The Circular Process as a tool for conflict management in a Basic Health Unit

ABSTRACT

This research aimed to report the mediation of conflicts between professionals linked to a Basic Health Unit in a city in the state of Sergipe. A descriptive study of the experience report type that sought to describe the applicability of the Circular Process as a form of conflict resolution with a multi-professional team. The results showed that restorative practices should be routinely implemented, because they are successful not only to mediate conflicts, but also to prevent them; after the first circle was held, there were collaborators with a conciliatory profile among the colleagues; the Circular Process provided an effective way to reconcile, motivate, and promote a change of attitude among those involved; the work processes began to be evaluated with the use of the circle to favor the empathic listening and the promotion of a culture of peace; this process allowed the subjects to perceive their own emotions and postures, reflecting positively in the work environment and in people’s care. That way, it is demonstrated that the Circular Processes can offer an adequate means for the resolution of interpersonal conflicts, once it promotes the dialogue between people in search of alternative solutions.

KEYWORDS
Organization and administration; Interpersonal relations; Primary Health Care

RESUMO

Este estudo objetivou relatar a condução de um Processo Circular como mediação para resolução de conflitos entre os profissionais vinculados a uma Unidade Básica de Saúde de um município do interior sergipano. Estudo descritivo, do tipo relato de experiência, que buscou descrever a aplicabilidade do Processo Circular enquanto ferramenta para resolução de conflitos em uma equipe multiprofissional. Os resultados evidenciaram que as práticas restaurativas devem ser implementadas rotineiramente, pois apresentam sucesso não apenas para mediar conflitos, mas para preveni-los; após a efetivação do primeiro círculo, surgiram colaboradores com perfil conciliador entre os colegas; o Processo Circular forneceu ferramentas eficazes para a conciliação, motivação e mudança de postura entre os envolvidos; os processos de trabalho passaram a ser avaliados com uso do círculo por favorecer a escuta empática e a promoção de cultura da paz; essa ferramenta permitiu aos sujeitos se conscientizarem de suas próprias emoções e posturas, refletindo positivamente no espaço de trabalho e na produção do cuidado. Dessa forma, os Processos Circulares se constituem em um meio adequado para a resolução de conflitos interpessoais, visto que favorece o diálogo entre as pessoas por busca de alternativas de soluções.

PALAVRAS-CHAVE
Organização e administração; Relações interpessoais; Atenção Primária à Saúde

Introduction

People are unique and complex beings who doesn’t always share the same goals, interests and needs. Those differences often results in conflict that can be considered inherent in human relations and they are almost inevitable.

[...] Conflict occurs when one involved realizes that the other affects, or may affect, negatively something that the first one considers important¹⁽¹⁸⁵⁾.

When conflict occurs in workplace, it is usually related to socializing between people with different personalities, values and interests. In the specific case of a Basic Health Unit (BHU) belonging to the municipal public service, this situation is accentuated by political differences and/or employment conditions, such as public tenders or temporary contracts.

Thus arises the need to manage the conflict that “[...] consists in the attempt to reconcile groups with interests, values, resources and eventually contradictory or antagonistic intentions”²⁽²³³⁾. Moreover, it is notorious in public health services, the need for managers to appropriate tools to mediate and resolve the existing conflicts, since it is a working space with human beings; and the way managers usually deal with conflict situations can be decisive for its result.

In searching for alternatives to resolve these disputes, the Circular Processes (CP) or restorative circles emerges, based on control, support, respect and cooperation, by using dialogue and empathic listening in order to restore social life and allowing the strengthening of ethical and moral values³. After all, in this practice, there is no distinction between victim, offender or community; on the contrary, everyone takes a privileged position in the dialogue⁴.

This mode of conflict resolution originates from Native American rituals that, by developing the circles, made room for participants to speak. To ensure respect and order at this sacred moment, they used an eagle feather that was passed from person to person to designate whose turn it was to speak, and thus arrive at the eventual solution of the problem⁵.

To understand work environment as a capable institution for full and extra professional attention to all users of health services demands from the manager much more than to clarify the rules of behavior based on unilateral and authoritarian decisions, but to pay attention to disorder as a challenge to overcome. Since neglecting this reality affects decisively the production of health care.

Given this, this article proposes to address the conflict in a public health institution mediated by the CP as a strategy for resolving conflicts, aiming at the participation, awareness and sensitiveness of all involved. It is believed that problems in work environment should be known, recognized and addressed in an oriented and contextualized manner from a social, relational and ethical perspective.

The objective of this case, therefore, is to report the authors’ experience in conducting a CP as a mediation tool for conflict resolution between health professionals, linked to a BHU in a municipality in the interior of the state of Sergipe.

Methodology

This is a descriptive experience report study aimed to describe the applicability of CP as a conflict resolution tool in a multi professional team linked to a BHU in a city in the interior of the state of Sergipe.

With a Territorial Extension of 406.8 km², the municipality in question has an estimated population of 15,349 inhabitants⁶. It has six health facilities in its physical network of its own services, being five Family Health Units and one small hospital with emergency and outpatient care. Obstetrics and the most complex cases are transferred to the care network at the regional center.

The BHU focused on this case is located in the rural area of the municipality, with an assigned population of approximately 2,000 inhabitants. The community is located on the edge of a Highway, about 14 km away from the urban center of the municipality. Almost all of the local population has this BHU as their main access to health policies and programs. The team consists of: one nurse, one nursing technician, one nursing assistant, one dentist, one oral health care assistant and one physician, all linked to the More Doctors Program, one attendant, seven Community Health Agents, two watchmen, one assistant of general services and one pediatrician.

The instrument used to conduct the CP was based on a script offered as a guide and linked to the Management Improvement Course in Basic Health Units, Clinical and Care Management⁷ and to the Restorative Circle Formation Guidelines proposed by Pranis⁸. With special attention to the formation of the pre-circle, circle and post-circle, emphasizing that the questions asked should lead the sequence of the circle and promote dialogue and understanding of communication among all parts involved.

Thus, the following steps composed the instrument: 1) Explanation about what would be the PC or Peacebuilding Circles was given; 2) Everyone was invited to try the wheel in the mold of peace circles; 3) The space around the circle was organized, placing in its center the speech stick (the object used was a standard family folder daily used in the unit); 4) Participants were invited to the circle, previously informed about the day, place and time; 5) The nurse and manager of the BHU identified herself as the guardian of the circle (reference person to organize and conduct the operation in the circle); 6) In the Opening Ceremony, the initial greetings and clarifications were given, exposing the objectives of the circle and how the speech stick works; 7) Participants were invited to express their thoughts and feelings through the following pre-selected question: How do I want to be treated by colleagues? Then the speech stick was passed from hand to hand clockwise. The participant who didn’t want to talk passed forward the stick in silence. Whoever had the speech stick had the right to express himself, and everyone else had to listen carefully, without interruption. Only the guardian needed to interrupt once to emphasize the importance of listening due to some communication noises that appeared during the process.

The circle lasted for approximately 90 minutes. At the end, a round of evaluation was made between all participants in a much more favorable environment than by the time of the pre-circle. Closing the circle, the facilitator or guardian presented a summary of the process, outlining the purpose and main conclusions for the participants, as well as pointing out the importance of quality of care for health promotion of users, followed by a short gathering among all participants.

Thus, with this description, it is not intended to make judgments about people’s intentions, but to constitute meanings to conflicts situation experienced, by bringing to understanding the context of its conduct and resolution, connecting these facts with the exposed reality and activities developed.

Results and discussion

The conflict that originated the report was interpersonal because it occurred among the employees of a BHU due to the incorrect filling of medical records of service users. These are usually organized in family folders; and, for each service provided by the doctor, nurse or dentist, the medical record was used to file the information, as well as to take notes of procedures offered at the BHU, such as dressings, rapid tests, nebulization, administration of drugs and vaccines.

The conflicting situation arose when one of the unit’s professionals did not accept the notes referring to an evolution in the medical record made by another professional because it considered it erroneous and incomplete. From that moment on, the whole team was involved as they began to state themselves and to criticize the issue that originated the dispute. The original scene between the two professionals occurred at the front desk of the work environment, in the presence of patients and other colleagues, causing embarrassment, damaging the relationship between the employees and the service’s image before the assisted population.

Given the situation, the nurse and manager of BHU proposed to make a CP in order to understand and seek solutions to the problem identified. Health professionals were invited to experience the peace-circle process, in which people placed themselves in a circle, and an object called a speech stick was placed in the center of this circle – something representative, meaningful, or with some familiarity to the participants. The nurse assumed the role of facilitator/mediator/guardian, a role in which the function of organizing the flow of participants’ speech, maintaining uninterrupted listening, facilitating receptivity among the participants and synthesizing the results from the speeches.

On the beginning of the circle experience, she greeted and explained the starting points, outlining the objectives of the circle and the function of the speech stick. She also showed a short video that outlined the importance of a healthy workplace relationships and the importance of ethics in health services.

As a trigger question, the following phrase was used: ‘how do I want to be treated by colleagues?’ After reflecting, the participants expressed their thoughts and feelings through pre-selected questions, connected with the triggering question, namely:

• ‘How can I improve my performance?’

• ‘How to help your colleague improve his/her performance?’

• ‘Do I also make mistakes?’

• ‘Can I do everything by myself?’

• ‘How can I help improve the work environment?’

• ‘How are they supposed to act with me when I make mistakes?

The speech stick then went from hand to hand, clockwise, always in a circle. The stick highlighted here was a family folder used daily by BHU professionals with the function of receptacle of medical records. At first, those involved showed some discomfort and shyness on the first contact with the tool, but during the activity, they were relaxing and showing greater acceptance and commitment to the process.

Some interruptions by the facilitator was needed due to the appearance of noises/parallel talks in the group communication, keeping the right of speech to the speech stick holder, informing those involved about the importance of listening. Throughout the process, everyone agreed on the relevance of good relationships, workplace ethics, and friendly treatment of co-workers using non-aggressive communication.

Thus, by the end of the circle, a round of evaluation was made among the participants, making clear the differences on the environment before and after the effective CP, in which the feeling of cooperation and belonging were exposed. At the end, the facilitator presented a summary of the process, explaining the purpose and results of the circle to the members, reflecting on the importance of peaceful coexistence and the quality of care for the health promotion of users, emphasizing that work from the centered-user’s perspective is the guideline for a quality work. It all ended with a celebration ceremony to close ties between people.

The situation shown above only reinforces the importance of a good interpersonal relationship in workplace, since conflicts at the interpersonal level are the main reason in changing the dynamics of workplace, as they can generate feelings that causes instability, discomfort, lack of cooperation, suspicion, tension and embarrassment between individuals or groups⁷.

From this perspective, rises the need to mediate conflict, seen as a possibility for cohesion between the social characters involved⁹. For the author, mediation may avoid exclusion, often favored by personal matters. Therefore, it is necessary to let go the preconceptions or judgments about the conflict, by listening to those involved and their antagonistic views about the event. This opportunity for dialogue tends to facilitate the understanding of the various parts and interpretations around a contradictory social fact. Circumstance that converges to the necessary relationship with

conflict mediation in health work by proposing understanding, acceptance of diversity and dialogue; acquires a sense of transformation of subjectivities and resistance to the propositions of exclusion and utilitarianism¹⁰⁽³²⁾.

This statement also connects with that mentioned by Franco et al.⁷ in stating out that, in restorative practices, the mediator helps the parts, directly or indirectly involved, to carry out a dialogical process aimed to transform a relationship of resistance and opposition into a relationship of cooperation and collaboration to solve the problem.

As an alternative solution, there are the Restorative Circles or RC, which are nothing more than meetings groups to respectfully and consensually repair the damage suffered, restore dignity, security and strengthen the bonds of justice and social cohesion.

The circle is a structured process for organizing group communication, relationship building, decision-making and conflict resolution efficiently. The process creates a space apart from our ways of being together. The circle incorporates and nurtures a philosophy of relationship and interconnectivity that can guide us in all circumstances - in and out the circle¹¹⁽³⁵⁾.

Thus, when considering conflict and the search for its resolution, it was understood that, with the use of the CP as a conciliation tool, those involved could realize the importance of a good relationship in work environment. Moreover, this particular circular format was used to demonstrate equality among the members of the circle, unmeaning between people.

This allowed the commitment among the participants to the strategy adopted, the creation of bonds between them and the mutual respect, reflected in the courtesy of speech and empathic listening during the CP. The geometry of the circle assumed great importance in this process because it created a convergent sense of focus that favored connectivity and avoided polarization, preventing noise in communication or subgroups, since the initial impact on people was uncomfortable with rearrangement, unlike what they were usually used to living in everyday life. As a result, “[…] the circular shape increases liability, since body language can be better assimilated by everyone”¹²⁽¹¹⁾.

It is appropriate to note that the participation of professionals occurred on a spontaneous basis, and the importance of this is emphasized since, in these processes, there is always exposure of thoughts and experiences, often personal and subjective. Therefore, the perspective of the involvement free from any obligation in the CP is reiterated, since it strengthens the feeling of being part of a group and the commitment to comply with the agreement, and avoiding the recurrence of conflict¹².

In addition to the spontaneity of those involved,

Nonviolent Communication (NVC) results is best shown in restorative practices and guides how we must express ourselves and listen other people for a good dialogue⁷⁽⁵³⁾.

Furthermore, for effectiveness, four key elements that must be respected:

observe without judgment, identify and express needs (others and yours), name the feelings involved (others and yours) and make clear and possible requests¹³⁽³⁾.

Communication between people should never occur through evaluation of the observed person, as the tendency will be resistance, defense or attack, since the reception of the speech can be reflected as criticism or judgment to the pronounced. Therefore, NVC consists on acquiring the ability to express and to communicate so there is understanding, and this can happen by reformulating the way words are verbalized when making appropriate choices with conscious use of them, as well as active listening without prejudgments or valuing expressions over others or fragments of situations without analyzing the context.

NVC³ is of great value to collaborative work, since it intends that everyone involved behaves with one another in a more kind, respectful and generous way. In which communication is understood as a way of treating the other with the respect that must exist between individuals, seeking first the understanding of facts free from pre-judgments, a peaceful form of coexistence in society. When expressing themselves, different ways of looking at life and acting on emerging problems are demonstrated. So there is the importance of coexistence, adaptation, dialogue, interaction and cooperation between the subjects in creating bonds.

The experience in NVC¹³ is unusual for many of us and is of great relevance for professional and social life, such as working on self-empathy and empathy in connection with others, in order to understand as a human being and to understand the point of view of another, since working with people requires establishing contact, communicating, interacting and cooperating. It is more than transmitting information; it is to but commit to understand. It is an adaptive process, in which it is necessary to share physical spaces, understand and respect the cognitive and emotional spaces of each person^14,15.

In social life, as in work, the subject needs to recognize the need of the other; this humanizes him and makes him singularly understand. It appears that, many times, this need is for speech, and when it is not given the possibility, conflicts emerge and overlap in interpersonal relationships. For this reason, learning to look, listen and understand them constitutes one of the greatest challenges in the development of work teams, in a context in which empathy can play a fundamental role¹⁶.

The facilitator role is manifested as the one who can favor the development of healthy relationship between individuals, which will directly, reflects in work environment. The facilitator is also responsible for assist on forming and organizing the circle, so the people can feel comfortable to express their feelings and opinions. Therefore, guiding the participants with the triggering questions to reach the goals for the CP is essential to conduct dialog and a healthy integration between people.

The purpose of guidelines is to relate the behaviors that participants feels that the circle is a safe place for them to speak about their truths¹⁷⁽¹⁵⁾.

The ceremonies are also important to mark the beginning and the end of the CP. This specific milestones means that, from that moment on, everyone is committed to the truth and active listening. Therefore, the participants are invited to get rid of pre-judgments or preconceived concepts, getting in touch with its essence¹².

As for the speech stick, its presence is important to create concentration point in the group. “It gives support when speaking from the heart and listening from the heart”¹⁷⁽¹⁴⁾. The object to be used as a speech stick should be something representative for those in a circle, that is known to everyone and that can unite them in times of crisis¹². The symbology of this object is even more relevant in the exposed situation because the conflict arose from a record in the medical record, a document belonging to a family folder that exists in the perspective of organizing work in a territory delimited with registered families.

By the end of the circle, the relationship between the professionals of the unit showed significant improvements, since the individual availability to problematize the circumstance that caused the conflict improved the understanding and tolerance among those involved. Individuals with a reconciling profile between colleagues emerged, reflecting on the quality of the work environment, without disagreements and/or aggressiveness.

The CP proved to be an extremely effective tool for reconciling, motivating and evolving everyone involved in the sense of empathy with others and non-anticipation for judgments of conduct. With each new process carried out at BHU, the resolutions began to happen more quickly and fruitfully, to the point that it was not only used for conciliation, but for planning and evaluating work processes. In this perspective, their results became surprising, since they allowed the anticipation and confrontation of problems inciting exchange of experiences and understanding of themselves, the other and the context of life and work⁸.

After mediation meetings, workers and managers were able to broaden the understanding of the conflict and become involved as protagonists in its conduct¹⁰. The narrative became the restructuring of the deliberative spaces. They began to discuss work processes, the structure of the collective and local responsibilities, reflecting on the relationships between them, with BHU and the community.

In other words, mediation needs to favor the deconstruction of the moral judgment narratives with preconceived concepts, so that they do not remain closed, sustaining a linear blaming directed towards behavior at the expense of the context’s perception of insertion of the subjects. On the other hand, restorative meetings needs to broaden the understanding of the conjuncture of work and the world of life in society.

Thus, it appears that the post-circle has as general objective to verify the degree of restorability for all involved, to evaluate the satisfaction among the participants of the CP, aiming the promotion of the culture of peace; this being the main expected result, since

the stories often overturn stereotypes or assumptions that the conflicting parties have about each other, making it possible for them to hear what each has to say more clearly when discussing problems later in the circle¹⁷⁽²⁹⁾.

This way, it is

becoming aware of your own emotions, the emotions of others, and how each one impacts the other is clearly a decisive interpersonal skill for a successful life, both personally and professionally¹¹⁽¹⁴⁾.

The desired result of all restorative practices, therefore, is resolution and reintegration without collateral damage. Resolution of eventual conflicts and their consequences, whether objective or subjective, and reintegration to the team, without labels or discrimination. “The main objective is that everyone becomes more aware of their actions and their social repercussions”³⁽⁵⁾.

Final considerations

The use of CP achieved its purpose as a tool for conflict mediation, since the issue was problematized by the group; and new perspectives, brought to the scene, providing improvements in the relationship between professionals of the work team.

It can be considered that the origin of the conflict came from the intolerance reflected in daily life in society. Perhaps due to the current conditions of existence, in which affection relationships have been unstructured, dialogue and understanding have lost space for professional ‘super competence’. As a result, the ability to deal with people has been lost, and the consequences of the acts have not been measured.

Thus, it was shown that the CP can be an appropriate tool for the resolution of interpersonal conflicts, as the solution was revealed by the dialogue between the people involved. This tool provides that everyone involved becomes co-responsible in the face of conflict situations and their resolution, in search of restoring peace in the workplace.

For this, mediation, usually performed by the team manager, needs to be qualified so the conduct can be as assertive as possible, in which subordination relationships do not affect or privilege one over the other. This space needs to be protected from relations of power, and for this, the manager needs to show security and impartiality, thus winning the trust of the team, and the group will be free from oppression to expose their feelings and thoughts.

This space, once achieved, will serve for decision-making after reflection and analysis of the meanings attributed, with the possibility not only of understanding conflicts, but also of contextualizing, identifying causes and consequences and giving a new meaning to the work and construction processes of care.

Lastly, the importance of using restorative circles is emphasized as a tool for more than conflict resolution, but as a prevention and/or evaluation of every work that aims care producing.

• Fnancial support: non-existent
• *
  Orcid (Open Researcher and Contributor ID).

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Publication Dates

• Publication in this collection
  10 July 2020
• Date of issue
  2019

History

• Received
  24 Feb 2019
• Accepted
  16 Nov 2019