1 Study extracted from Master Thesis, Presented at the World Assem bly for Mental Health / The 26th Congress of the World Federation for Mental Health, Vancouver, Canada, 2001; 2 Psychiat rist , Assist ant at t he Hospit al das Clinicas, Doct oral St udent , e- m ail: scherer@eerp.usp.br; 3 Psychoanalyst, Retired Professor. University of São Paulo at Ribeirão Preto, Medical School, Brazil; 4 Nurse, Professor, University of São Paulo at Ribeirão Preto, School of Nursing, WHO Collaborating Center for Nursing Research Developm ent, Brazil
Disponible en castellano/ Disponível em língua portuguesa SciELO Brasil w w w .scielo.br/ rlae
THEMES AND TI ME USE BY PARTI CI PANTS I N GENERAL TEAM MEETI NGS AT A
PSYCHI ATRI C DAY HOSPI TAL
1Edson Ar t hur Scher er2 Mar ia Au x iliador a Cam pos3 Zey n e Alv es Pir es Scher er4
Scherer EA, Cam pos MA, Scherer ZAP. Them es and t im e use by part icipant s in general t eam m eet ings at a psychiat ric day hospit al. Rev Lat ino- am Enferm agem 2007 set em bro- out ubro; 15( 5) : 949- 57.
This nat uralist ic st udy was realized t hrough observat ion and aim ed t o charact erize general st aff m eet ings held at a day hospit al regarding t hem e and t he professionals’ part icipat ion in t he use of t im e. We observed 21 m eet ings, during which 144 announcem ent s were m ade and 46 issues were discussed, wit h great er part icipat ion in discussions by fix ed t eam m em ber s. I n 18 of t hese m eet ings, t he discussed t hem es cor r esponded t o daily sit uat ions r egist er ed dur ing t he w eek s pr eceding t he m eet ings. Our findings r ev eal t hat t hese m eet ings ar e insert ed in t he service on a regular basis. Power relat ions and differences in experience and t echnical knowledge bet w een t he differ ent pr ofessionals seem t o cont r ibut e t o t he higher or low er num ber of announcem ent s and issu es p r esen t ed . As t h is sp ace f av or s ex ch an ges, w e su ggest t h ese m eet in gs t o b e u sed in ot h er h ealt h ser v ices w or k ing w it h assist ance t eam s.
DESCRI PTORS: pat ient car e t eam ; day car e; psy chiat r y ; m ent al healt h
TEMAS Y UTI LI ZACI ÓN DEL TI EMPO POR LOS PARTI CI PANTES DE REUNI ONES DEL
EQUI PO GENERAL EN UN HOSPI TAL DÍ A PSI QUI ÁTRI CO
La finalidad de este estudio, configurado com o una investigación naturalística conducida m ediante observación, fue la de caracterizar las reuniones del equipo general de un hospital día respecto a la tem ática y la participación de los profesionales en la utilización del tiem po. Fueron com unicados 144 avisos y discutidos 46 asuntos en 21 reuniones observadas, con m ayor participación del equipo fijo en las discusiones. En 18 de las reuniones estudiadas, los tem as discutidos correspondieron a las situaciones diarias registradas durante las sem anas antecedentes a las m ism as. Los hallazgos m uestran que estas reuniones están insertadas regularm ente en el servicio. Las relaciones de poder y las diferencias de experiencia y conocim ient os t écnicos ent re los diversos profesionales parecieron cont ribuir para la m ayor o m enor colocación de avisos y asuntos. Com o son un espacio que favorece cam bios, sugerim os la utilización de estas reuniones en otros servicios de salud que trabaj en con equipos de atención.
DESCRI PTORES: gr upo de at ención al pacient e; cuidados diur nos; psiquiat r ía; salud m ent al
TEMAS E UTI LI ZAÇÃO DO TEMPO PELOS PARTI CI PANTES
DE REUNI ÕES DE EQUI PE
GERAL EM UM HOSPI TAL-DI A PSI QUI ÁTRI CO
O pr esent e est udo, configur ado com o pesquisa nat ur alíst ica, conduzida pela obser v ação, t ev e com o obj et iv o car act er izar as r euniões de equipe ger al de um hospit al- dia quant o à t em át ica e à par t icipação dos pr ofissionais na ut ilização do t em po. For am com unicados 144 avisos e discut idos 46 assunt os em 21 r euniões obser v adas, com par t icipação m aior da equ ipe f ix a n as discu ssões. Em 1 8 das r eu n iões est u dadas, h ou v e cor r espondência ent r e os t em as discut idos e as sit uações diár ias r egist r adas nas sem anas que ant eceder am as m esm as. Os achados m ost r am que essas r euniões est ão inser idas r egular m ent e no ser viço. As r elações de p od er e as d if er en ças d e ex p er iên cia e con h ecim en t os t écn icos en t r e os d iv er sos p r of ission ais p ar ecer am cont r ibuir par a a m aior ou m enor colocação de av isos e assunt os. Por ser um espaço fav or ecedor de t r ocas, sugere- se a ut ilização dessas reuniões em out ros serviços de saúde que t rabalhem com equipes de assist ência.
I NTRODUCTI ON
P
sychiatric treatm ents have historically gonet hr ough differ ent appr oaches, r anging fr om m yst ic-religious, m oral and biological ones to, m ore recently, approaches at t em pt ing t o offer a m ore hum anit arian care to patients. Several m odels are found in current pract ice, which result from t he reform s im plem ent ed in m en t al h ealt h policies. Th e av ailable pr oposals include part ial hospit alizat ion, in Day Hospit als.
The Day Hospit al ( DH) st udied here at t ends 1 6 u se r s o l d e r t h a n 1 5 i n a p sy ch i a t r i c se m i -hospit alizat ion r egim e. I t funct ions ever y day, fr om Mo n d ay t o Fr i d a y, b et w een 7 : 3 0 a n d 1 6 h o u r s. Pr o g r a m m e d a c t i v i t i e s a r e o f f e r e d , s u c h a s o p e r a t i o n a l g r o u p s , s o c i a l t h e r a p i e s , f a m i l y int er v iew s and m eet ings, indiv idual psychot herapy, occupat ional t herapy, physical act ivit ies, recreat ional act ivit ies, educat ional m eet ings, com m unit y m eet ings, besides act ivit ies volunt eers developed at t he service ( ch oir an d y og a) . Fu r t h er m or e, im m ed iat e p ost -d isch ar g e ou t p at ien t car e is of f er e-d -d u r in g t h r ee m ont hs, as w ell as a w eek ly long- t er m car e gr oup t o im prove t he social int egrat ion of pat ient s who left t he ser v ice.
As t his is a universit y service, besides care, the service is also directed at teaching and research, wit h in- service t raining for professionals from areas related to Mental Health who take their training period on sit e. This configur es t w o gr oups, one fix ed and
another floating, each with characteristic properties( 1).
Th e f i r st co n si st s o f t h e p r o f essi o n a l s f r o m t h e perm anent work team , while the second is com posed of graduat ed professionals who at t end t he service t o co m p l y w i t h r e q u i si t e s f r o m sp e ci f i c g r a d u a t e p r o g r a m s i n Me n t a l He a l t h a n d , o cca si o n a l l y, under gr aduat e st udent s.
Since 1974, t he t wo groups part icipat e in a m eet ing k now n as “ gener al t eam m eet ing” ( GTM) , t o ad d r ess ad m in ist r at iv e su b j ect s, in t er p er son al relat ions and conduct involving pat ient s. Am ong t he specific obj ect iv es of t hese m eet ings, t he follow ing st an d o u t : v i su al i zi n g an d assessi n g t eam w o r k ; ad d r essin g em er g in g con f lict s; p r om ot in g f u r t h er in t egr at ion bet w een t h e f ix ed t eam an d t r ain ees; e s t a b l i s h i n g e x c h a n g e s b e t w e e n b o t h g r o u p s ; discussing conduct s wit h t he part icipat ion of a larger num ber of ser v ice pr ofessionals and assessing t he t r a i n e e s h i p s w i t h t h e p r e s e n c e o f a l l D H pr of ession als.
Si n ce 1 9 8 7 , i n t u r n , t h e f i x ed t eam h as par t icipat ed in t he “ fix ed t eam m eet ing” ( FTM) , t o co n t i n u o u sl y r e f l e ct o n t h e i r p r a ct i ce , d i scu ss bur eaucr at ic and adm inist r at iv e issues and addr ess co n f l i ct s a m o n g se ct o r s. Th u s, t h e t e a m i s st rengt hened as a group t hat m aint ains t he service.
I n 1992, the “ com m unity m eeting” ( CM) was cr eat ed, w hich is open t o m em ber s of t he DH and aim s t o fav or t he com m unit y ’s or ganizat ion; br ing pat ient s, fix ed t eam and t r ainees closer t oget her ; prom ote the relief of tensions am ong the groups and seek a m ore social and collective dim ension for private issues( 2).
These three m eetings constitute the axis that sust ains t he service, and t he evolut ion of t he w ork
proposal highly depends on t hem( 2). The GTM is an
act ivit y t hat has been m aint ained at t his inst it ut ion f or m or e t h an t w o d ecad es, of f er in g a sp ace f or t e a ch i n g - l e a r n i n g . I t se e m s t o b e a sp a ce f o r d em o cr a t i c ex ch a n g es a m o n g p a r t i ci p a n t s. Th i s hypothesis gave rise to the interest in researching on t he GTM.
St u d y i n g t h e GTM i s a com p l ex t ask , as som e v ar iables ar e h ar d t o con t r ol, su ch as each m e m b e r ’ s i n d i v i d u a l a s p e c t s f o r e x a m p l e , t h e sit u at ion s t h e g r ou p is ex p er ien cin g , con sid er in g a s p e c t s o f t h e i n s t i t u t i o n , s o c i e t y a n d t h e int er act ion bet w een pr ofessionals and client s. Thus, t his st udy aim ed t o char act er ize t he GTM in t er m s of t h em es an d p ar t icip an t s’ t im e u se in a g iv en p er i o d .
METHOD
The strategy chosen for this study was natural research, that is, the investigation of the phenom enon within and in relation to the natural context it occurs in. I n this kind of research, the exam ined environm ent ( n at u r ally occu r r in g ev en t , p r og r am , com m u n it y, r elat ionship or int er act ion) does not hav e a cour se t hat is predet erm ined and est ablished by or for t he r esear cher( 3).
Charact erizat ion of st udy sit uat ion
t im e. The t eam had agr eed t o lim it t he num ber of t opics t o t hree per m eet ing, so as t o m ake possible discussions.
Elev en pr ofessionals w er e par t of t he fix ed t e a m : t w o p s y c h i a t r i c f a c u l t y m e m b e r s , o n e assist ant psychiat rist , t wo nurses, one social work er, on e occu pat ion al t h er apist , on e r ecr eat ion ist , t w o nursing aids and one adm inist rat ive aid. There were ei g h t t r a i n ees: t h r ee r esi d en t p h y si ci a n s, t h r ee sp ecializat ion cou r se st u d en t s ( p sy ch olog y, social ser v ice, occu p at ion al t h er ap y ) , on e p ost d oct or al st u den t in m en t al h ealt h ( social w or k er ) an d on e u n d e r g r a d u a t e st u d e n t ( o ccu p a t i o n a l t h e r a p y ) . Pr of ession als f r om ot h er ser v ices an d in st it u t ion s w h o w er e occasion ally p r esen t d u r in g GTM w er e ident ified as v isit or s.
Dat a collect ion and analy sis
Th e p r o ced u r e u sed w as n o n - p ar t i ci p an t ob ser v at ion( 4 ) of 2 1 m eet in g s h eld d u r in g a six
-m on t h per iod. I n t h is r esear ch , t h e obser v er h ad con t act w it h t h e GTM b u t d id n ot t ak e p ar t an d r em ained an out sider, w it nessing t he fact s w it hout part icipat ing in t hem , wit hout get t ing involved in t he sit uat ions, t hat is, being m or e of a spect at or. The o b s e r v a t i o n w a s o r d e r e d a n d d i r e c t e d t o t h e est ab lish ed g oal, u sin g a sy st em ized p r ot ocol t o collect dat a, w hich had been defined and t est ed in t he pilot phase of t he st udy. The records perm it t ed focusing on t he cont ent ( what t he group was saying) and t he com m unicat ion process ( w ho w as speaking
and how m uch)( 3- 5).
The obser v er s w er e t he fir st aut hor of t his st udy and a psychologist , bot h of whom used t o be t rainees at t he DH before t he dat a collect ion period. Their t r aining t ook place in t he const r uct ion phase of t he dat a collect ion inst r um ent , and a m inim um a g r e e m e n t o f 8 0 % w a s o b t a i n e d b e t w e e n t h e obt ained r ecor ds. For each GTM, t he pr ot ocol w as used, which included not ices, subj ect s, t he m em ber ( pr ev iously defined indiv idual t w o- let t er code) and t he dur at ion of t he per son’s t alk.
To r e c o r d n o t i c e s a n d s u b j e c t s , t h e m e cat egor ies( 6 ) w er e est ablish ed, ex t r act ed fr om t h e
m at er ial r ecor ded in m inut es of 44 GTM t hat t ook place du r in g t h e y ear bef or e dat a collect ion , an d t est ed in t he pilot phase. The t hem es relat ed t o t he n o t i ce s a n d su b j e ct s w e r e d e f i n e d a s f o l l o w s:
se r vice rou t in e s a n d fu n ct ion in g ( R) - act ivit ies,
t i m e s , e x p l a n a t i o n s a n d c l a r i f i c a t i o n s a b o u t f u n ct ion in g an d occasion al ch an ges in t h e r ou t in e
( such as st rikes, holidays) ; physica l st r uct ur e ( PS)
- m ain t en an ce an d m od if icat ion s in t h e p h y sical st r u ct u r e ( in st allat ion s) , bu ildin g or en v ir on m en t ;
pa t ie n t s ( P) - indicat ion for t r eat m ent , adherence, evolut ion, m anagem ent and conduct wit h t he users;
t r a i n e e s ( T) - s t a r t a n d e n d o f t r a i n e e s h i p s , ev a l u a t i o n s, r el a t i o n sh i p s b et w een t r a i n ees a n d bet ween t hem and t he fixed t hem e and t heir specific d i f f i cu l t i e s; s c i e n t i f i c a c t i v i t i e s ( SCA) -part icipat ion of DH professionals in scient ific event s ( co n g r e sse s, sy m p o si a , co n f e r e n ce s, co u r se s) , p u b l i ca t i o n s a n d st u d i e s a b o u t t h e D H; s o c i a l a ct ivit ie s ( SA) - part ies, get t oget hers, encount ers, cock t ails, t r ip s, sh ow s b y t eam m em b er s w it h or w it hout user s and w it h or w it hout t he com m unit y ;
v i si t o r s ( V) - r ecep t ion an d or g an izat ion of t h e
service for visit ors; a t t e n da n ce ( A) - t rainees’ and
fix ed t eam m em ber s’ at t en dan ce at m eet in gs an d DH act iv it ies ( ab sen ces, d elay s, h olid ay s) ; f i x e d t e a m ( Fx T) - t em por ar y or per m anent absence of f i x e d t e a m m e m b e r s ( h e a l t h l e a v e s, l e a v e s o f a b se n ce , r e t i r e m e n t s a n d r e si g n a t i o n s) . Th e se cat egor ies w er e used t o r egist er t he dat a collect ed from t he 21 GTM.
I n order t o est ablish a relat ion bet ween t he daily service reality and the GTM, two team m em bers r egist er ed t he sit uat ions t hat happened dur ing t he p er i o d b et w een o n e m eet i n g a n d t h e n ex t . Th e m at er ial r eg ist er ed in t h is w ay w as su b m it t ed t o
t hem at ic cont ent analysis( 6), based on t he previously
defined not ices and subj ect s.
Th e r esear ch p r oj ect w as d ef in ed b y t h e I nstitutional Review Board of the institution the DH is insert ed in. The t eam m em bers were asked t o give t h ei r i n f o r m ed co n sen t d u r i n g a g en er al ser v i ce m eet ing, which was recorded in t he m inut es.
To a n a l y ze t h e f i n d i n g s, t h e t h e o r e t i ca l r e f e r e n ce f r a m e w o r k o f i n d i v i d u a l , g r o u p a n d
organizat ional psychodynam ics was used( 5,7- 9).
RESULTS
Not ices and subj ect s
m o r e f r e q u e n t l y g a v e n o t i ce s i n t h e ca t e g o r i e s
a t t e n d a n ce a n d r o u t in e s, cor r espon din g t o 1 0 1 ( 70.1% ) of t he t ot al. Trainees produced 18 ( 12.5% ) not ices and fixed t eam m em bers 126 ( 87.5% ) .
Table 1 - Dist r ibu t ion of Not ices in GTM at a DH, acco r d i n g t o cat eg o r i es, i n f o r m an t s an d n o t i ces t ransform ed int o subj ect s
Table 3 - Distribution of notice and subj ect categories*
during GTM at a DH in com parison with daily service sit uat ion records
s a i r o g e t a C d e x i F m a e
T Trainees
d e m r o f s n a r T s t c e j b u S o t n
i Total
f % F % f % f %
e c n a d n e tt
A 70 55.5 10 55.5 0 0 80 55.5
s e n it u o
R 20 15.9 1 5.6 2 20 21 14.6
s e it i v it c A l a i c o
S 11 8.8 1 5.6 3 30 12 8.3
s e it i v it c A c if it n e i c
S 7 5.5 4 22.2 3 30 7 7.6
e r u t c u rt S l a c i s y h
P 8 6.3 0 0 0 0 8 5.6
s e e n i a r
T 4 3.2 2 11.1 0 0 6 4.2
s t n e it a
P 3 2.4 0 0 2 20 3 2.1
s ti s i
V 3 2.4 0 0 0 0 3 2.1
l a t o
T 126 100 18 100 10 100 144 100
Table 2 - Distribution of Subj ects in GTM at a DH, per cat egories and proposing subj ect s
y r o g e t a
C Fixedteam Trainees Total
f % F % f %
s e n it u o
R 9 25 3 30 12 26.1
s t n e it a
P 6 16.7 4 40 10 21.7
s e it i v it c A l a i c o
S 8 22.2 0 0 8 17.4
s e e n i a r
T 5 13.9 2 20 7 15.2
s e it i v it c A c if it n e i c
S 5 13.9 0 0 5 10.8
m a e T d e x i
F 1 2.8 1 10 2 4.4
e r u t c u r t S l a c i s y h
P 2 5.5 0 0 2 4.4
l a t o
T 36 100 10 100 46 100
Table 2 present s t he subj ect s t hat cam e up in t he m eet ings and t heir dist r ibut ion accor ding t o categories and proposing subj ects. I t is observed that t h e p r e d o m i n a n t su b j e ct s w e r e r e l a t e d t o adm inist r at ion and conduct inv olv ing user s, in t he
categories rout ines, pat ient s, social act ivit ies and
ph y sica l st r u ct u r e , t ot aling 32 ( 69.5% ) of t he 46 t hem es t hat were discussed. The subj ect s relat ed t o the professionals, teaching and research, represented
by the categories t rainees, scient ific act ivit ies and
fixed t eam , corresponded to 14 ( 30.5% ) of the total. Fixed t eam m em bers proposed 36 subj ect s ( 78.3% ) and t rainees 10 ( 21.7% ) .
Com par ison bet w een m eet ing r ecor ds and daily DH r ecor d s
The r ecor ds m ade dur ing t he w eeks befor e each of t he GTM are present ed in Tabel 3 and were com pared wit h dat a from Tables 1 and 2.
* Category description: R - service routines and functioning; PS - physical structure; P - patients; T - trainees; SCA - scientific activities; SA - social activities; V - visitors; A - attendance; FxT - fixed team .
Daily ser v ice sit u at ion s w er e r ecor ded f or an aly sis as fr om t h e secon d GTM. Tot al or par t ial c o r r e s p o n d e n c e w a s o b s e r v e d b e t w e e n t h e d i s c u s s e d s u b j e c t s a n d t h e d a i l y s i t u a t i o n s r eg ist er ed at t h e ser v ice, in 1 8 of t h e 2 0 w eek s u n der st u dy. Th e cat egor y f ix e d t e a m w as list ed 17 t im es in daily service records and appeared once as not ice and t wice as subj ect s during t he m eet ings. Th e t h em e t r a i n e e s ap p ear ed 1 4 t im es in d aily
service records and nine t im es in GTM. V isit s were
m ent ioned 14 t im es in daily not es and as not ices in t hr ee GTM.
Par t icipat ion
The duration of each GTM ranged from 49 to 67 m inutes and 30 seconds, with a m ean tim e of 58 m i n u t es. Th e m ean si l en ce p er m eet i n g w as 4 2 seconds. I n only one m eeting, there was silence for 5 m inut es.
A s t o u s a g e t i m e , t h e t e a m m e m b e r s ’ v er b al p ar t icip at ion w as d ist r ib u t ed as sh ow n in Figur e 1.
M T
G Notices Subjects DaliySituations
2
0 SCA;PS;T;A SCA;R;FxT SCA;R;FxT;PS;V;P;SA
3
0 P;R;PS;SA;SCA;T;A P;R P;R;PS;SA;SCA;T;FxT;V
4
0 R;PS;SCA;T;V;A R;PS;SCA R;PS;SCA;T;P;FxT
5
0 R;P;A R;P R;P;PS;SCA;FxT;V;T
6
0 FxT;R;V;A FxT;T;SA FxT;T;SA;R;V;SCA;P
7
0 SA;SCA;R SA;SCA;P SA;SCA;P;R;FxT;T;V
8
0 SA;A;PS P;R P;R;SA;V
9
0 R;PS;SCA;T;A R R;PS;SCA;T;SA;V;P;FxT
0
1 R;FxT;V;A P;T P;T;R;FxT;V;SCA
1
1 --- SCA SCA;R;PS;FxT;SA;P;T;V
2
1 SCA;T;SA;A SA;P SCA;T;R;V
3
1 SA;R;A SA;P;T SA;P;R;FxT;V
4
1 R;A PS;SA PS;SA;R;FxT;P;V
5
1 R;SA;A T R;P;FxT
6
1 T;PS;R;SA;A T;P T;PS;R;SA;V
7
1 R;A T T;R;FxT;P
8
1 R;SA;T;A R;SA R;SA;T;V;PS;FxT
9
1 R;P;SCA;SA;A R R;P;T;V;PS;FxT
0
2 R;SCA;A R R;P;SA;FxT
1
Figure 1 - Verbal part icipat ion of GTM m em bers from a DH according t o t im e occupat ion during m eet ings
The equiv alence bet w een t he cat egor ies of notices and subj ects and the possibility of using them t o cat egor ize t h e daily sit u at ion s f r om t h e w eek s before each GTM perm it s concluding t hat t here is a con st an t cir cu lat ion of in f or m at ion at t h e ser v ice, apparently in accordance with the m eeting’s obj ectives. The correspondence bet ween t he daily sit uat ions and the subj ects discussed in 18 of the 20 m eetings that were assessed ( Table 3) allows us to infer that these results indicate that the service context was exam ined during t hese m eet ings.
The not ice and subj ect cat egories appeared m ore frequent ly in t he records of daily DH sit uat ions t h an in t h e cor r esp on d in g GTM ( Tab le 3 ) . Th is is underst andable, as bot h t he t im e and t he num ber of subj ect s ar e lim it ed dur ing t he m eet ings. How ever,
t he findings r elat ed t o t he cat egor ies f ix e d t e a m ,
t rainees and visit s cannot be ignored. As to the low
frequency of the visit s category during the m eetings
( Tables 1 and 2) , as t he t eam is accust om ed t o t his rout ine, m em bers m ay not feel t he need t o discuss t his t hem e.
Th e low f r eq u en cy of su b j ect s r elat ed t o
t r a ine e s and t he fix e d t e a m during GTM ( Tables 1 and 2) , m ay be j ust ified by t he hypot hesis t hat t he existence of weekly fixed team m eetings ( FTM) m akes it easier for t he fix ed pr ofessionals t o leav e som e specific t hem es for discussion dur ing t his m eet ing. The FTM seem s t o m ake it easier not t o account for all pr oblem s inher ent in int er disciplinar y w or k , lik e that of the team in question, in the face of the trainees. Hence, t he general obj ect ive of t he GTM, which is t o 0
10 20 30 40 50 60
Team members
M
inut
e
s
Faculty Non faculty Trainees Visitors
Non faculty (sec. Level) Silence
Th e v er b al p ar t i ci p at i o n o f t h e DH’s interdisciplinary team m em bers in the study period, in view of the tim e occupied in the choice and the discussion of t he t hem es, in Figur e 1, show s t hat t he facult y m em bers t alked m ost . They occupied 48.5% of t ot al tim e during the 21 GTM, that is, alm ost half of the m eeting tim e. The other participants used 50.5% of the tim e, distributed as follows: non faculty higher education level 28% ; non faculty secondary level 3.5% ; trainees 15% ; visitors 4% . Silence corresponded to 1% .
No n - f a cu l t y em p l o y ees w i t h h i g h er - l ev el f u n ct i o n s p r o p o se d 2 0 ( 4 3 . 5 % ) o f t h e su b j e ct s discussed in t he m eet ings dur ing t he st udy per iod, followed by the faculty m em bers with 16 ( 34.8% ) and t r ain ees w it h 1 0 ( 2 1 . 7 % ) su b j ect s. Th e su b j ect s p r op osed b y t h e t r ain ees w er e all ch osen b y t h e r esident physicians.
DI SCUSSI ON
The im portance of the general team m eetings for t he DH can be observed t hrough t he inform at ion present ed in a ret rospect ive survey, covering a t en-y ear per iod, w hich r egist er ed m inut e t r anscr ipt s of 437 GTM, t hat is, an av er age of appr ox im at ely 43
GTM per year( 10). This is a considerable num ber if one
facilitate the articulation between the trainees and the f i x e d t e a m , a d d r e ssi n g su b j e ct s r e l a t e d t o t h e int er per sonal r elat ionships am ong it s com ponent s, would not be fully cont em plat ed.
W h e n co n si d e r i n g p r o b l e m s r e l a t e d t o int er disciplinar y t eam w or k , lit er at ur e( 11) ev idences
other factors that can also be related with the results of t his research: 1. t he need for furt her clarificat ion of roles and the distribution of functions am ong team m e m b e r s; 2 . i n t e r p e r so n a l co m m u n i ca t i o n w i t h p r o b l e m s; 3 . h i e r a r ch i ca l d i f f e r e n ce s m a r k i n g relations; 4. the occurrence of in- service training; and 5. each m em ber’s t im e at t he inst it ut ion.
The t rainees part icipat ed verbally, occupying 1 5 % o f m e e t i n g t i m e ( Fi g u r e 1 ) . Th i s t i m i d participation in the GTM under study can reflect their lack of experience, m aking them assum e a secondary role in the choice and discussion of them es. The fact t h a t t h ei r p r o f essi o n a l i d en t i t i es a r e st i l l u n d er const ruct ion can favor t heir expressions of insecurit y and per secut iv eness.
Th e t h er ap eu t i c co m m u n i t y en v i r o n m en t f av or s gr eat er ex posu r e of lear n er s, so t h at t h eir weaknesses becom e m ore evident . The young m ake effort s in t he search for knowledge and ident ificat ion with their supervisors, seeking in them a professional m odel they want to be in the future. Som etim es, they end up behaving like children that wait for their parents’ directions, which m akes the group function at the level
of t he basic dependence assum pt ion( 12). Hence, m ore
ex per ienced pr ofessionals ar e ex pect ed t o assum e t he role of facilit at ors in t he t rainees’ developm ent , ser v in g as a m od el an d look in g ov er t h em m or e ca r e f u l l y a n d co n t a i n e d l y, so a s t o f a v o r t h e i r i n t e g r a t i o n a n d l e a r n i n g . I f n o t , f r u st r a t i o n , persecut iveness, envy and t he feeling of inadequacy can m ake it easier for these young people to adopt a post ure in which t hey silent ly alienat e t hem selves at t he inst it ut ion or even end up im plem ent ing act ions t hat sabot age service t asks.
Therefore, t he fact t hat t he DH t rainees are e x p e r i e n ci n g a v e r y sp e ci a l m o m e n t i n t h e i r professional t raining cannot be underest im at ed. Their previous learning at college inst it ut ions was cent ered on the bi- personal relation. I nterdisciplinary team work in t he t herapeut ic com m unit y m odel presupposed a plural dim ension in t he t herapeut ic relat ion. Client s are no longer “ m ine” but becom e “ ours”. I n a parallel way, t he new Curricular Guidelines of undergraduat e cour ses hav e at t em pt ed t o pr iv ilege pr ofessionals’
m or e h u m an ist ic ed u cat ion , st im u lat in g t h em t o assu m e a m or e cr it ical an d r ef lex iv e post u r e an d enabling them to attend to local and regional dem ands,
wit h t he social com m it m ent t o m ake changes( 13).
The sear ch for cohesion in t he pr ofessional group of any int erdisciplinary t eam and t he need for a space t o reflect on direct pract ice involving users h a s b e e n a co n se n su s i n sp e ci a l i ze d l i t e r a t u r e . Therefore, syst em at ic m eet ings of t eam professionals em er ge as a r esou r ce t o f acilit at e t h e in t egr at ion am on g differ en t w ay s of t h in k in g an d act in g. Th e discussions are im plem ented so as to review concepts, post ures, at t it udes, conduct s; provide for innovat ions in pract ice; address em erging conflict s and facilit at e interpersonal relationships am ong team m em bers and b et w een t h em an d u ser s. As t h ey co n t r ast w i t h vert icalized hierarchical decisions, at any inst it ut ion, t eam m eet ings facilit at e t he dem ocrat ic dist ribut ion of aut horit y t o perform t he t asks( 5,7).
I n st it u t ion s or or g an izat ion s can f u n ct ion
according t o t he requisit e or par anogenesis m odel( 7).
Requisit e inst it ut ions have a funct ional adm inist rat ive structure, that is, authority and responsibility com bine. Par an og en ic inst it ut ions end up m olding behav ior s t h at lead t o m ist r u st , en v y, r iv alr y, an x iet y an d hostilities, m aking interpersonal relations difficult, even when individual good will exist s.
The DH’s char act er ist ics and funct ioning of
t he GTM seem t o favor par anogenesis. There seem s
t o be an at t em pt t o cont r ol t he p ar an og en esis by
est ablishing dem ocracy in t he GTM. How ev er, as a political system , dem ocracy works better in the social r eg u l at i o n o f o p en so ci et i es. As a l i m i t ed so ci al or gan izat ion , t h at is, w it h a r est r ict ed n u m ber of delim it at ion s an d specif ic pr im ar y t ask s, t h e GTM r eq u i r es a f u n ct i o n a l l ea d er sh i p . Th e f u n ct i o n a l decision involves t he possibilit y of group discussions and decision m aking am ong leaders from a specific hierarchical level. Aut horit y can be delegat ed t o any of the involved groups, but the leaders who hold the legitim ate power ( authorities) are still responsible. This can m ake the functional organization seem dem ocratic when, in fact, it corresponds to the functional principles of t he social organizat ion( 5,7).
ten ( 21.7% - Table 2) out of 46 subj ects. Medical faculty m em ber s t alk ed m ost , occupied alm ost half of t he m eet ing t im e ( Figure 1) and suggest ed 16 ( 34.8% -Table 2) discussion t hem es. Their r esponsibilit y for t eaching and research, t he st ruct ural adm inist rat ive concerns of t he inst it ut ion t he service is insert ed in ( Universit y) and t he necessary worries wit h t he care populat ion can fav or t he hier ar chizat ion and fix ed d et er m in at ion of t h e lead er sh ip f u n ct ion an d t h e consequent legit im at e pow er. Thus, deliver ing car e, t eaching, serving as a m odel, adm inist ering and also d e v e l o p i n g r e se a r ch a r e f u n ct i o n s t h a t e n d u p facilitating or pressuring m em bers from this group to part icipat e m ore in t he GTM. This m akes it possible t o infer t hat , in t he t hem e under st udy, t her e ar e k n ow led g e an d p ow er d if f er en ces. Wh at p ow er is con cer n ed , it seem s t h at , lik e in m ost u n iv er sit y
hospit al services, t he m edical m odel is hegem onic(
14-15). Hence, DH physicians appear as t he group wit h
aut hor it y ov er t he ser v ice, t hat is, w hich assum es
responsibilit y and funct ional leadership( 5,7).
Daily cont act w it h t he problem s creat ed by i l l n e ss a n d co n se q u e n t l o sse s t e n d s t o cr e a t e defensiv e behav ior s in t he car e t eam . The m edical pr ofessional’s oft en om nipot ent post ur e can appear as the dislocation of tensions to the auxiliary staff or clients. This ends up stim ulating dependence in them , w hich is facilit at ed by t he r egr ession conduct ed by t h e d isease it self. How ev er, t h is d ep en d en ce can in cr ease dem an ds, f r u st r at ion s an d in gr at it u de or per secut or y sit uat ions am ong people r eceiving car e as w el l as am o n g au x i l i ar y t ech n i ci an s. An o t h er possible attitude is identification with the problem the institution intends to solve, which can m ake it acquire t he sam e st r uct ur e and m eaning. I n t he case of a m ental health service, this can segregate and alienate
its users, while it actually aim s to reintegrate them( 9).
A hospital, as an institution the client can turn to in case of a disease or problem that affects his/ her i n t e g r i t y, e sse n t i a l l y a i m s t o p r o v i d e f a v o r a b l e co n d i t i o n s f o r h i s/ h e r r e h a b i l i t a t i o n . Ho w e v e r, som et im es, it ends up st ruct uring it self according t o healt h and adm inist rat ive professionals’ convenience, w hich ar e fr equent ly opposed t o user s’ needs. The institutions repeat life, that is, its dynam ic nature and t he presence of conflict are im m anent . The universal ch a r a ct e r o f t h e t e n d e n cy t o w a r d s t h e inst it ut ionalizat ion of hum an groups, t he progressive dist ancing of t he gr oup’s or iginal obj ect iv es t o t he ex t ent t hat it s inst it ut ionalizing pr ocess occur s and
t h e co n q u est o r m ai n t en an ce o f “ p o w er st at es”, appear as characteristics of any hum an grouping, that is, gr ou ps ar e alw ay s pow er - seek in g in st r u m en t s,
which is inherent in the hum an condition( 7- 8).
An o t h er j u st i f i ca t i o n f o r t h e d i f f er en ces observed in t he t eam m em bers’ verbal part icipat ion ( Tables 1 and 2, Figure 1) could be the fact that the t eam includes professionals wit h different educat ions, q u alif icat ion s an d af f iliat ion s w it h t h e in st it u t ion , interacting in a university service. Fixed team m em bers have different educat ion levels, while t he difference am ong trainees refers to the m odels they have learned. Th e h et er og en eou s com p osit ion of t h e t eam can facilit at e disagreem ent and knowledge shock. These differences and their developm ents, in turn, derive from t he division of hum an sciences, which t end t o seek
refuge in their sm all intellectual feuds(14,16).
Besides pr esent ing t echnical differ ences in t erm s of knowledge and at t ribut ions, t he specialt ies t h a t m a k e u p a t e a m ca n r e ce i v e a n u n e q u a l treatm ent within the group itself. This ends up m aking possible a clim at e of t ension am ong t eam m em bers ( each o f w h o m h as h i s/ h er o w n k n o w l ed g e an d aut onom y) , charact erizing t he t eam as a “ grouping” ( j ux t aposed act ions and gr ouping of pr ofessionals) or “ int egr at ion” ( ar t iculat ed act ions and int er act ion a m o n g p r o f e ssi o n a l s) . Th i s e v i d e n ce s t h a t t h e reciprocit y bet ween work and int eract ion is essent ial f o r t e a m w o r k , w i t h co m m u n i ca t i o n a m o n g
professionals as it s support base( 14,16).
I n the m eetings observed at the DH, the team m em bers’ different participations can reflect these and other defense m echanism s aroused by knowledge and pow er relat ions. These aspect s deserve assessm ent t hrough t he inclusion of inst it ut ional supervision int o t he r out ine of a ser v ice lik e t he one st udied her e. I nstitutional psychology can be an effective therapeutic
approach when applied at healt h inst it ut ions( 8- 9,14).
During the study period, the DH team did not directly discuss them es related to feelings of frustration or helplessness in the face of practice with patients in m ent al suffering, which som et im es creat es anguish. No m ention was m ade of seeking external supervision for the professionals. This does not differ from findings in a st udy about nursing pract ice at psychiat ric day hospit als in t he St at e of São Paulo, which observed t he occurrence of supervision in only t hree ( 20% ) of
t he 15 services t hat were exam ined( 17).
cl e a r, u n d e r st o o d a n d a cce p t e d , p r e f e r a b l y b y ev er y body. I n case of indiv idual goals, t hese m ust
be com pat ible wit h t he group’s( 5,11,15). The m ot ivat ion
t o per for m t he t ask m ust be nour ished const ant ly. This is found in t he exchange it self w it h user s and ot h er t eam com pon en t s, w h er e each m em ber can feel t hat t he sat isfact ion wit h t he realizat ion of his/ her t ask r est s in par t icipat ion and in being able t o ex t r a ct t h e en r i ch m en t o f l ea r n i n g f r o m sh a r ed t h e r a p e u t i c e x p e r i e n c e s . Th e t e a m ’ s c o m m o n obj ect iv es seem ed t o be in confor m it y dur ing t his DH’s general t eam m eet ings, alt hough t he individual obj ect iv es and m ot iv at ion of gr oup m em ber s w er e not assessed.
I n v iew of t h e ser v ice ch ar act er ist ics an d different professional groups com posing the ( fixed and float ing) t eam s, t he m eet ings under st udy fav or a space for constant teaching- learning. According to the observat ions in t his st udy, t he m eet ings seem t o be st r u ct u r ed as a space f or en cou n t er an d possible in t egr at ion am on g pr of ession als. Th e dy n am ics of their functioning inserts the GTM into the service as a part of it s st ruct ure, of it s support base, needed for t h e ex ist en ce it self an d con t in u at ion of t h e DH’s act iv it ies.
I t is known that attending people experiencing em ot ional suffer ing is a har d and painful t ask t hat m obilizes t he m ost diverse feelings in professionals. Therefore, the clim ate of reliability that can be created on the basis of team m eetings, which is not im m une t o conflict s, is facilit at ed by t he pr ofessionals’ and t r ain ees’ in cr eased cr eat iv it y an d p leasu r e in t h e realization of tasks. I f this occurs, users, in turn, detect the spontaneity produced like this and can internalize t he experienced m odel and seek less st rict form s of
r elat ing. This fav or s t he const r uct ion of a space of cont inuous im provem ent in m ent al healt h pract ice.
Like any health service, the DH is inserted in a society and, therefore, subject to its expectations and dem ands ( m acro- social cont ext ) . These can int erfere in team m em bers’ relationships or behaviors. The GTM’s functioning, in turn, ends up reflecting these situations. Would the subj ects discussed during the m eetings be independent from ext ernal variables and would t hey repeat them selves over tim e? Would they be different at other tim es? These questions rem ain open.
FI NAL CONSI DERATI ONS
This st udy about general t eam m eet ings at t h i s D H m a d e i t p o ssi b l e t o i d en t i f y t h em a s a com ponent part of the service and to understand them bet t er by exam ining t heir funct ioning. Based on t he p r e se n t e d r e su l t s, t h e i r u se i s su g g e st e d i n i n t er d i sci p l i n a r y m en t a l h ea l t h t ea m p r a ct i ce i n “ t h e r a p e u t i c co m m u n i t i e s”, w h e t h e r d i r e ct e d a t t eaching, research or care.
Th e in qu ir ies ar ou sed by t h is r esear ch , in com bin at ion w it h t h e pr esen t ed r esu lt s, st im u lat e fut ur e r esear ch on int er disciplinar y t eam m eet ings, whether at this DH or at any other health institution.
ACKNOW LEDGEMENTS
To psychologist Mart a Maria Daud, t o nurse Maria Aparecida Vilas Boas and t o adm inist rat ive aid Ângela Lúcia Zanini Rodrigues for t heir help in dat a collect ion.
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