Institutional analysis in scientific health production: an integrative literature review

El análisis institucional en la producción científica en salud: una revisión integradora de literatura

Abstract

Objective:

To analyze the use of the Institutional Analysis theoretical-methodological framework and of the central concept of institution in its three moments - instituted, instituting and institutionalizing in health studies.

Method:

Integrative review conducted in databases of PubMed/Medline, LILACS, Scopus, and CINAHL including original research articles published between 2012 and 2017.

Results:

Analysis of 26 publications. A plurality of study objects was found, and the most common were related to collective health, namely: mental health, violence, family-team relationship, family health, primary care, health of women, children and adolescents, oral health, continuing education, micropolitics of health work, health surveillance, HIV, law, pedagogical practices, school education and Autism. Nursing and psychology were the areas that most opted for Institutional Analysis. The polysemy of the institution concept was confirmed in the findings, indicating the richness of modes and uses of the concepts.

Conclusion:

Institutional Analysis presents tool-concepts to perform analyzes of health practices consistent with the Unified Health System.

Descriptors:
Institutional Analysis; Organizations; Public Health; Investigative Techniques; Review

Resumen

Objetivo:

Analizar, en los estudios del área sanitaria, la utilización del marco de referencia teórico metodológico del Análisis Institucional y del concepto central de institución en sus tres momentos - instituido, instituyente e institucionalización.

Método:

Revisión integradora llevada a cabo en las bases de datos PubMed/Medline, LILACS, Scopus, CINAHL, incluyéndose en la búsqueda artículos originales de investigación, publicados entre 2012 y 2017.

Resultados:

Fueron analizadas 26 publicaciones. Se encontró una pluralidad de objetos de estudio, siendo los más comunes los relacionados con la salud colectiva: salud mental, violencia, relación familia-equipo, salude de la familia, atención primaria, salud de la mujer, infancia y adolescencia, salud bucal, educación permanente, micropolítica del trabajo en salud, vigilancia en salud, VIH, derecho, prácticas pedagógicas, educación escolar y Autismo. La enfermería y la psicología fueron las áreas que más optaron por el Análisis Institucional. La polisemia del concepto de institución se confirma en los hallazgos, señalando una riqueza en los modos y usos de los conceptos.

Conclusión:

El Análisis Institucional presenta conceptos herramienta capaces de operar análisis de prácticas en salud acordes con el Sistema Único de Salud.

Descriptores:
Análisis Institucional; Organicaciones; Salud Pública; Técnicas de Investigación; Revisión

Resumo

Objetivo:

Analisar, nos estudos da área da saúde, a utilização do referencial teórico-metodológico da Análise Institucional e do conceito central de instituição em seus três momentos - instituído, instituinte e institucionalização.

Método:

Revisão integrativa realizada nas bases PubMed/Medline, LILACS, Scopus, CINAHL, sendo incluídos na busca artigos originais de pesquisa, publicados entre 2012 e 2017.

Resultados:

Foram analisadas 26 publicações. Encontrou-se uma pluralidade de objetos de estudo, sendo mais comuns os relacionados à saúde coletiva: saúde mental, violência, relação família-equipe, saúde da família, atenção primária, saúde da mulher, infância e adolescência, saúde bucal, educação permanente, micropolítica do trabalho em saúde, vigilância em saúde, HIV, direito, práticas pedagógicas, educação escolar e Autismo. A enfermagem e a psicologia foram as áreas que mais optaram pela Análise Institucional. A polissemia do conceito de instituição se confirma nos achados, indicando uma riqueza nos modos e usos dos conceitos.

Conclusão:

A Análise Institucional apresenta conceitos-ferramenta capazes de operar análises de práticas em saúde condizentes com o Sistema Único de Saúde.

Descritores:
Análise Institucional; Organizações; Saúde Pública; Técnicas de Pesquisa; Revisão

INTRODUCTION

Institutional Analysis is a theoretical-methodological framework derived from the social sciences and built from the dialogue between different disciplines and fields of knowledge - law, economics, sociology, psychology and anthropology - and theoretical frameworks - philosophy of law, Marxism, psychoanalysis, psychosociology, psychopedagogy and institutional pedagogy⁽¹⁾. The social and historical genesis of Institutional Analysis (IA) was in the 1960s in France, marked by the dissatisfaction of a large part of French society with the role of some organizations, namely of students with the university, workers with companies, families with schools, the society in general with politics and the care of psychiatric hospitals, among others. Unions and parties supported this general dissatisfaction, culminating in a wide-ranging protest movement in May 68^(1-4). Although student mobilization has suffered strong police repression since the beginning, in a short time the movement expanded, paralyzed 2/3 of the country’s activities and led to the resignation of the president of the time and the holding of new elections. Although the demands questioned conservatism in politics, economics, education, culture and the arts, and proposed wide-ranging structural changes, after May 68, “a paradoxical presence of a posteriori prophecies is established in France”, and existed a line that “led agitations of May towards calm waters” and another that “prefers storms to the calm”⁽³⁾.

In this context of crisis and ruptures, the gap between the expected role of institutions - education, work, politics, health - and the role played by them in society became evident. In 1970, the French sociologist René ^{Lourau published the book Institutional Analysis, based on his doctoral thesis defended in 1969} at the University of Nanterre. He proposed the concept of institution from the dialectical relationship between three moments - instituted, instituting and institutionalization - removing any notion of institution as something static. Lourau differentiates institution from establishment and organization by emphasizing the immaterial dimension of the whole institution⁽¹⁾. Also important for this field was the publication, in 1972 in Brazil, of the book Chaves da Sociologia (Sociology Keys)⁽²⁾. The work ‘Institutional Analysis’ had its first Brazilian edition in 1975.

In addition to the aforementioned concept of institution, the following are concepts proposed by IA: implication, analyzer, transversality, self-management, self-analysis, resistance, order and demand, restitution and transduction^(1-2). Institutional Analysis can be used for “paper analysis” based on the analysis of documents, interviews and observations and as an intervention practice, the Socioanalysis. Within the scope of IA, the socio-historical approach is also considered, which has as its object the investigation of historical realities of the past that relate to the present. In recent years, the Institutional Socioclinic has developed, derived from Socioanalysis. In addition to this aspect, Schizoanalysis is also present in Brazil⁽⁵⁾.

In this country, the IA was inserted in the 1970s, initially with the Departments of Psychology of some public universities and in different research groups, although the articulation of IA with Health and Public Health would only take place in the 2000s⁽⁴⁾. Both areas found concepts in the theoretical-methodological contribution of IA that enabled a better understanding of situations experienced in the health service routine, and contributed to increase the capacity to analyze such situations and intervene in them⁽⁴⁾. In addition to academic research based on this framework, some IA concepts such as transversality, self-analysis, self-management, devices, and subjects’ protagonism inspired the theoretical framework of some public policies of the Unified Health System (SUS - Sistema Único de Saúde), such as the National Policy Humanization and the National Policy for Permanent Education in Health.

Some scholars⁽⁴⁾ mention that the history of IA in Brazil has not yet been told, as very little is known about its insertion, particularly in the area of health, and even less about the way it is offered in universities, private or philanthropic organizations. Furthermore, the form how concepts are articulated with the daily practice of health services is also little explored, among other forms of intervention and analysis, and “an investigation of these texts based on descriptors would be very relevant to deepen the study of IA in Brazil”⁽⁴⁾. For these reasons and to understand the concepts of IA as a tool-concept capable of operating social practices, among them, health practices, this integrative literature review was performed to know the current scenario of scientific production with this theoretical framework.

By taking into account the fundamental concept of IA, the Institution, and always considering its three moments - Instituted, Instituting and Institutionalization - this study was conducted with the purpose of obtaining answers to the following questions: 1) Which objects of studies in the field of health have been using Institutional Analysis? 2) How is the concept of institution and its three moments - instituted, instituting, institutionalization - used in these studies? 3) Which areas of health use the concept and its three moments? 4) Which journals were chosen for the publication of these studies? 5) How has the concept and its three moments been used in health research? Thus, the objective of this study was to analyze the use of the theoretical-methodological framework of AI and the central concept of institution in its three moments - institution, instituted, instituting, institutionalization in studies in the health area.

METHOD

Type of study

The integrative review consists of a “type of literature review that brings together findings from studies developed using different methodologies, allowing researchers to synthesize results while respecting the epistemological affiliation of the empirical studies included”. This type of analysis requires that reviewers evaluate and synthesize primary data in a systematic and rigorous manner⁽⁶⁾. Among the various purposes of developing an integrative review, according to a study of this type performed in 2014, this is a “form of research that allows to review, criticize and synthesize representative literature on a topic or subject in an integrated manner that can generate new approaches and perspectives on the revised subject”⁽⁶⁾.

Data collection

Based on the objective of this study, a search for Health Sciences Descriptors (DeCS) was carried out to select the most suitable for this purpose. The present review was carried out in databases of Pubmed/Medline, LILACS, Scopus and CINAHL with controlled and uncontrolled descriptors. The controlled descriptor “Health” and the uncontrolled descriptors, “Institutional Analysis”, “Socioanalysis”, “Schizoanalysis”, and “Socioclinic” in Portuguese and English were used. The Boolean operators OR and AND were used to combine these descriptors.

Next, the following inclusion criteria were used for the selection of studies: a) original research articles, b) available in full version, c) published in the 2012-2017 period, in Portuguese, French, Spanish and English , d) belonging to the health area, according to the list of professions indicated by the Ministry of Health⁽⁷⁾. Initially, the definition of the search period was based on the pioneering publication on the topic in Brazil⁽⁴⁾, the collection Institutional Analysis in Brazil (Análise Institucional no Brasil), by Saidón & Kamkhagi (1987) that completed 30 years in 2017. However, due to the significant number of studies found, the search was redefined for the last five years, remaining from 2012 to 2017.

One defined the following exclusion criteria: a) studies in which the approach to IA was not the central theoretical-methodological option of the study in the results and conclusions; b) studies that presented interventions in IA as in training at institutional level, c) experience reports, notes, reflection articles, dissertations, theses, public policies and videos. The search in databases took place between November 1 and 6, 2017, using an advanced form.

The search strategy used was (saúde or health) AND (“análise institucional” OR “institutional analysis” OR socioclínica OR socioclinic OR socioanálise OR socioanalysis OR esquizoanálise OR schizoanalysis) in the field “words” and AND (2012 or 2013 or 2014 or 2015 or 2016 or 2017), in the field “country, year of publication”. After identification, studies were selected according to the guiding question and the inclusion and exclusion criteria previously defined. The instrument was designed with the purpose of extracting and analyzing data from the included studies. It was composed of the following items: 1- identification of the article; 2- presence or not of the concept of institution, considering its three moments - instituted, instituting and institutionalization; 3- authors who used the concept; 4- objects of study.

In the study, 450 articles were found in PubMed/Medline, 18 in LILACS, 138 in Scopus, and 18 in CINAHL. The stages of study selection comprised the identification, screening, eligibility and inclusion, totaling 26 publications^(8-33) that met the defined criteria, as explained in the analysis flowchart (Figure 1).

Figure 1 -
Flowchart of the study selection process for the integrative review - Ribeirão Preto, SP, Brazil, 2018.

Data analysis and processing

Categorization was the form adopted for the analysis of results related to the concept of institution and its three moments - instituted, instituting and institutionalization - as explained above. Such categorization provided the grouping by similarities and/or conceptual approximation, as shown in Chart 2. The work of analyzing and integrating the concepts consisted of a delicate and complex task, which was transformed while appeared the plural forms of functioning of concepts that required numerous resumptions and re-analyzes of studies. One chose to present the results by means of sequential tables that show how the concept of institution (always considering the three moments that compose it) was used by the authors and how it dialogued with the study objects.

The interest was to know and characterize the scenario of studies, and highlight the various possibilities taken by researchers according to their investigated object. The choice was to keep distance from the perspective of analysis focused on a single perspective of addressing these concepts, and in this sense, the polysemy of concepts was explored, as well as their approximations and divergences for the different authors.

RESULTS

The articles were published in 19 different journals in the areas of psychology, nursing, public health and education, as shown in Chart 1. Regarding the year of publication, years 2012 and 2013 presented 26.9% of articles (⁷) each, followed by the distribution: 7.7% (2) in 2014; 23% (6) in 2015; 11.5% (3) in 2016; 3.8% (1) in 2017. In relation to language, most studies were published in Portuguese, in addition to one in Spanish⁽²⁷⁾ and two in French^(28,32).

The contexts of studies were quite varied and linked to the following themes: Violence, Family-team relationship, Family Health, Parenting, Primary Care, Health of Women, Children and Adolescents, Mental Health, Oral Health, Training and Permanent Education, Micropolitics of the Process of Health Work, Health Surveillance, HIV, Law, Pedagogical Practices, Production of Scientific Knowledge in Postgraduate Studies, School Education and Autism, as shown in Chart 2.

Chart 1
Journals chosen for publication of the studies - Ribeirão Preto, SP, Brazil, 2018.

Authors	Journal	Frequency
Romagnoli RC, Magnani NR, 2012(8)Fortuna CM, Monceau G, Valentim S, Mennani KLE, 2014(33) Romagnoli RC, 2015a(9)	Fractal: Revista de Psicologia (UFF)	12.1%
Pezzato LM, L'Abbate S, 2012 (11) Archanjo AM, Schraiber LB, 2012 (12)	Saúde e Sociedade (USP)	7.7%
Pezzato LM, L'Abbate S, Botazzo C, 2013 (17) Sanches ICP, Couto IRR, Abrahão AL, Andrade M, 2013 (19)	Ciência & Saúde Coletiva (ABRASCO)
Gontijo TL, Xavier CC, Freitas MIF, 2012 (15) Fortuna CM, Mesquita LP, Matumoto S, Monceau G, 2016 (30)	Cadernos de Saúde Pública (FIOCRUZ)
Garcia RA, L'Abbate S, 2015(24) Dóbies DV, L'Abbate S, 2016(31)	Saúde em Debate (CEBES)
Muniz MP, Tavares CMM, 2012 (16) Silva AB, Gomes BCF, Torres OM, Siniak DS, 2013 (22)	Revista de Pesquisa: Cuidado é Fundamental Online (UNIRIO)
Zambenedetti G, Silva RAN, 2015(29)	Estudos de Psicologia (Natal) (UFRN)	3.8%
Garcia RA, L'Abbate S, Arakaki J, 2015 (27)	Interface (Botucatu) (UNESP)
Pereira WR, Ribeiro MRR, Santos NC, Depes VBS, 2012 (14)	Acta Paulista de Enfermagem (UNIFESP)
Fortuna CM, Matumoto S, Camargo-Borges C, Pereira, MJB, Mishima SM, Kawata LS et al., 2012 (10)	Revista da Escola de Enfermagem da USP (USP)
Depes VBS, Pereira WR, 2013 (20)	Revista Gaúcha de Enfermagem (UFRGS)
Romagnoli RC, 2015b(25)	Barbarói (UNISC)
Lima AIO, Severo AK, Andrade NL Soares GP, Silva LM, 2013 (21)	Temas em Psicologia (SBP)
Silveira L, Nunes MO., 2013 (18)	Polis e Psique (UFRGS)
Zambenedetti G, Piccinini CA, Sales ALLF, Paulon SM, Silva RAN, 2014 (23)	Psicologia: Ciência e Profissão (CFP)
Silva DCR, 2015 (26)	Psicologia da Educação (PUC/SP)
Barreto L, Dimenstein M, Leite JF, 2013 (13)	Athenea digital (UAB/Spain)
Passos ICF, Vieira K, Moreira L, Rodrigues F, Amorim M, Santos C et. al., 2017 (32)	Santé Mentale au Québect - Érudit (EdeM/Canada)
Spagnol CA, L'Abbate S, Monceau G, Jovic L, 2016 (28)	Recherche en Soin Infirmiers (Cairn/France)

Chart 2
Object/Question/Objective of the study, Type of study, Techniques and/or Tools, Data analysis - Ribeirão Preto, SP, Brazil, 2018.

Object/Question/Objective of the study	Type of study	Techniques and/or Tools	Data analysis
To configure and problematize the relationships in the team-family territory and show what makes the effective family participation difficult in the treatment of children attended at the Renato de Avelar Azeredo Psychopedagogical Center (Portuguese acronym: CPP) of the Municipality of Nova Lima(8).	Intervention research Cartography	Semi-structured interview, Observation, General assemblies	Institutional analysis
To investigate violence against women in Montes Claros, Minas Gerais(9).	Qualitative and quantitative research	Document analysis Participant observation	Schizoanalysis SPSS
To map the instituted and instituting movements in the work of the Family Health Strategy with regard to the composition of their care practices(10).	Intervention research	Group meetings	Schizoanalysis
To present the methodological strategy produced and exercised during the development of a doctoral research in which the theoretical-methodological framework of Institutional Analysis in Collective Health was adopted(11).	Action-intervention research	Diary, Discussion groups	Socioanalysis
To study the performance of psychologists in Health Centers (Portuguese acronym: UBS - Unidade Básica de Saúde)(12).	Qualitative research	Semi-structured interview	Content analysis
To discuss the care offered to women in situations of violence with mental disorders and/or treated at the psychosocial care network (Portuguese acronym: RAPS) in two agencies that make up the care network for women: Reference Center and Shelter Home(13).	Intervention research	Semi-structured interview	Institutional analysis
To know the pedagogical practices developed in the teaching of undergraduate Nursing courses for the identification and analysis of those that promote subjectification processes which reinforce students’ desire to learn(14).	Qualitative research	Semi-structured interview Focus group	Institutional analysis
To understand the difficulties and facilities for the implementation of the Kangaroo Method in Brazilian maternities with training by the Ministry of Health, from the perspective of health professionals, managers and mothers of low birth weight newborns treated in these services(15).	Qualitative research	Semi-structured interview	Grounded Theory
To analyze the nursing team’s understanding of the educational processes experienced by them in a psychiatric hospital(16).	Exploratory, qualitative research	Participant observation	Institutional analysis
To reflect on the effects and meanings provoked by an instituting proposal put under analysis by a group of oral health professionals working in primary health care in the city of Campinas (state of São Paulo)(17).	Socioanalytical Intervention	Diary	Socioanalysis
To put into analysis the modes of subjectification of madness through the experiences of users of a Psychosocial Care Center (in Portuguese CAPS) in Pentecostal religions by identifying possible articulations between these institutions(18).	Qualitative research Ethnography	Semi-structured interview Participant observation	Discourse analysis
To know the perception and difficulties experienced in the exercise of hospital follow-up in surgical inpatient units of a public hospital in the city of Niterói (state of Rio de Janeiro) from the perspective of the inpatient and discuss them in the light of the concepts of Institutional Analysis (IA)(19).	Qualitative research Descriptive research	Semi-structured interview Observation	Content analysis
To understand how the training process in the Master in Nursing contributed to the mobilization of formal and political aspects of scientific knowledge by graduates working in health services(20).	Qualitative research Exploratory research	Semi-structured interview	Content analysis
To analyze the care provided by Family Health Teams to mental health users(21).	Qualitative research	Semi-structured interview, Diary, Participant observation, Focus Group	Institutional analysis
To present the concepts, perceptions and experiences brought by Mental Health professionals in relation to their daily lives in services(22).	Qualitative research	Diary, Participant observation, Conversation group, Questionnaire	Categorized results
To present an intervention study conducted with Community Health Agents from Family Health Teams of a district management in the city of Porto Alegre (state of Rio Grande do Sul)(23).	Intervention research	Discussion groups	Not mentioned
To analyze the institutionalization process of Health Surveillance in Campinas (state of São Paulo) based on the theoretical-methodological framework of Institutional Analysis in the socio-historical perspective(24).	Institutional analysis	Semi-structured interview	Socio-historical
To investigate quantitatively and qualitatively the violent acts against women in the city of Montes Claros, Minas Gerais(25).	Qualitative and quantitative research	Document analysis - occurrence reports	Institutional analysis SPSS
To analyze the relationships based on (mis)encounters between health and education workers, and the sources of tension between these professionals and the students’ families in the form of demands and referrals from the school(26).	Intervention research Socioanalysis	Diary, Group meetings, Evaluation report	Concepts of the philosophy of difference
Analizar y comprender cómo se realizan las acciones de Vigilancia en Salud en el municipio de Moreno, cómo se articulan con los efectores de la Atención Primaria de la Salud, y qué dispositivos se han implementado para que estos procesos se hagan efectivos (27)	Qualitative research	Diary, Participant observation	Institutional analysis
Décrire et analyser l´utilisation d´un dispositif socianalytique comme outil de collecte de données dans une approche de recherche qualitative en sciences infirmières, ceci en créant un espace pour l’analyse de la pratique professionnelle et des relations de travail, auprès d´un groupe d´infirmières de l´Hôpital universitaire UFMG, Brésil (28)	Qualitative research Intervention research Socioanalysis	Analysis of professional practices Meetings Questionnaire	Institutional analysis Socioanalysis
Analysis of the paradoxical dimension of the territory and the processes of stigmatization in access to HIV diagnosis in the context of Primary Health Care(29).	Analytical-institutional perspective	Observation Focus group Restitution	Institutional analysis
To analyze the involvement of researchers during the process of an intervention study and the interferences caused by this analysis(30).	Qualitative research, Intervention research	Semi-structured interview Restitution, Meetings, Researchers group, Analysis workshop, Notes	Institutional analysis Socioclinic
To analyze a resistance movement of a Collegiate Forum of Mental Health in Campinas (state of São Paulo), where the current situation puts at risk its innovative history and the care network in mental health because of the organizational stiffening and the tension between the current municipal government and the partner entity in this area(31).	Qualitative research	Semi-structured interview, Diary, Participant observation	Institutional Analysis concepts
Contribuer au développement intersectoriel et interdisciplinaire du réseau local, notamment du Sistema de Garantia dos Direitos Humanos da Criança e do Adolescente (SGDHCA), pour faire face à des vulnérabilités psy-chosociales des enfants et des adolescents, spécialement celles liées aux situations de violences sexuelles et à l’usage de drogues (32)	Critical action Research Cartography	Workshops	Institutional analysis Schizoanalysis Schizodrama
To present and discuss the production process of socioclinic research on parenting developed in Gennevilliers, France, during 2011 and 2012(33).	Intervention research	Participant observation, Restitution, Discussion groups, Informal interviews	Institutional analysis

Most studies conducted from this theoretical-methodological perspective were qualitative, given the nature of their study objects, as shown in Chart 2. The Institutional Analysis theoretical framework allows explaining how the objects of study are built, move and transform according to the political, economic, social and cultural scenario of their context, thereby constituting social constructions. The IA concepts contribute to visualize the modes of functioning of a given social reality by promoting a movement of complexification of analyzes and interventions.

Among the authors of the selected articles, there was prevalence of those in the areas of Psychology with 45.4% (25), followed by Nursing with 43.6% (24). In a smaller number was Medicine with 9% (5), Dentistry with 5.4% (3), Pedagogy with 1.8% (1) and Social Sciences with 1.1% (1). Two authors had more than one degree: one was graduated in Nursing and Medicine and the other in Law and Psychology.

The distribution of studies by region in Brazil was varied. The majority was from the Southeast region (23) (São Paulo-12, Minas Gerais-7, Rio de Janeiro-4), followed by the South region (4) (Paraná-2, Rio Grande do Sul-2), Northeast (2) (Natal-1, Rio Grande do Norte-2), Midwest (2) (Mato Grosso-2) and North region (0). Four articles included foreign authors: one from Argentina (27)⁽²⁷⁾ and three from France^(28,30,33).

In the studies analyzed, there was a multiplicity of IA concepts that supported the production of health knowledge. The most used concept was chosen to compose this integrative review, that is, the concept of institution, always considering its three moments - instituted, instituting and institutionalization - as shown in Chart 3.

Chart 3
Definitions used for Institution - Instituted, Instituting and Institutionalization - Ribeirão Preto, SP, Brazil, 2018.

AUTHORS	CONCEPT OF INSTITUTION
INSTITUTION AS NORMS, RULES AND LAWS
Fortuna, Matumoto, Camargo-Borges, Pereira, Mishima, Kawata, Silveira and Oliveira, 2012 (10)	"They constitute what is given, which is allowed and accepted".
Sanches, Couto, Abrahão and Andrade, 2013 (19)	Norms, rules, regulations transmitted to groups.
Depes and Pereira, 2013 (20)	"Tree of logical compositions which, depending on their materialization and degree of formalization adopted, can be laws or norms if described, or can be guidelines, regularities of behavior when they are not stated in a manifest way."
Silva, Gomes, Torres e Siniak, 2013 (22)	"Set of laws, rules and practices."
Lima, Severo, Andrade, Soares and Silva, 2013 (21)	"Dominant forces in our society, values, rules, made official or not, which are configured as a network, a fabric of institutions."
Silveira and Nunes, 2013 (18)	"Institution as a social practice historically produced and made natural by an effect of forgetting the power/knowledge practices." "Institutions are vectors affecting the modes of existence that cross and are crossed by material bodies."
INSTITUTION IS IMMATERIAL
Pezzato and L'Abbate, 2012 (11)	"It is immaterial, it is never directly understandable. It can only be apprehended through the materiality of the organization".
Depes and Pereira, 2013 (20)	Institution is abstract and is materialized by the organization and unfolds into smaller units (establishments).
Pezzato, L'Abbate and Botazzo, 2013 (17)	"The institution is immaterial". "It can only be apprehended through the materiality of the organization".
Fortuna, Monceau, Valentim, Mennani, 2014 (33)	"They are abstract logics, but also material, resulting from a dialectical process consisting of a more fixed part (the instituted), which is their most visible part, a mutable part (the instituting) that causes ruptures with traditional pacts, and a third moment called institutionalization, in which the instituting is incorporated by the institution and becomes instituted".
INSTITUTION IS COMPOSED IN THREE MOMENTS: INSTITUTING, INSTITUTED AND INSTITUTIONALIZATION
Pezzato and L'Abbate, 2012 (11)	Result of the dynamic and dialectical movement between instituted, instituting and institutionalization.
Pezzato, L'Abbate and Botazzo, 2013 (17)	"Dynamic and dialectical movement between three moments: the instituted, the instituting and the institutionalization".
Spagnol, L'Abbate, Monceau and Jovic, 2016 (28)	"Concept dialectique."
Fortuna, Monceau, Valentim, Mennani, 2014 (33)	"They are abstract logics, but also material, resulting from a dialectical process consisting of a more fixed part (the instituted) which is their most apparent part, a mutable part (the instituting) that causes ruptures with traditional pacts, and a third moment called institutionalization, in which the instituting is incorporated by the institution and becomes instituted".
Garcia and L'Abbate, 2015 (24)	"It is the result of the dynamic articulation between three moments: the instituted, the instituting and the institutionalization".
Garcia, L'Abbate, Arakaki, 2015 (27)	"Que reconoce três momentos de descomposición: instituído, instituyente, institucionalización."
INSTITUTION IN ITS THREE MOMENTS: INSTITUTING, INSTITUTED AND INSTITUTION
Silva, Gomes, Torres and Siniak, 2013 (22)	"Three moments: institution, instituted and instituting."
INSTITUTION AS TWO MOMENTS: INSTITUTED AND INSTITUTING
Romagnoli and Magnani, 2012 (8)	"Field of forces of the instituted and the instituting".
Fortuna, Matumoto, Camargo-Borges, Pereira, Mishima, Kawata, Silveira e Oliveira, 2012 (10)	Interplay between the instituting and the instituted.
Archanjo e Schraiber, 2012 (12)	Constant movement between the instituted and the instituting.
Silveira e Nunes, 2013 (18)	It has flows that move and/or conserve it.
Fortuna, Mesquita, Matumoto e Monceau, 2016 (30)	"A dynamic, they are always in motion, a game between maintenance and creation, conservation and dissolution".
Dóbies and L'Abbate, 2016(31)	"Institutions are dialectically constituted by instituted and instituting moments".
Passos, Vieira, Moreira, Rodrigues, Amorim, Santos, Abreu, Gomes, Mendes, Lima, Moura, França, Ferraz, 2017(32)	"Paradigme institutionnel pour l'analyse des logiques sociales (les institutions) en intervenant sur le fonctionnement collectif et sur les thématiques et procédés de recherche. Elle présente des concepts pour la compréhension du fonctionnement de la réalité dans ses aspects contradictoires: les aspects institués et anti-productifs et ceux instituants et productifs."
INSTITUTION AS ORGANIZATION OR ESTABLISHMENT
Muniz, Tavares, 2012 (16)	Organization or establishment.
INSTITUTION AS MULTIPLE CRYSTALLIZED MEANINGS
Zambenedetti and Silva, 2015(29)	Something that can be interrogated in its multiple crystallized meanings.
LOGICAL BODIES OF MEANINGS
Barreto, Dimenstein and Leite, 2013 (13)	"Logical bodies of meanings".
AUTHORS	INSTITUTED MOMENT
DIALECTICAL FORCES
Romagnoli, 2015a(9)	"These are dialectical forces".
Romagnoli, 2015b(25)	"They are dialectical forces".
VISIBLE PART OF THE INSTITUTION
Fortuna, Monceau, Valentim, Mennani, 2014 (33)	"The most fixed part (the instituted) that is their most visible part".
PLAN OF FORMS ALSO CALLED ORGANIZATION PLAN
Romagnoli and Magnani, 2012 (8)	"The plan of forms, also called the organization plan, corresponds to what is socially instituted".
CONSERVATIVE AND ESTABLISHED
Pezzato and L'Abbate, 2012 (11)	"What is set, established".
Muniz, Tavares, 2012 (16)	The instituted is the fixed institution, it denies the social knowledge. It resists changes.
Archanjo and Schraiber, 2012 (12)	"What is given". "Established order according to the values and modes of representation of the organization, considered normal. It corresponds to what is already known".
Depes and Pereira, 2013 (20)	As conservative and established.
Pezzato, L'Abbate and Botazzo, 2013 (17)	Instituted moment that is set, established, norms and laws.
Zambenedetti, Piccinini, Sales, Paulon and Silva, 2014 (23)	"Crystallized aspects of reality".
Garcia, L´Abbate and Arakaki, 2015 (27)	Refers to the established things.
Dóbies and L'Abbate, 2016(31)	"The established order, the values, the modes of representation and organization, considered normal". "The instituted depends on the instituting to make progress".
Fortuna, Mesquita, Matumoto and Monceau, 2016 (30)	"Effect of instituting action and is imbricated with the equipment and its functions. It tends to reproduce other instituted forms and maintain the order".
NORMS AND LAWS
Pezzato and L'Abbate, 2012 (11)	Norms, laws, universal.
Pezzato, L'Abbate and Botazzo, 2013 (17)	Norms and laws.
Silveira and Nunes, 2013 (18)	"From the norm, hegemonic in the asylum logic".
Garcia, L'Abbate and Arakaki, 2015 (27)	"Las normas."
KNOWLEDGE AND PRACTICE
Garcia, L'Abbate and Arakaki, 2015 (27)	"Los conocimientos y la práctica."
INCESSANT REPRODUCTION
Fortuna, Matumoto, Camargo-Borges, Pereira, Mishima, Kawata, Silveira and Oliveira, 2012 (10)	"Incessant (instituted) reproduction".
GAMES OF FORCE THAT TRY TO PRODUCE IMMOBILITY
Archanjo and Schraiber, 2012 (12)	"Games of force that try to produce immobility [...] in constant contradiction with instituting forces".
Passos, Vieira, Moreira, Rodrigues, Amorim, Santos, Abreu, Gomes, Mendes, Lima, Moura, França, Ferraz, 2017(32)	"Aspects institués et anti-productifs."
CONTINUING EDUCATION
Muniz, Tavares, 2012 (16)	"The spaces for continuing education must become instituted, guaranteed and supported in their instituting potential to subsidize changes".
HIERARCHIZED, VERTICAL AND FUNCTIONAL
Silva, 2015 (26)	Hierarchized, vertical and functional.
AUTHORS	INSTITUTING MOMENT
PRESSURES EXERTED
Sanches, Couto, Abrahão and Andrade, 2013 (19)	"Pressures exerted by groups or individuals".
Romagnoli, 2015a(9)	"These forces are dialectical".
Romagnoli, 2015b(25)	They are dialectical forces.
PRODUCTIVE AND INNOVATIVE FORCE
Gontijo, Xavier and Freitas, 2012 (15)	"The instituting ideas are innovative that provide changes or improvements in technologies or in social reorganization". They also bring the implementation of the kangaroo method as an instituting force.
Pereira, Ribeiro, Santos and Depes, 2012 (14)	Potential, transforming. "New, the motivation". "It always conveys a dynamic, changeable and mutant characteristic. Where the new insinuates itself and reaffirms itself". "Transforming, creative and revolutionary side. [...] It is informed by the instituted that generates it, that makes it appear and then, ends up being regenerated by it (instituted). Thus, both are necessary and neither exists without its opposite, they are complementary, they live in an always unstable balance".
Muniz, Tavares, 2012 (16)	"Opening escape lines, operating innovative practices".
Archanjo and Schraiber, 2012 (12)	"Renovation, urging creative processes". "Capacity for innovation."
Depes and Pereira, 2013 (20)	"Productive/innovative forces that tend to be the foundation of institutions". "Final effect, exhausted from the instituting activity".
Zambenedetti, Piccinini, Sales, Paulon and Silva, 2014 (23)	"It refers to the movement, the possibility of creating new meanings, strategies and solutions".
Dóbies and L'Abbate, 2016(31)	"Capacity for innovation".
Fortuna, Mesquita, Matumoto and Monceau, 2016 (30)	Creation.
Passos, Vieira, Moreira, Rodrigues, Amorim, Santos, Abreu, Gomes, Mendes, Lima, Moura, França, Ferraz, 2017(32)	"Aspects instituants et productifs."
DENIAL OF THE INSTITUTED, THE CONTESTATION
Pezzato and L'Abbate, 2012 (11)	"It expresses the particularity, the denial of the instituted, of the universal, the contestation, the questioning of the instituted by the project of what is not yet but can come to be". "Unshaping everyday life"
Archanjo and Schraiber, 2012 (12)	"Represent contestation".
Pezzato, L'Abbate and Botazzo, 2013 (17)	"The denial of the instituted, the contestation".
Silva, Gomes, Torres and Siniak, 2013 (22)	"As the transformer/questioner of this process".
Silveira and Nunes, 2013 (18)	"Subversive, counter-hegemonic, being able to radicalize the production of new encounters with madness and the madman".
Garcia and L'Abbate, 2015 (24)	"The instituting denies the instituted in the opposite meaning to the idea of renovation/innovation".
Garcia, L'Abbate and Arakaki, 2015 (27)	Denies the instituted.
Dóbies and L'Abbate, 2016(31)	Contestation.
INSTITUTING MAY BE CONSERVATIVE IN RELATION TO THE INSTITUTED
Garcia and L'Abbate, 2015 (24)	"The instituting can be conservative in relation to the instituted".
PROCESS OF TRANSFORMATION
Fortuna, Camargo-Borges, Pereira, Mishima, Kawata, Silveira and Oliveira, 2012 (10)	"Movements of change (instituting)."
Muniz, Tavares, 2012 (16)	"The instituting is the movement for changes in the institution. In other words, the instituting breaks with the instituted in search of free subjectification".
Silva, Gomes, Torres and Siniak, 2013 (22)	"The act of transformation and self-management of a subject belonging to an institution".
Fortuna, Monceau, Valentim, Mennani, 2014 (33)	"A changing part (the instituting) that causes ruptures with traditional pacts".
Fortuna, Mesquita, Matumoto and Monceau, 2016 (30)	"The transformation processes".
THE NEW, THE STRANGE, THE UNKNOWN
Archanjo and Schraiber, 2012 (12)	"It corresponds to the new, the strange, the unknown". "Mobilizers of reflection and criticism regarding their practices and assumptions (psychologists)".
THE CRISIS
Silveira and Nunes, 2013 (18)	The crisis (madness) covers and reveals the instituting power that speaks of the lack of strength of the instituted.
AUTHORS	INSTITUTIONALIZATION MOMENT
GAME BETWEEN THE INSTITUTED AND THE INSTITUTING
Pezzato and L'Abbate, 2012 (11)	"The result of the relationship between two moments - instituted and instituting - Is institutionalization, the moment of singularity, that is, metastable balance in perpetual becoming and not definitive synthesis". Virtual object produced by the analysis that elaborates it, while interpreting it at the same time.
Archanjo and Schraiber, 2012 (12)	"Permanent struggle between the instituted-instituting, all are somehow involved and assume a position and role that contribute to the institution always being an open field, in which forces coming from multiple directions interact, negotiate and, at times, have tension between themselves".
Pezzato, L'Abbate and Botazzo, 2013 (17)	"The result of the relationship between instituted and instituting". "The singularity, the balance".
Fortuna, Monceau, Valentim, Mennani, 2014 (33)	"Third moment called institutionalization in which the instituting is incorporated by the institution and becomes instituted".
Romagnoli, 2015a(9)	"It will sustain exactly the conflict of institutional forces between the instituted and the instituting".
Garcia and L'Abbate, 2015 (24)	"It implies duration, temporality and historicity". "The permanent confrontation between the instituted (that which seeks to maintain) and the instituting (forces of subversion and change)".
Garcia, L'Abbate, Arakaki, 2015 (27)	Moment of synthesis between instituted and instituting.
PROCESS BY WHICH THE INSTITUTION PRODUCES ITSELF
Muniz, Tavares, 2012 (16)	"It is continuity, not interruption"
Dóbies and L'Abbate, 2016(31)	"The process by which the institution produces itself is not always positive to the extent that each institution lives with its denial all the time".

• Source: Virtual Health Library; 2018.

DISCUSSION

The concept of institution in its three moments was analyzed in the present study, in the perspective of a tool-concept, that is, which aims to understand how to operate the concept and perceive it as life in movement that expands the experimentation possibilities, a tool to live the concept⁽³⁴⁾.

The results showed that in some studies, approximations were established with the IA framework without opting for specific affiliation to its aspects. In other studies, the concepts of Socioanalysis or Schizoanalysis were followed exclusively without crossing them. In a third group, the lines of Socioanalysis and Schizoanalysis were approximated. In Brazil, there is disagreement between the approximation of aspects of IA. Some authors claim there are epistemological differences between them but choose to bring concepts together by understanding that they coexist and dialogue with each other to intervene. They are: institution - instituted, instituting and institutionalization - implication, analyzer, flows, forces, agencies, control, territorialization and deterritorialization. Institutional Analysis is inserted in the institutionalist movement, constituted by “a heterogeneous, heterological and polymorphic set of guidelines, among which a common characteristic can be found: its aspiration to trigger, support and improve self-analytical and self-managing processes of social collectives”⁽³⁵⁾. However, although the two strands come from the same social genesis - May 68 in France - other authors discuss important differences in the theoretical genesis between them⁽⁴⁾, known as mixture (mélange), which is how these productions are called.

The analyzed studies made use of several IA works and authors for their theoretical and methodological foundation. In the first choice, the ‘Compendium of Institutional Analysis’⁽³⁵⁾ was used and, subsequently, the ‘Institutional Analysis’ book⁽¹⁾ . Perhaps the choice for the first work is linked to the more understandable form of writing, especially for readers approaching the theme for the first time. The ‘Institutional Analysis’ work discusses the concept of institution by crossing several theoretical perspectives of the social sciences and is a rich but dense text for an initial reading. Six years after writing, the author declared that “under the pretext of theorization, generalization, conceptual ordering, I wrote a cold book on a scorching subject”⁽¹⁾.

The Institution concept was analyzed in this integrative review, since this is a central aspect of the IA theoretical framework, as described in Chart 3. In the studies analyzed, it varied according to the need of the topic in question, which demonstrated the multiplicity of uses and modes to operate health practices and confirmed the polysemy around the concept and object under analysis. Most modes and uses were close to René Lourau’s perspective. For IA, the institution has a visible dimension that materializes in the organization and/or establishment, and an immaterial dimension constituted by norms, rules and laws including the way how individuals agree or not, to participate in these same norms^(1-2,36).

In IA, the concept of institution is linked to the Hegelian dialectic perspective, consisting of three moments: instituted (thesis), instituting (antithesis) and institutionalization (synthesis)^(1-2,36-38). The traditional Greek dialectic, the Platonic dialectic, comprised two moments, a duality with the exclusion character (two opposites). The addition of the third moment proposed in the Hegelian dialectic aimed at the character of overcoming and conservation in the search for a synthesis between opposites, where the thesis accommodates or not the antithesis in infinite movements of negation and accommodation that constitute the Hegelian system⁽³⁹⁾. In Hegelian logic, “dialectics obliges us not to be content with the dualistic opposition between particular interests and general interest. The universality of the institution, through the mediation of each particular case, is embodied in singular and differentiated forms”⁽³⁸⁾.

Considering the polysemy of the institution concept and from the varied modes and uses in the studies analyzed (Chart 3), at times taken in their immaterial dimension, at other times taken in their dimension of rules, norms and laws, and at other times being the two moments, there are many analysis possibilities. The game between instituting versus instituted may or may not result in accommodation and conservation and may be refuted or accepted in the institutionalization process, which does not invalidate studies that demonstrate only one or another moment of the concept, as long as the operation process appears. Institutional Analysis is considered a dynamic and instituting theoretical contribution. Its concepts can be directed to operate social practices that transform them while transforming realities.

However, some authors point out the polysemic character of the concept and refer that isolating the instituted is restricting to the transcendent positivist conception of the institution regarding real social relationships. To isolate the instituting, a tendency of economism and subjectivism (group psychology), is to fall into a phenomenologist and psychologist view. To isolate institutionalization, as done in the sociology of organizations and in organizational ideology in general, is to make the rationality and positivity of social forms autonomous, to the detriment of history, contradictions and class struggle⁽²⁾. In other words, in order to capture the institutionalization process of every institution, it becomes “impossible to isolate any one of the three moments”⁽⁴⁾.

On the other hand, some authors mention the creative way in which the strands of IA are approximated⁽³⁵⁾ - Socioanalysis and Schizoanalysis - and the concepts are operated in Brazil. The Brazilian IA is historically marked by the hybridism between the French Socioanalysis strand and the Latin American production about groups - especially the Operative Group - that integrates the institutionalist movement, constituting what is called a “heterogeneous marriage”⁽⁴⁰⁾.

There was an interesting variability in the study objects that chose the IA, as shown in Chart 2. However, some study objects in the health field were little explored, such as the hospital area, which was addressed in only three studies^(15-16,19). The IA framework was more used in studies related to Public Health and Mental Health.

The institutions that crossed the objects of study explicitly were education (university, research, school)^(8,10,33), the group⁽¹⁰⁾, health⁽¹⁰⁾, the technical and social division of labor⁽¹⁰⁾, the justice⁽¹⁰⁾ and parenting⁽³³⁾. In other investigations, the institutions appeared implicitly, such as in health professions, beliefs/religions, the family, sexism and/or patriarchal society, death and the biomedical model of healthcare.

In the various study objects analyzed, the research institution, for example, was put under analysis by questioning the methodological procedure - techniques and/or tools, the crystallized places of the researcher, neutrality and the idea of interviewer’s non-interference in data production, the lack of experience and skill of researchers, and the time limit and research schedule frequently imposed by research agencies and foundations in the country. These questions explain the instituted form of this institution and cross the analyzed study objects. In this sense, IA interrogates the instituted and hegemonic modes of knowledge production by putting into play the possibility of creative and more flexible arrangements, being itself the instituting of the research institution.

As shown in Chart 3, the most analyzed moment of the institution concept was the instituted. The rules and laws were repeated at the institution and the instituted moment, demonstrating that authors chose to use one of several dimensions of the concepts. Thus, “it is considered that the instituted contemplates the social forms installed, recognized and validated socially; in the ‘instituted’ we will place not only the established order, values, modes of representation and organization considered normal, but also the usual forecasting procedures (economic, social and political)”^(37-38). A conceptual mistake that may occur in the operation of this concept is to think of it as something bad that should always be replaced by another new social practice, as if the “new” and the change were always better than the “old”. The “way of analyzing the institutions brought some difficulties for the IA, especially in identifying the instituting with the ‘good’ and the instituted with the ‘bad’”⁽⁴⁾. The substitution of social practices instituted by other instituting, among which health practices, demands having the health needs of people and communities as the centrality. Thus, the operation of IA concepts is aimed at interrogating which objectives such practices wish to establish, which society projects are being implemented and to whom they are interesting. Therefore, the instituted can represent something better than the instituting and vice versa, depending on the point of view of the analysis and the object in question.

The second moment of the concept of institution, the Instituting, is described in Chart 3. It consists of marginal social forces that may or may not be recognized by the installed social forms, which is not necessarily good or bad in relation to the instituted. “By ‘instituting’, we will understand, at the same time, contestation, the capacity for innovation and, in general, the political practice as ‘signifier’ of social practice”⁽³⁷⁾. In the study objects analyzed, the instituting processes that questioned the instituted stood out. In this way, the operation of the moment could contribute to maintain instituted health practices and/or modify those that were not aligned with assumptions of institutions under analysis.

The third analyzed moment of the institution concept was Institutionalization, as described in Chart 3, which was the least highlighted in the studies. This third moment incorporates the existence of two other moments within the institutionalization: the founding institutionalization, understood as the initial moment of creation of the institution and when it takes shape; and the permanent institutionalization, which consists in updating and resuming its purpose of functioning throughout time, whether or not towards its creation purpose⁽⁴¹⁾. It is the process by which the institution legitimates itself and remains or not, over time, and consists of successive transformation processes that make its existence lasting or ephemeral. The analysis of successive institutionalization processes is essential. They reveal the capacity for adjustments, refinements, and integration of their contradictions⁽⁴²⁾. For IA, the more transformations of accommodation of the instituting by the instituted, the more lasting the institution becomes. Institutionalization is the third moment in Hegel’s dialectic, “it is up to the moment of singularity - moment of integration - in singular forms of organization, management, administration, functioning - to ensure the institutional implication of each individual constituting society. In this sense, the negative unity of social forms, always in an unstable balance, makes singularity the moment of regulation”⁽³⁷⁾. An example of a long institutionalization process is that of the Catholic Church: with more than two thousand years of existence, it was one of the objects of study of IA⁽¹⁾.

The IA concepts added knowledge for the areas of nursing and psychology, the two that most published works using this theoretical-methodological framework in the health field. Several objects of study analyzed are priority themes for the areas of health and nursing, and they could be questioned in order to know if the perspectives they met were consistent or not with the principles and guidelines of the SUS. In this way, the IA contributed to analyze the instituted social forms, their modes of operation, the instituting movements, and the most present institutions that have crossed the field of health and nursing, as well as their institutionalization processes.

Within the limits of this study, the expressive number of publications in the last five years stood out. This fact increased the curiosity of knowing other ways of putting IA into action that did not constitute research. The production of new reviews is recommended in order to know the scenario of theses, dissertations, interventions, among others, and expand the knowledge of experiences acquired with the theme in Brazil.

CONCLUSION

The scenario found showed that the theoretical-methodological framework of IA offers consistency for the analysis of objects of health studies crossed by a complex and interconnected network of institutions, broadening this concept. The concept of institution in its three moments - instituted, instituting, institutionalization - under analysis in this integrative review, proved to be a tool-concept of interrogating health practices for understanding them better.

The multiple forms found in the use of concepts referred to a creative and interesting polysemy, with studies that approached René Lourau’s perspective but revealed an open and instituting paradigmatic perspective of producing knowledge and health practices, which allows approximating concepts and favoring the production of new modes of functioning of institutions.

Neither the creation of new concepts nor that of misconceptions was found. In this analysis, the most distant of all referred to the understanding of “institution” as an organization or establishment. This perspective distances itself from the conception supported especially in the postulate by this referential. The polysemic form approached by the different researchers may be connected to the relation of such concepts to their objects of study, which may have led them to reinforce a certain facet of the institution concept or its movements (instituted, instituting and institutionalization). A partial or total adoption of IA concepts was identified in the articles, sometimes supported by the framework of socioanalysis and sometimes by schizoanalysis.

Given that Institutional Analysis constitutes a multi-referential theoretical framework, most objects of study that chose it dialogued with the field of public health, especially with the nuclei of knowledge from social sciences and management.

The study revealed that, in the area of health, nursing and psychology have adopted this theoretical-methodological framework and contributed to interrogate objects of study of priority themes by adding knowledge and proposing health practices more aligned with the principles and guidelines of the SUS.

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• Financial support:

  Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP). Technical Training Scholarship 3.

Publication Dates

• Publication in this collection
  24 Aug 2020
• Date of issue
  2020

History

• Received
  31 Oct 2018
• Accepted
  25 Sept 2019