PERMANENT EDUCATION AND ITS INTERFACE WITH BEST NURSING PRACTICES IN PRIMARY HEALTH CARE

ABSTRACT

Objective:

to analyze the implication of the permanent education process for the development of best Nursing practices in Primary Health Care.

Methodology:

a quanti-qualitative study conducted in two health macro-regions in the state of Santa Catarina, Brazil. The sample was made up of 216 nurses, from 97 municipalities. The data were obtained by applying a questionnaire, and analyzed using descriptive statistics. The qualitative data were produced by means of focus groups, in three municipalities, and analyzed with the aid of Atlas.ti 8.0®.

Results:

A total of 174 nurses (80.6%) have some specialization. 200 (92%) participate in permanent education processes, including exchange of experiences and updates, with Telessaúde (Telehealth) standing out. The discourses originated five code groups: sharing knowledge and experiences; knowledge and experience qualify the practice; education: liberation and change; teaching-service integration, and time to learn.

Conclusion:

the permanent education processes approach concepts of liberating education and point to the experience and use of evidence.

DESCRIPTORS:
Primary Health Care; Nursing Care; Continuing Education; Evidence-Based Nursing; Education

RESUMO

Objetivo:

analisar a implicação do processo de educação permanente para o desenvolvimento das melhores práticas em enfermagem na Atenção Primária à Saúde.

Metodologia:

estudo quanti-qualitativo, realizado em duas macrorregiões de saúde do estado de Santa Catarina – Brasil. A amostra quantitativa foi de 216 enfermeiros, de 97 municípios. Os dados foram obtidos mediante aplicação de questionário e analisados via estatística descritiva. As informações qualitativas foram produzidas via grupos focais, em três municípios, e analisadas com auxílio do Atlas.ti 8.0®.

Resultados:

174 enfermeiros (80,6%) possuem especialização. 200 (92%) participam de processos de educação permanente, incluindo troca de experiências e atualização, com destaque para o Telessaúde. Os discursos originaram cinco codegroups: compartilhar saberes e experiências; conhecimento e experiência qualificam a prática; educação: libertação e mudança; integração ensino-serviço; tempo para aprender.

Conclusão:

os processos de educação permanente tangenciam concepções da educação libertadora e apontam para a experiência e uso de evidências.

DESCRITORES:
Atenção Primária à Saúde; Cuidados de Enfermagem; Educação Continuada; Enfermagem Baseada em Evid á ncias; Educação

RESUMEN:

Objetivo:

analizar la implicancia del proceso de educación permanente para el desarrollo de las mejores prácticas de Enfermería en la Atención Primaria de la Salud.

Metodología:

estudio cuanti-cualitativo, realizado en dos macroregiones de salud del estado de Santa Catarina – Brasil. La muestra cuantitativa estuvo compuesta por 216 enfermeros, de 97 municipios. Los datos se obtuvieron mediante la aplicación de un cuestionario y se los analizó a través de estadística descriptiva. Los datos cualitativos se produjeron a través de grupos focales, en tres municipios, y se los analizó con la ayuda del programa Atlas.ti 8.0®.

Resultados:

174 enfermeros (80,6%) poseen alguna especialización. 200 (92%) participan de procesos de educación permanente, incluyendo intercambio de experiencias y actualización, destacándose el programa Telessaúde (Telesalud). Los discursos originaron cinco code groups: compartir saberes y experiencias; el conocimiento y la experiencia califican la práctica; educación: liberación y cambio; integración enseñanza-servicio; y tiempo para aprender.

Conclusión:

los procesos de educación permanente entran en contacto tangencial con conceptos de la educación liberadora y apuntan a la experiencia y al uso de evidencias.

DESCRIPTORES:
Atención Primaria de la Salud; Atención de Enfermería; Educación Continua; Enfermería Basada en Evidencias; Educación

INTRODUCTION

Grounded on the pedagogical assumptions formulated by the Pan American Health Organization and by the World Health Organization (PAHO/WHO) in the 1980s, Permanent Education in Health (PEH) is guided by significant learning. This implies addressing the issues that are expressive to the protagonists of the health production practices, with a view to significant changes in the work process of health teams and based on their previous needs and knowledge⁽¹⁾.

With such outlines, at the international level, the bases of PEH also converge with Interprofessional Education (IPE), following assumptions of critical pedagogy and interactive learning methods. It is based on the sociological perspective to promote the articulation between the different health professions⁽²⁾. One author⁽³⁾ presents interprofessionality as an emerging concept of IPE and of the interprofessional practices, which requires reevaluating the relationships between professions, investing in mutual understanding and exploring ways to combine knowledge, to improve service delivery, user safety and quality of care⁽⁴⁾.

In Brazil, the movements to strengthen the Unified Health System (Sistema Único de Saúde, SUS) are marked by policies that induce the reorientation of training, bringing teaching and service closer, especially related to the work process in Primary Health Care (PHC)⁽¹⁾. Particular emphasis must be placed on the National Policy for Permanent Education in Health (Política Nacional de Educação Permanente em Saúde, PNEPS), whose pedagogical basis supports practices that value the emancipation and protagonism of the individuals in teamwork processes, with a view to practices that favor interprofessionality(²,³,⁴).

Nursing has significantly contributed to the quality and effectiveness of the health systems and to the construction of the identity of the SUS because, in addition to representing the largest workforce, it is present in most actions involving care to the population, such as Nursing consultations, education in health and immunization, among others⁽⁵⁾. Nursing work is characterized as collective and requires collaboration with other professions and workers in the health field. The consolidated knowledge of Nursing is the basis of the daily work and guides decision-making in the work process, through challenges arising from the dimensions of care, management and research⁽⁶⁾.

Currently, there is a wide-ranging discussion about the euphemism of the concepts of best practices and Advanced Nursing Practice (ANP)⁽⁷⁾, the latter related to increasing accessibility and coverage in PHC, maintaining quality of care. In Canada, such discussions started in the late 1960s and, in Europe and Asia, during the 1980s⁽⁸⁾. In the midst of such controversies, the concept of best Nursing practices emerges in Brazil as a possibility to qualify care and as a path for the development and exercise of creativity, combined with everyday experience and the implicit skills or competences⁽⁹⁾.

The best practices are characterized by a triad, in the form of a technique or methodology that, through experience or research, has proven reliability for a good outcome, taking into account the needs of users/patients⁽⁵⁾. Thus, in order to carry out the best practice, it is necessary to recognize the most appropriate option for specific situations and contexts, based on the rational use of resources, in order to achieve the expected results. Professionals are guided by the best updated evidence for clinical management, considering a specific context, such as the care protocols in PHC(⁵,⁹).

Thus, investigating and recognizing the potential of the best practices to broaden the debate on ANP implies recognizing what has been done by nurses in this direction and how the initiatives related to the training process can contribute to their conduct. Based on this verification, this study aims to analyze the implication of the permanent education process for the development of best Nursing practices in PHC.

METHOD

A quanti-qualitative study, whose quantitative stage was developed in PHC Units with Family Health Strategy (FHS), in the 131 municipalities that make up the nine Health Macro-regions of the state of Santa Catarina-SC, Brazil. Data collection was carried out between April 2018 and August 2019.

The population was composed of the nurses working in the Health Units of the municipalities belonging to the Macro-regions. The inclusion criterion was working as a nurse in the FHS of the municipality for at least one year. Nurses who were on leave or away from the service for any other reason were excluded. Sample calculation for the quantitative stage respected the 5% significance level, 95% confidence interval, and 50% proportion, estimating 205 participants.

The qualitative data were obtained through focus groups with nurses who worked in the PHC of three municipalities representative of the Macro-regions, established by means of a draw, with the following characteristics: one with up to 50,000 inhabitants, one with 35,001-140,000 inhabitants, and one with more than 140,000 inhabitants, adjusted according to feasibility of access. Three groups were organized in each municipality.

For the collection of the quantitative data, a survey-type structured questionnaire in Google Forms was used, with variables that contemplated the sociodemographic profile, the work process, and the practices developed by the nurses. This was sent via e-mail to all nurses of the Macro-region teams, in partnership with the Brazilian Nursing Association - Santa Catarina Section (Associação Brasileira de Enfermagem - Seção Santa Catarina, ABEn/SC) and with the Regional Health Departments. The Free and Informed Consent Form was annexed in the content of the e-mail message. Accessing and answering the survey formalized their consent to participate in the research.

A total of 231 nurses were invited to take part in the quantitative stage of the study; 15 were excluded for not meeting the criteria, totaling 216 respondent nurses. Of the 31 municipalities contacted, no answers were obtained in 34, totaling 74.04% of the municipalities contemplated in the Macro-regions.

29 nurses participated in the qualitative stage: 19 from the largest municipality, five from the medium-sized municipality, and five from the small municipality. Data production was closed according to theoretical saturation. The focus groups lasted a mean of two hours and were led by a researcher, a reporter and supporters; and the participants’ speeches were recorded and transcribed in full.

The SPSS 21.0 software was used for the quantitative analysis procedure. The qualitative data were treated by means of thematic analysis⁽¹⁰⁾, following: pre-analysis, exploration of the material, and data treatment. They were inserted into Atlas.ti Qualitative Data Analysis & Research Software, version 8.0. From the documents, it was possible to select significant passages, based on the study objectives, associating them with the identifying codes, which originated five code groups: (1) sharing knowledge and experiences; (2) knowledge and experience qualify the practice; (3) education: liberation and change; (4) teaching-service integration, and (5) time to learn.

The project was approved by the Committee of Ethics in Research with Human Beings of the proposing institution, under Opinion No. 2,380,748. To ensure the participants’ anonymity, the speeches will be designated with the letter E for interview o nurse (entrevista and enfermeiro in Portuguese, respectively), followed by order number; and the letter M for municipality, followed by order number, with M1 referring to the smallest municipality, and so on.

RESULTS

Table 1 reflects the participation of the nurses working in the PHC of the West and Midwest Macro-regions of Santa Catarina in PEH actions. They state they participate in permanent education in health actions to a large extent (n=200/92.6%), with Telessaúde (a tool used as a possibility of distance education) being the most accessed source (n=120/55%).

Table 1
Participation of the PHC nurses from the West and Midwest Macro-regions of Santa Catarina in PEH actions, use of Telessaúde and tutoring activities (n=216). Xanxerê, SC, Brazil, 2019

Variables	n	%
Participation in PEH* actions
Yes	16	7,4
No	200	92,6
Uses Telessaúde
Yes	120	55,6
No	96	44,4
Participation in tutoring activities
No	92	42,6
Yes, with direct and indirect supervision by the professor	70	32,4
Yes, only as a technical visit	17	7,9
Yes, with direct supervision by the professor	6	2,8
Yes, only with indirect supervision by the professor	31	14,4

• *Including exchange of experiences in team meetings, group studies and refresher courses. Source: The author (2019).

The nurses’ speeches illustrate that preference:

[...] that Telessaúde course is wonderful; I’m in the last module, now I’m finishing it, it talks about how the perfect dream PHC should be [...] the importance of an education based on the SUS guidelines, the importance of the teaching-service integration for the professionals and how it makes a difference. (E9M2).

The participants draw the attention to work overload in the PHC routine, highlighting lack of time for study, reflection and research:

[...] even in the usual hurry, in the overload of tasks, these moments [of collective study] make us reflect on what we do and where we want to go. (E2M1).

You even know where you’re having difficulty, either with the patient or in the professional [performance], but you don’t stop and think: let’s search for a qualification, an improvement. (E1M1).

[...] when you’re at work, you’re overwhelmed, you’re on autopilot and don’t reflect much. [...] on a daily basis, I think that hardly a day goes by without doing some procedure or routine that we don’t think: oh, but I can do it like this, it’s better! (E2M1).

They admit knowledge is an important element for the qualification of practices and, in this direction, they highlight the best practices as those that favor patient care, based on this qualification:

[...] the greater your knowledge, the better your practice [...] these best practices are what you can do best for that patient, who is in need of that care. (E1M1).

The study also showed the nurses’ impression about the fact that distance from the university favors the gradual loss of certain skills:

This exchange is important for us to keep updated, because outside the universities things become more difficult, there needs to be some recycling. (E4M1).

With such inferences, they acknowledge the importance of the university being present in the services and the possibility of accompanying professors and students in internships, highlighting the need for greater teaching-service integration:

The university is important in this process [...] this movement that takes us out of the unit, of care and of the daily routine, to reflect and try to improve. (E7M3).

[...] each one [of the team] focuses on their specific area! We need to share more [...] there has to be an alignment between the service and the university. (E8M2). I would highlight the importance of improving teaching-service communication. (E10M2).

[...] we know and hear a lot about the master’s degree being difficult, but we don’t imagine the proportion, only after we’re there [...] learning is immense, you change the conception about many things [...] (E11M2)

This is reinforced by the comments about the nurses’ participation in tutoring activities - monitoring students in professional training internships - as a service professional, an aspect that was also highlighted in the quantitative data, with a considerable number of nurses who mentioned welcoming students, with direct and indirect supervision by the professor (n=70/32.4%).

[...] when you welcome this student in the Unit, you never start a conversation and leave without learning something new; so, as nurses, we also learn in this teaching-service integration, because we also rethink our practices [...] you study, teach, guide and also learn, this integration that exists is fundamental, I can’t see myself without that part in PHC. (E12M2).

Table 2 presents the sociodemographic, schooling and labor characteristics of the nurses working in PHC, in the study locus.

Table 2
Sociodemographic and labor characteristics of the PHC nurses of the West and Midwest Macro-regions of Santa Catarina (n=216). Xanxerê, SC, Brazil, 2019 (continues)

Characteristics	n	%
Gender
Female	203	94
Male	13	6
Age - Mean (Standard Deviation)	36,26	(7,06)
Schooling
Graduation	29	13,4
Specialization	174	80,6
Residency	1	0,5
Master's degree	12	5,6
Working time in PHC (years) - Median (interquartile range)	8,50	(4 – 13)

• Source: The author (2019).

The participants’ age varied from 26 to 36 years old, mostly women, with a lato sensu graduation degree (n=174/80.60%). In the qualitative stage, all the participants were women. It is noteworthy that a considerable percentage of the nurses from the Macro-region have stricto sensu graduation degrees (n=12/5.60%). In this scenario, it should be noted that the region is nearly 500 kilometers from the state capital, for a long time considered an education hub in the Nursing area.

The nurses share some ideas about permanent education, such as the possibility of exchanging experiences, sharing knowledge with other professions and from practical situations:

I think these meetings are very good; we always want to stay longer, exchange experiences, get to know each other’s reality. (E3M1).

[...] clarifying the importance of Permanent Education, based on the reality experienced. (E3M1).

[...] I believe in dividing things, I think it’s just a matter of getting started, talking to other professionals. By leading the team, I think we can delegate duties, share practices and knowledge. (E6M3).

They perceive education as an empowering practice, which favors a critical and liberating attitude and, in this context, they acknowledge Nursing as a profession composed of oppressed people, referring to the work of Brazilian educator Paulo Freire:

[...] Freire talks about it, about the oppressed, we’re an extremely powerful class due to everything we do, what we can change, but we’re oppressed [...] whenever someone tries to do something different, that person is politically persecuted [...] While we’re out there putting out the fires, we don’t stop to reflect and think and I believe that’s what the political-party issue does to us: ‘Do not let them realize the power they have because they will change things [...]’. (E5M3).

Figure 1 presents the code groups related to the implication of the permanent training/education process for the development of best Nursing practices in PHC, which will be discussed below.

Figure 1
Code groups related to the implication of the permanent training/education process for the development of the best Nursing practices in Primary Health Care, Xanxerê, SC, Brazil, 2019

DISCUSSION

Considering the Macro-regions under study, located farthest to the capital state, the still modest but growing number of nurses who are accessing master’s programs drew the attention. In this sense, it is important to highlight that, until recently, training opportunities in the stricto sensu modality focused on Nursing were only accessible in the state capital. In 2017, a Professional Master’s (PM) program in Nursing was created in a public institution in the West of SC, the first in the region⁽¹¹⁾. To meet the social, political and economic demands associated with the qualification of workers in service, PMs aim at training directed to “advanced and transforming professional practice of applied procedures and processes, through the incorporation of the scientific method, enabling professionals to work in technical-scientific and innovation activities”(¹²,²⁰).

In Brazil, the Federal Nursing Board (Conselho Federal de Enfermagem, COFEN) invested in the qualification of nearly 500 professionals over four years and started to support research through PMs in partnership with the Coordination for Improvement of Higher Level Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, CAPES), especially directed to the theme of the Systematization of Nursing Care (SNC)⁽¹³⁾. In the state in which the research took place, two public institutions were contemplated in this edict, one of them located in the Macro-region under study. In 2019, CAPES launched a new edict and the institution was again contemplated.

Nursing represents more than half of the number of health professionals in Brazil and this figure grows 12.5% per year. Although in the last decades there has been a tendency towards an increase in male participation in the profession, women still predominate, influencing the feminization of health in Brazil(¹⁴,¹⁵). Nurses operate in PHC based on a work process that points to protagonism, with technical-scientific, legal and political bases, through practices committed to social well-being. Their work is organized in dimensions that permeate care, education and management⁽¹⁶⁾. In the case of PHC, they involve education and interprofessional work⁽¹⁷⁾. The research evidences some aspects of IPE, present in the nurses’ ideas, which highlight teamwork, collaboration among professionals⁽¹⁷⁾ (represented in code 1) and integration with the university (represented in code 4), emphasizing the theoretical, philosophical and political assumptions that guide PEH(¹⁸,¹⁹).

The spaces for action and reflection on the practice are configured in two units of cooperation and transformation – work and education – which, integrated, promote the transformation of reality(¹¹,¹⁹). In this perspective, nurses seem to seek support to improve their practices through the exchange of information and from practical situations, through the accumulation of experiences or access to guidance via Telessaúde. They seem committed to the need to act (do) and reflect (think about the action) from everyday problems, with a view to improving their praxis, in a manner consistent with the critical and liberating perspective of education (code 3)(¹,²⁰).

In PHC, the articulation between services and actions for comprehensive care can be enhanced by the use of Information and Communication Technologies (ICTs), as is the case with Telessaúde. In Brazil, under different modalities, technology has gradually been incorporated into health care and management, even in the at-distance modality, with cost reduction as one of the main concerns⁽²¹⁾. In the research, this possibility of access to information also stands out, consistent with another study carried out in the region⁽¹⁾.

The nurses’ conceptions regarding the aspects of the health professionals’ education go against the hegemonic view, which conceives education as unidirectional transmission of knowledge and attitudes (banking conception), in which the educator (and the health professional) is expected to provide updated scientific information and the student (and the user) is expected to play a passive and obedient role in apprehending the information and guidelines for the execution of the prescriptions⁽²⁰⁾. With such outline, the role of learners/ users would be to understand and execute the information and prescriptions determined by the educator/professional⁽²²⁾. The results of the study, on the other hand, draw the attention to the perception that nurses are sometimes placed in a condition of oppression, strengthened by political interests that operate so that they do not empower themselves, keeping them busy (overwhelmed) and with no time to study⁽²⁰⁾.

An important finding for development of the Nursing practices was that the groups understood the importance of welcoming students in the setting in which PHC operates. By considering the importance of teaching-service integration, the Brazilian Nursing Association (ABEn), together with the National Health Council (Conselho Nacional de Saúde, CNS), recently developed recommendations for the new National Curricular Guidelines for Nursing courses, with the aim of qualifying and expanding the training of nurses, considering the current scenario of Nursing education in Brazil. Although the recommendations do not specify the role and do not review training in tutoring, mainly with regard to the pedagogical practices necessary for the better performance of nurses in the pedagogical practices, it is an important recognition to strengthen teaching-service integration⁽²³⁾.

All these elements demonstrate the implication of PEH for the qualification of the Nursing practices, from the perspective of the participants in this study. They converge with studies that demonstrate that the best Nursing practices can be improved through the permanent search for knowledge; however, nurses acknowledge a daily burden that influences lack of time for study (an aspect present in code 5)⁽²⁴⁾. However, they recognize that a best practice is only possible through constant improvement (code 2), which, combined with the experience that emerges with the years in the role⁽⁷⁾, contributes to qualified care.

It is to be noted that Nursing care and management needs theoretical support and scientific evidence. On this regard, this study highlighted the concern of nurses, who seem to be able to relate care to their subjective dimension, interwoven in the relationships produced in the act of caring and/or managing⁽²⁵⁾.

The study had limitations, such as the difficulty in gathering professionals from all the state Macro-regions, as well as analyzing the different social contexts in which they work, inducing the reflection on the importance of conducting research studies that explore other dimensions of this theme.

CONCLUSION

The processes of permanent education for development of best Nursing practices in PHC in the Macro-region under study reveal a contingent of professionals motivated for professional improvement. Their ideas on the educational practices touch on concepts of liberating education (based on Freire’s theory) and point to experience, collaboration and the use of evidence in the development of the best practices.

The search for graduation courses and distance learning as a possibility for updating demonstrates not only the interest in professional improvement, but that information and knowledge are accessible in the most remote Brazilian regions. Thus, they recognize that devices such as Telessaúde offer conditions for professional development, covering topics that imply best practices.

The nurses distinguish the role and importance of the University, by integrating teaching and service and, despite work overload, show interest in qualifying their training, by accessing Master’s programs, for example. This shows that investments in the educational processes must be part of the work process in PHC, as there is an undeniable potential for these movements to build new paths taken in Nursing and with an impact on the SUS.

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Publication Dates

• Publication in this collection
  29 Oct 2021
• Date of issue
  2021

History

• Received
  08 Apr 2020
• Accepted
  23 July 2020