Permanent education actions of nurse facilitators at a nursing education centre

ABSTRACT

Objective

To identify actions of nurse facilitators of a permanent healthcare education centre of a teaching hospital.

Methods

A single case study with a qualitative approach conducted with eight nurses from a hospital in the state of Rio Grande do Sul, Brazil. The data were generated through document analysis, systematic observation, and a focus group from April to September 2013.

Results

The study produced the following categories: powerful strategies to promote permanent healthcare education actions from facilitating nurses and limitations for the development of these actions.

Conclusions

The establishment of a permanent nursing education centre can trigger the Permanent education actions of nurses in teaching hospitals.

Continued education; Professional practice; Health services; Nursing

RESUMO

Objetivo

Identificar ações desenvolvidas por enfermeiros facilitadores de um Núcleo de Educação Permanente de um Hospital de Ensino.

Método

Estudo de caso único com abordagem qualitativa, realizado com oito enfermeiros de um hospital no Estado do Rio Grande do Sul. A produção dos dados foi por meio de análise documental, observação sistemática e grupo focal, realizada de abril a setembro de 2013.

Resultados

O estudo aponta para as seguintes categorias: estratégias potentes para promover ações de Educação Permanente em Saúde a partir dos enfermeiros facilitadores e as limitações para desenvolver essas ações.

Conclusão

A implantação de um Núcleo de Educação Permanente em Enfermagem é um dispositivo para o desencadeamento das ações de Educação Permanente feito pelos enfermeiros em hospitais de ensino.

Educação Continuada; Prática Profissional; Serviços de Saúde; Enfermagem

RESUMEN

Objetivo

Identificar las acciones desarrolladas por los enfermeros facilitadores de un Núcleo de Educación Permanente de un Hospital de Enseñanza a fin de promover sus acciones en referido núcleo.

Método

Estudio de caso único con abordaje cualitativo, realizado con ocho enfermeros de un hospital en el Estado de Rio Grande do Sul. La producción de los datos se dio a través de análisis documental, observación sistemática y grupo focal, realizado desde abril hasta septiembre de 2013.

Resultados

El estudio apunta a las siguientes categorías: estrategias de gran alcance para promover acciones de educación permanente en salud de las enfermeras y limitaciones facilitadores para desarrollar estas acciones.

Conclusión

La implantación de un Núcleo de Educación Permanente en Enfermería es un dispositivo para el desencadenamiento de las acciones de Educación Permanente hecho por los enfermeros en hospitales de enseñanza.

Educación Continuada; Práctica Profesional; Servicios de Salud; Enfermería

INTRODUCTION

The act of nursing, as a profession, is expressed as the care of people with different health debilitations in a wide range of practice scenarios¹. Hospitals, an example of the practice scenario of nurses, are complex systems that absorb much of the healthcare workers. The healthcare model employed in this practice field has been undergoing some gradual changes at national level. Traditionally, the main practice location of these professionals, the hospital, is marked by a technicist hegemonic healthcare model and resistance to the changes that occur in the field of health.

In the hospital, nursing professionals face the challenge of working with different healthcare models that favour significant changes in health practices. Consequently, permanent education for healthcare (PEH) emerged in the international arena as an educational and political strategy through the Pan American Health Organisation (PAHO), and in the national arena with the Secretariat of Management of Healthcare Work and Education (“SGTES”).

PEH is a proposal for an education that seeks to enhance the knowledge and actions of healthcare workers and the users that interact and intervene based on reflection of health practices, meaningful learning, and the perspective of transforming professional practices²-³. The theoretical bases of the PEH are autonomy, citizenship, the subjectivity of the actors, and learning in, by, and for the practice⁴.

PEH was created and implemented as a policy, in accordance with the Federal Constitution, Ordinance No. 1.996 of 20 August 2007, of the Ministry of Health (MS)⁵. Consequently, PEH became a possibility for nurses to develop their competencies and improve their professional performance in a qualified way, given the complexity of their work⁶.

In spite of the growing number of studies on the PEH, there is still a knowledge gap in relation to the object of this study. This object includes PEH action of nurses in hospital settings. In this setting, it is difficult to effectively adopt PEH actions in relation to nursing workers that want to accompany the changes in healthcare according to the principles of the Unified Health System (SUS)⁷.

Therefore, the research question was, “How do nurse facilitators develop Permanent education actions at the permanent healthcare education centre of a teaching hospital?” The aim of this paper is to identify the actions of nurse facilitators of the permanent healthcare education centre of a teaching hospital.

METHODOLOGY

This is a qualitative study with a single care study⁸ that is part of a master´s dissertation⁹. Research was conducted at a permanent nursing education centre (“NEPE”) of a teaching hospital, in a municipality of the state of Rio Grande do Sul, Brazil. It is a medium to high complexity hospital with 328 beds that provides healthcare services to the residents of 42 municipalities, and serves as a teaching, research, and extension institution.

Eight nurse facilitators of the NEPE participated in this study from a total of 15. The other facilitators did not meet the exclusion criteria, which were nurses on sick/maternity leave and professors or representatives of the head office. Nurse facilitators are the professionals who work at the NEPE to promote education in their work unit. They are indicated by the head office of each unit.

Data were collected from April to September of 2013, in three stages: identification of the evidence of PEH actions in the meeting minutes, systematic observation, and a focus group. The first stage consisted of reading the nursing meeting minutes of the 11 sectors of the hospital, from 2007, when the NEPE was opened in the hospital, to 2012, to identify evidence of actions or topics related to PEH. The second stage consisted of systematic observation in 8 consecutive meetings of the NEPC totalling 16 hours, between May and July 2013, until the research objective was satisfied. These meetings were held every week and lasted 2 hours each, with the participation of nurse facilitators and the coordination of the studied NEPE.

The third stage consisted of the focus groups (FG)¹⁰, developed according to the discussions on a specific topic of PEH actions of the nurse facilitators. The FGs were conducted in all encounters by a moderator assisted by two observers in the auditorium of the teaching hospital. The first group had eight people, the second group had six people, and the third had eight people. The two-hour meetings were recorded on audio and subsequently transcribed. The researcher used a field journal to take notes on the verbal and non-verbal manifestations of the members of the FG.

To organise and analyse the data, we considered the analysed documents, the field journal according to systematic observation, and the transcriptions of the recordings in the FG. Data triangulation was used to obtain a greater understanding of the purpose of the study¹¹ since all the material that made up the body of this study was analysed to answer that purpose and observe the recommendation of the case study.

Next, this material from the triangulation of data was submitted to thematic content analysis¹⁰. Following classification, the data were categorised according to the topics that were addressed in the body of analysis. Categorisation consists of three stages: pre-analysis; exploration of the material; and treatment of the results. The first stage, pre-analysis, consisted of skim reading the collected material with the use of exhaustiveness, representativeness, homogeneity, pertinence, and exclusivity of data. In the second stage, the material from the research was explored and the data were encoded in units of meaning after exhaustive readings. In this stage, the categories are built to group the data elements with common characteristics, namely powerful strategies to promote permanent healthcare education actions from facilitating nurses and limitations for the development of these actions. Finally, the third stage consisted of treating the obtained results by means of interpretation.

The protocol of the research project observed Resolution No. 466/2012, of the National Health Council¹², and was approved by the Human Research Ethics Committee (“CEP”), filed under No. 13354513.6.0000.5346. Furthermore, all the participants voluntarily signed an informed consent statement. To ensure their anonymity, the participants were informed that they would be identified with the letter “E”, for nurse in Portuguese, and a number (E1, E2, E3, ...) that did not correspond to the order of their participation in the study.

RESULTS AND DISCUSSION

Powerful strategies to promote permanent healthcare education actions from facilitating nurses

In light of the challenges of PEH in the healthcare services of a teaching hospital, the nurse facilitators of the NEPE are encouraged to plan strategies that promote education in their service units. These strategies conceive how the professionals conduct PEH actions in each nursing scenario.

The nurses can use strategies that promote the inclusion of education in the routine of nursing professionals. These strategies can be understood as a set of actions and decisions that can be reached from a dialogical relationship between the professionals who work in a healthcare institution¹³. These strategies are described and articulated with the statements of the participants.

The flexibility for the meetings of the nurse facilitators is one of these strategies, and it is understood as the ability to operationalise PEH in the hospital setting, as shown below:

To participate in the meetings I tried to switch the schedule of meetings. A meeting is held at 8 a.m. and another at 1:30 p.m., and another at 6:30 p.m. to cover the three shifts. (E4)

There was no way we could stop and make the whole team watch [...] we decided train the POPS outside the schedule. (E7)

This strategy was also addressed in the analysis of the meeting minutes of the sectors and in the NEPE records, where the nurses stated they were available to attend the meetings at different times. As regards compensation for hours in service due to educational activities outside the shift, the workers were given time off from their work for education. The meetings minutes of all the analysed sectors, especially from 2007 to 2009, showed this flexibility in the work hours and approval of this benefit.

The nurse facilitator can identify and propose appropriate strategies for the production of new knowledge to change health practices⁶. Through this incentive, they are encouraged to participate in PEH actions, which signals the need to address the problems of health services to improve the quality of comprehensive care to society¹⁴.

In some sectors, the strategy was to include PEH activities in the routine as part of the work activities. These meetings were systematic, planned, and scheduled according to the needs of each hospital service unit. This strategy can increase the job satisfaction of workers, as shown below:

In my sector I put it in the work programme as hours [...] it counts as works worked (E3)

The education at work that E3 organises, someone goes there and talks about the emergency car, and we go there and talk about hand hygiene, and so on, according to the demands of that moment. (E5)

The PEH activities incorporated into the daily lives of the workers and mentioned by the nurses occur within educational spaces and become intrinsic to the organisation of their work¹³. These activities can occur through meetings in informal spaces where the nursing professionals discuss and reflect on their practices and organisation in the context of a work team¹⁴.

The functional progression was mentioned as a powerful strategy for the promotion and development of PEH. The statements also revealed a movement of professionals in the hospital regarding the pursuit of knowledge through graduate and postgraduate courses that reflected on the institution where they work and on their work unit.

In our experience, it is our practice to never perfect. Here at the institution, with the issue of progression, we can say that this has changed a bit. If there is no need for progression, the maximum we can do is specialisation. There is no reading papers, there is no search for new knowledge, there is no practice of improving, doing better, your knowledge. (E6)

What I notice there in the sector is people studying with this benefit of progression. Everyone is attending college. Once I heard that when we go to school, we rethink and never go back. They’re having a benefit, a positive benefit. They are rethinking how they do things. (E8)

From the analysis, it was observed that there are investments in PEH projects that observe the educational needs of nurses and requirements prescribed in the progression of functional training. PEH increases the awareness of health workers regarding the educational process because they are responsible for their qualification and training¹, although the financial incentive is the driving force behind this attitude.

Another strategy that is thought to drive PEH actions is meetings enabled by the NEPE. In these meetings, the nurse facilitators can share and exchange knowledge and practices. They are also encouraged to continue overcoming obstacles of their everyday routine with regard to the educational process of nursing, as mentioned below:

I think the NEPE strengthens us when we’re getting discouraged. You go there to the NEPE and discuss lots of things, and come back with the strength to start again. If we do not attend these meetings, if we don’t participate, everything becomes the same, that same day-to-day routine. (E1)

Between us, we are trying to emerge, grab on, move forward. But, we also need to be motivated. I think we end up energizing [at the meetings]. I think it would be harder if we didn’t meet once a week [NEPE meeting]. (E5)

Given the difficulties of daily life, the NEPE meetings help the nurses to strengthen ties among themselves and encourages them to cope with the critical nodes of implementing PEH. This shows that the spaces for discussion enable workers to build closer relationships that, in turn, help them to collectively cope with the problems of everyday work¹⁵.

Thus, it can be said that the NEPE meetings provide the facilitators with the feedback they need to deal with everyday problems and share their practices and knowledge in relation to PEH. In addition, these meetings allow nurses to discuss PEH in a more dialogical manner, and strengthen the group through shared experiences¹⁴.

For these strategies to function in a space such as a hospital, they require a management design that supports a change of reality. An example would be participatory management that seeks to decentralise decisions and the approximation of the entire work team. These strategies can be used to implement PEH in the hospital setting, and provoke the deconstruction of the existing hospital-centred model in favour of significant changes in the production of healthcare². It should be noted that these strategies were implemented as a result of the autonomy that the nurses had in relation to the work process. These professionals have the opportunity to participate in the decision-making process in relation to their professional performance and the continued improvement of work, based on the guidance of the PEH.

Limitations for the development of PEH actions

According to a study², the authors found hypotheses that hinder the implement of PEH in hospitals. One of these hypotheses that was confirmed in this study was the low number of nurses in different units and services can hinder their participation in PEH in their work schedule. The following statements reveal the significant demands of care and the work overload they produce in the healthcare workers:

We need more people for permanent education, but inside this schedule (30 hours). Nurses work in a scale. With the scale we have to plan for permanent education. So, once a week, switch the groups around. (E2)

You have to complete a heavy workload and then do another activity. (E3)

The difficulties mentioned by the nurses regarding their work and PEH in the hospital revealed the high demands of care in the current context. Therefore, it is necessary to identify the causes that affect the workload of nurses and consider these causes when redesigning their work to improve the quality of life of nursing staff¹⁶.

It is important to overcome these elements, especially in relation to the facilitators of the NEPE, since they are the potential agents of change and a reference of the nursing staff that stimulate integration and personal¹⁵-¹⁸, as stipulated in the policies that support the SUS.

Studies point to difficulties in implementing PEH in healthcare institutions, especially regarding the low attendance of professionals in the educational activities due to their resistance and the belief that they have the knowledge they need to promote healthcare². The statements revealed the centralisation of PEH actions in the nurse facilitator:

The core service representative can’t do work that reflects on the service without it being connected to the leadership and the other nurses of the service. So if leadership is connected to the nurses maybe they will notice those permanent education actions. (E2)

We have to be facilitators in our own unit, but the others [nurses] should also be facilitators. At least the shift nurses should be [facilitators], not the chief, but the shift manager, to give continuity to permanent education. At most, it happens with those who participate in the unit and its leadership. (E7)

It is believed that the viability and continuity of nursing education is associated with the contribution of the outreach nurses since they work with the teams and experience the demands of everyday work⁴. Therefore, the outreach nurses can identify the learning needs of their colleagues, especially those of their work sector.

In addition, PEH can be implemented when the outreach nurse effectively participates with the head of the sector, who uses management skills to promote actions and minimise the barriers of routine work. These barriers can interfere with the education of workers who are under his or her leadership. Therefore, the manager is expected to acknowledge PEH as a learning space in the work process of these teams². In the statements, E2 stresses that nurse facilitators experienced this reality as soon as the NEPE was implemented:

When the NEPE was created, it was priority in the policy of the nursing service. It was so much easier that the unit was a success in the first years due to the nursing service policy and the advisory service and because it was a priority. (E2)

Nursing conceives its supply locus in the provision of care, which considers multiple dimensions, such as ethics, management, technology, and education. These dimensions establish relationships of dependency, interdependency, and autonomy between professionals and users, configuring a complex and dynamic structure of care¹⁷. In the bias of PEH, this complex scenario involving the actions of nursing is mobilised through the nurse’s performance as the leader of your team. The nurse is responsible for providing healthcare strategies and practices for those who are part of the system, namely workers, users, and their families, to exercise their autonomy in a way that is shared through significant learning in their daily lives¹⁷. In this way, nurses can provide different ways of knowing and doing by practicing care and education in a model that is better adjusted to the needs and context of PEH actions¹⁹.

Although there have been some advances, the training of health professionals, especially nurses, is still far from comprehensive care. The profile of the nurses shows that they lack the qualifications to change healthcare practices. The growing need to provide permanent education for professionals with the aim of (re)signifying their work profiles to strengthen healthcare in the SUS is a challenge¹⁸.

FINAL CONSIDERATIONS

The results of this research show that the NEPE is a device that drives the permanent education of nurses in the teaching hospitals. Of the powerful strategies that the nurse facilitators have been developing in the teaching hospital, the most significant are flexibility for meetings, autonomy (dedicated moments educational activities immersed in the work process), meetings planned by the NEPE, nursing consultations, and professional progression. However, the limitations for the implementation of these actions detected in this study include increased demand, resistance of the workers, and lack of commitment of the nurses regarding education.

It is believed that PEH may be present in different healthcare scenarios, embedded in the work of nurses and other professionals who are part of a healthcare team. It is necessary to implement PEH in teaching hospitals to qualify healthcare in accordance with the principles of the SUS, and to consider significant changes in the practices of professionals in scenarios that are still based on the technicist model. Consequently, the implementation of NEPE in hospitals is a device that promoted PEH through the nurse facilitators and the participation of all the professionals of the health institution in education.

Although this study was limited by the complexity of permanent healthcare education, it has restrictions in relation to the generalisation of the results, study participants, and the local context of the research scenario. We hope that the findings of this study will contribute with the scientific knowledge in PEH and help qualify nursing care to develop PEH in hospital care. Moreover, this study can benefit nursing education at graduate and postgraduate level to enable the effective implementation of PEH. We also stress the importance of management to stimulate the creation and use of PEH cores and enhance the actions that support nurses in their routine work.

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Publication Dates

• Publication in this collection
  2017

History

• Received
  11 Mar 2016
• Accepted
  01 Feb 2017