Language and Hearing Sciences

OBJETIVO: relacionar as estratégias comunicativas adotadas na gestão de uma instituição de saúde com a percepção da comunicação pelos sujeitos participantes. MÉTODO: estudo descritivo-comparativo, com amostra por tipicidade, de recorte transversal. O estudo foi realizado em uma instituição de saúde do estado de Minas Gerais. Foram entrevistados 56 sujeitos de seis setores da instituição por meio de aplicação de questionário com 15 questões fechadas, que abordam desde a identificação do sujeito até as ações de planejamento, execução e avaliação da gestão e a percepção da comunicação e meios utilizados para se comunicar. Foi realizada análise descritiva e utilização do índice Kappa. RESULTADOS: os entrevistados, em sua maioria, relataram que as reuniões nas quais ocorre o planejamento não são exclusivas para tal atividade. Nelas sempre estão presentes as chefias diretas, ao contrário das indiretas. Quanto à execução das ações, observou-se que todos os membros da equipe se responsabilizam pelas atividades e compartilham informações durante o processo de trabalho. Foi relatado ainda que a avaliação ocorre de maneira assistemática e a presença das chefias direta e indireta é semelhante ao que ocorre na etapa de planejamento. Foi encontrado baixo grau de concordância entre as respostas. A percepção dos sujeitos sobre a comunicação foi considerada satisfatória, apontando que não é estabelecida relação direta entre a comunicação e o processo de trabalho. CONCLUSÃO: considera-se que os dados obtidos nesse estudo foram relevantes, de modo que permitiram discutir o papel da comunicação no sistema gestor pesquisado.

Gestão em Saúde; Comunicação; Fonoaudiologia

ORIGINAL ARTICLES

^IFederal University of Minas Gerais - UFMG, Belo Horizonte, Minas Gerais, Brazil

^IISchool of Public Health of Minas Gerais - ESP-MG, Belo Horizonte, Minas Gerais, Brazil

^IIIFederal University of Minas Gerais - UFMG, Belo Horizonte, Minas Gerais, Brazil

^IVFederal University of Minas Gerais - UFMG, Belo Horizonte, Minas Gerais, Brazil

Mailing Address

ABSTRACT

PURPOSE: to relate the communicative strategies adopted in the management of a health institution with the communication perception of the participants.

METHODS: descriptive-comparative and cross-sectional study with a sample defined by type. 56 subjects from six sectors of the institution were interviewed with a closed questions questionnaire. For this study, we analyzed the questions related to stages of management and perception of communication at work.

RESULTS: most of the respondents reported that the meetings in which planning occurs are not exclusive to this activity. The direct supervisors are always present, as opposed to the indirect ones. Regarding the implementation of actions, it was observed that all members of the sector take responsibility for the activities and share information during the process. It was reported that the evaluation occurs in an unsystematic way and the presence of direct and indirect leadership is similar to what occurs in the planning stage. It was found a low degree of correlation between the answers. The perception of the subjects about the communication was adequate, noting that no direct relationship is established between the communication and work process.

CONCLUSION: it is considered that the data obtained in this study were relevant, so that led to discuss the role of communication in the system manager searched.

Keywords: Health Management; Communication; Speech, Language and Hearing Sciences

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 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; the implementation is related to the management of the proposed actions⁴; and the evaluation is related to the follow-up, accountability on the achieved results⁵. 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 Relations⁶ 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 Rivera⁵ presents a counterpoint between the Theory of Communicative Action of Habermas⁷ and the Situational Strategic Planning of Carlos Matus⁸, 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 management⁵, 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 Koch⁹. 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.

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).

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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.

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").

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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.

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While checking the degree of agreement (Kappa index) between the responses related to the three management stages among the 56 respondents, there was little agreement (kappa<0.4) or even disagreement (kappa <0) in all questions. This means that the way as the action planning and evaluation occurs is not similar according to the respondents. In the stage of implementation of the actions, although most of the subjects state that the information is shared among all staff members and that everybody undertakes the actions, there was disagreement between the perceptions of the participants of the research.

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 organization¹⁰. 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^11-13that 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 process¹⁴.

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 processes¹⁵.

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 responsibility⁵ 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 cycle⁵, 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 institutions¹⁸must 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 themselves¹⁹.

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 management²⁰. 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 model⁵.

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 concept¹⁵.

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.

REFERENCES

¹
Brasil. Ministério da Saúde. Norma Operacional da Assistência à Saúde / SUS – NOAS-SUS 01/02. Disponível em <http://bvsms.saude.gov.br/bvs/saudelegis/gm/2002/prt0373_27_02_2002.html>. Acessado em 29 de fevereiro de 2012.
2. Schraiber LB, Peduzzim M, Sala A, Nemes MI, Castanhera ER, Kon R. Planejamento, gestão e avaliação em saúde: identificando problemas. Ciênc. saúde coletiva [online]. 1999;4(2):221-42.
3. Paim JS, Teixeira CF. Política, planejamento e gestão em saúde: balanço do estado da arte. Rev. Saúde Pública. 2006; 40(N Esp):73-8.
4. Rocha AA. O planejamento no cotidiano de uma instituição hipercomplexa: o caso da SES/Sergipe [tese]. Salvador (Bahia): UFBA; 2008.
5. Rivera FJ. A gestão situacional (em saúde) e a organização comunicante. Cad. Saúde Públ. 1996;12(3):357-72.
6. Etzioni A. Organizações Modernas. 8Ş ed. São Paulo: Pioneira; 1989.
7. Habermas J.Teoria da la acción comunicativa, I. Madrid: Taurus, 1v, 1987.
8. Matus C. Carlos Matus e o Planejamento Estratégico-Situacional. In: Rivera FJU (org). Planejamento e programação em saúde. Um enfoque estratégico. São Paulo: Cortez/Abrasco, 1989.
9. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159-74.
10. Campos GW. O anti-Taylor: sobre a invenção de um método para co governar instituições de saúde produzindo liberdade e compromisso. Cad. Saúde Públ. 1998;14(4):863-70.
11. Rivera FJ, Artmann E. Planejamento e gestão em saúde: flexibilidade metodológica e agir comunicativo. Ciênc. saúde coletiva [online]. 1999;4(2):355-65.
12. Kunsch MM. Planejamento e gestão estratégica de relações públicas nas organizações contemporâneas. Anàlisi. 2006;34:125-39.
13. Hennington EA. Gestão dos processos de trabalho e humanização em saúde: reflexões a partir da ergologia. Rev. Saúde Pública. 2008;42(3):555-61.
14. Rivera FJU. Cultura e liderança comunicativa. In: Rivera FJU. Análise estratégica em saúde e gestão pela escuta. Rio de Janeiro: Ed. Fiocruz, 2003.
15. Figueiredo PP, Cezar-vaz MR, Soares JF, Sena J, Cardoso LS. Processo de trabalho da Estratégia Saúde da Família: a concepção de gestão que permeia o agir em saúde. Physis: Revista de Saúde Coletiva. 2010;20(1): 235-59.
16. Figueiredo AM, Tanaka O. A avaliação no SUS como estratégia de reordenação da saúde. Cadernos FUNDAP. 1996; 98-105.
17. Gonzales MML. Planejamento estratégico em saúde com base em determinantes: o caso do município de Campo Bom (RS). Ciênc. saúde coletiva. 2009;14(1):1587-97.
18. Trad LAB, Esperidião MA. Gestão participativa e corresponsabilidade em saúde: limites e possibilidades no âmbito da Estratégia de Saúde da Família. Interface - Comunic., Saúde, Educ. 2009;13(1):557-70.
19. Scherer MDA, Pires D, Schwartz Y. Trabalho coletivo: um desafio para a gestão em saúde. Rev. Saúde Pública. 2009;43(4):721-5.
20. Favoreto RL, Ishikawa EC, Favoreto GL, Aquino GP, Favoreto JL. Alguns impactos da tecnologia da informação sobre a comunicação interna organizacional. In: 30ş EnANPAD: Anais do EnANPAD; 2006; Salvador (Bahia).