Managing educational practices for qualifi ed nursing care in cardiology

Objective: to understand signifi cances attributed by nurses who manage nursing care to the individual affected by cardiovascular disease to relations, interactions and associations of the educational practices in a cardiovascular reference hospital. To elaborate a theoretical explanatory model based on signifi cances attributed in the light of the complex thinking. Method: qualitative study, which used Theory Based on Data (TBD) as methodological reference. Twenty-two professionals of nursing participated in the study. Results: the results indicate need of professional qualifi cation to ensure the safety of patients, institutional support for the realization of educational practices, attitude of openness and availability of dialogue of the health professionals and other institutional conformations for the workers’ development. Conclusion: the study presents a new space for the nurse’s action that can be used to qualify and optimize the nursing practice, as it provides visibility to management and care in health institutions. Descriptors: Nursing; Nursing Management; Permanent Education; Hospital Service of Education; Cardiology. RESUMO Objetivo: compreender os signifi cados atribuídos por enfermeiros gestores do cuidado de enfermagem ao indivíduo acometido por doença cardiovascular às relações, interações e associações das práticas educativas em um hospital referência cardiovascular. Elaborar um modelo teórico explicativo com base nos signifi cados atribuídos à luz do pensamento complexo. Método: estudo qualitativo, o qual utilizou a Teoria Fundamentada nos Dados (TFD) como referencial metodológico. Participaram do estudo 22 profi ssionais de enfermagem. Resultados: os resultados apontam a necessidade de qualifi cação profi ssional para garantia da segurança do paciente, apoio institucional para a efetivação das práticas educativas, atitude de abertura e disponibilidade dialógica dos profi ssionais de saúde e de outras conformações institucionais para o desenvolvimento dos trabalhadores. Conclusão: o estudo apresenta um novo espaço de atuação para o enfermeiro que pode ser utilizado de forma a qualifi car e potencializar a práxis em enfermagem, por conferir visibilidade à gestão do cuidado de enfermagem nas instituições de saúde. Descritores: Enfermagem; Gestão em Saúde; Educação Permanente; Serviço Hospitalar de Educação; Cardiologia. RESUMEN Objetivo: comprender los signifi cados atribuidos por enfermeros gestores de atención de enfermería al paciente de enfermedad cardiovascular respecto de relaciones, interacciones y asociaciones de prácticas educativas en hospital cardiovascular de referencia. Elaborar modelo teórico explicativo basado en los signifi cados atribuidos a la luz del pensamiento complejo. Método: estudio cualitativo, utilizando la Teoría Fundamentada en los Datos (TFD) como referencial metodológico. Participaron 22 profesionales de enfermería. Resultados: los resultados expresan la necesidad de califi cación profesional para garantizar la seguridad del paciente, apoyo institucional para hacer efectivas las prácticas educativas, actitud de apertura y disponibilidad dialógica de los profesionales de salud y de otros sectores institucionales para el desarrollo de los trabajadores. Conclusión: el estudio presenta un nuevo espacio de actuación para el enfermero, que puede utilizarse apuntando a califi car y potenciar la praxis en enfermería, por otorgarle visibilidad a la gestión de la atención de enfermería en las instituciones de salud. Descriptores: Enfermería; Gestión en Salud; Educación To be continued; Servicio de Educación en Hospital; Cardiología. Managing educational practices for qualifi ed nursing care in cardiology Gerenciando práticas educativas para o cuidado de enfermagem qualifi cado em cardiologia Gestionando prácticas educativas para la atención de enfermería califi cada en cardiología Cintia Koerich E-mail: cintia.koerich@gmail.com CORRESPONDING AUTHOR


INTRODUCTION
The technological advance, especially in the high complexity, requires health professionals to follow the knowledge evolution in their practice area.Brazilian research has advanced in cardiology, and nursing has contributed effectively for this advance.The nurse's understanding of how the problematic of cardiovascular diseases integrates the daily life of care comprises the application of methodologies for prevention of these diseases, as well as care of the individual affected by cardiovascular disease (CVD), to benefit care management of nursing (1) .
Such management includes capacitation, revitalization, or recognition of the abilities and development of the nursing workers' potentials as practice that emerges of the work to profit better actions of care in the institutional setting.Therefore, the nurse has collaborated for implementation and maintenance of health policies, with potential to take a differentiated posture in management of health systems (2) .
The need for new models for management raises discussions on a more participative management that includes health workers in the discussions, decisions and improvement of the work.Therefore, when the nurse favors practices of permanent education to the staff, it allows the opening of new spaces to the workers in the institution and, therefore, contributes to a qualified care (3) .
The concept assumed by the National Policy on Permanent Education (PNEPS) in that permanent education is the learning in work, in which learning and teaching are incorporated in the daily life of the organizations and in the work.Permanent education anchors itself in the significant learning and in the possibility of transforming professional practices.It is performed in the daily life of work, based on problems encountered in this environment, and it considers previous experiences and knowledges of the professionals.It proposes that the health professionals' learning occurs based on the problematizing of the work process and that the training considers the health needs of the people and populations, aiming at the transformation of the professional practices and those of the very organization of the work (4) .
Therefore, it is possible to think on permanent education in health as a tool for management of the nursing care to the individual affected by CVD, and it is possible to improve the quality of care by permanent education, which means that through implementation of actions that seek to understand the complexity that involves the interrelations of humans, the work space and the very health-disease process.Through the analysis of the permanent education experiences, it is possible to notice/ understand the possibilities and difficulties that exist in the work process, as well as strategies, abilities and attitudes needs (5) .
Thus, human comprehension is understood as essential to education.It is necessary to equally understand the objective and subjective conditions of the human nature, which means that the comprehension requires conscience of the human complexity.It is possible to say that to understand a certain phenomenon, it is necessary to emerge and submerge in the context of each human being's singularity and in the complex relations, interactions and interrelations that one establishes with oneself, with the environment and with the others (6) .Bases on the considerations above, there is a question: how do the nurses that manage the nursing care to the individual affected by CVD experience/signify the relations, interactions and associations of the educational practices in a cardiovascular reference hospital?

OBJECTVE
To understand the significances attributed by nurses that manage the nursing care on the individual affected by CVD regarding relations, interactions and associations of the educational practices in a cardiovascular reference hospital.This study aims to elaborate a theoretical explanatory model based on significances attributed in light of complex thinking.

METHOD
This is a qualitative study that used Theory Based on Data (TBD) (7) as data collection and analysis method.The study setting was a public hospital institution, cardiovascular reference in the South of Brazil.The participants were chosen intentionally, considering the objective of the study, and were invited to participate at their work space.
The process of data collection to build the TBD began by a wide central question: how do you signify the educational practices as a nurse who manages nursing care and acts in a cardiovascular reference institution?Hereinafter, other derived questions were made to the participants for the exploration of the significances through in depth interview.The interviews, recorded with digital voice recorder, occurred from June to October 2014.Twenty-two nursing professionals were interviewed, constituting three sample groups.The method adopted in this study allows to search for places, people or facts to discover the investigated phenomena, not expected in the beginning of the study (7) .
Ten manager nurses of the admission units composed the group, represented by the letters "EE", followed by the respective numbers to the interview sequence "EE1", "EE2", and so on.After analysis and formation of hypothesis of the first group, a second sample group was formed, composed by seven nursing professionals involved with care practice, which were four nurses and three nursing technicians, represented by the letters "EA" followed by the number respective to the interview sequence "EA1", "EA2", and so on.After data analysis and formation of hypothesis of the second group, the need of a third sample group emerged, composed by five nurses who were commissions, centers and sectors managers of the institution, related in this study by the participants with educational practices, represented by the letters "EG" followed by the number respective to the interview sequence "EG1", "EG2", and so on.
Data were organized in the NVivo 10 software.Thus, a theoretical explanatory model was elaborated based on the significances shows in the categories and in the central category and its respective interrelations, so the phenomenon of the study emerged from the data.For structuration of the results a pragmatic model was used, composed by the components: casual conditions, context conditions, interventional conditions, strategical interactions and consequences.The phenomenon explains what is happening.The casual conditions are those that unleash or influence their development.Context conditions are the place and moment when the phenomenon happens.Interventional conditions interfere or modify the impact of the casual conditions in the phenomenon.The strategical interactions are actions planned to handle the phenomenon.The consequences refer to the current or potential results of the actions (7) .
The study was approved by the Ethics Committee in Research with Human Beings, respecting the ethical aspects of Resolution 466/2012.

RESULTS
The phenomenon "Envisioning the management of permanent educational practices in the emergence of qualified nursing care in cardiology" is composed by five categories and 11 subcategories, presented in the figure and hereinafter discussed.
Identifying needs of professional knowledge and improvement in cardiology to promote safety of the patient The category represents the casual condition for the phenomenon under study.The first subcategory "Observing that the patient's safety depends on professional preparation" reveals the need of professional training and improvement as principle for ensuring the patient's safety.The professionals report that the knowledge promotes safety for both professional and patient, considering the amount of new professionals in the institution and the lack of professional updating of those in activity.
[…] I cannot understand a safe and scientific health unit without the knowledge in the area, which is used in everything we do.If we do not understand the reason of our practices, we are going to make mistakes.(EG4) In the second category entitled "Recognizing that the knowledge in cardiology is constantly changing", the professionals value the updating of the knowledge in cardiology, regarding the speed of scientific and technological advances in the area.The nurses describe professional updating in this area as essential, considering its generalist education, and they recognize that the nurse with updated knowledge has a better background to discuss with the staff, manage the practices of permanent education and therefore benefit the patient.
[…] cardiology is an area that is constantly improving.[...] So, as it is specific, we need to always update ourselves in order to provide right orientations to the patients and to the staff.(EA5) The third subcategory "Noticing impairments in the education of the health professional" brings the discussion about the formation of health professionals, especially nurses.It highlights the low quality of technical higher education, with professors with low capacity and students who do not have interest.It enhances the need of greater interaction between theory and practice still during education, so that the students can establish relevant relations in the educational process and then, in professional performance, considering that they enter the labor market clearly insecure regarding their performance.
[…] I realize that today, more than when I graduated, the nurse enters the labor market very unprepared, very insecure.I think that there are good professionals who were not sufficiently stimulated and did not receive sufficient demands to feel like this, look at himself like this Thus, according to the participants, when the professional updates himself, he tends to view and accept better change proposals in practice.

Revealing specificities of the setting and the incipient support of the reference institution regarding practices of education in the work
The category reflects context conditions in which the phenomenon occurs.The first subcategory "Highlighting specificities of each care setting in the institution" shows that even though it is an institution that works with a certain specialty, each unit has its specificities regarding the knowledge needed  for action, establishing interdependence relation with the institution.The professionals report that it is important to know the work environment completely, to better understand the needs of each sector.
[…] sometimes we do not know the institution where we work […] I think that this is something that we could work on: Guys, in the surgical center we do this.Because we know that they perform surgeries, but how do they do it?How many surgeries per day?How many people work there?How do they work with these people?We do not have this, so it needs to be shown.(EA2) In the second subcategory "Noticing the incipient support of the reference institution for the permanent education", the professionals reveal that the institution has a "training sector" responsible for organization of courses/speeches/trainings and internship coordination.The support of the institution for the training sector is considered small, and its action is impaired.Thus, even though they know about the existence of this sector in the institution, most of the professionals do not know how it works and face difficulties in their performance, which complicates the interaction of this sector with the rest of the institution, which results in failure of communication and support to the initiatives of changes.

So, what happens and has been historically happening inside the institution? The person in training is someone to who the institution delegates a lot of things and he ends up often overloaded […] (EG3)
In this context, it is important to highlight the little interaction between hospital institution and educational institutions, considering the rare involvement of the professionals with the internship students and the low result of this relation regarding results of studies conducted in the institution.

Noticing potentialities and fragilities for management of the practices of permanent education in the institution
The category presents the intervening conditions to the phenomenon.In the first subcategory "Noticing management attitudes that interfere in the practices of permanent education", the professionals report the need of better organization of the managers to ensure the participation of the professionals in the educational practices offered in the institution.They point out the little involvement between managers of "key" sectors -pharmacy, Commission of Hospital Infection Control (CCIH), Center of Safety of the Patient (NSP), training sectorand their involvement with care units, to favor practices of permanent education.They also report the need of nurse's supervision, as manager of the nursing care, to identify the needs of professional improvement and orientation to the staff.
The nurse has the ethical and legal responsibility to it, it is in the law of professional acting and in the ethics code of the nursing professionals.The nurse is responsible for evaluating the technical conditions of each worker in his/ her staff, because he/she has a staff, he/she is part of this staff and he/she is the responsible.(EG3) The second subcategory "Highlighting professional attitudes that favor/impair the management of practices of permanent education" presents, as factors that favor the management of practices of permanent education, the insertion of the used in the care process, through orientation groups, and the understanding of the complete care by the professionals, since even though cardiology is a specialty, the patient needs to be analyzed in totality, which means that the care must contemplate every dimensions of this complex human being in its process of health-disease.In contrast, the participants revealed that the lack of compromise, questions inheres to public service, to hegemonic model, the interpersonal conflicts and difficulties of interaction with the staff are factors that impair the management of practices of permanent education and the improvement of care quality.
[...] I think that someone who choses nursing has to know about the compromise of caring.It is not simply doing your job mechanically, but really practicing care.(EE2) Regarding this setting, the interaction of the staff depends on the attitude of the professionals involved, depending on the communication, openness and availability for a dialogical relation.

Searching management strategies for practices of permanent education regarding the adhesion incipient to the traditional practices
The category represents strategical interactions that search an answer to this phenomenon.In the first subcategory "Managing information and knowledge in the daily life work", the nurses reveal that, regarding the setting experienced in the institution, where there is low qualification and incipient adhesion of the professionals to the educational practices offered, they are used to use informal moments of staff meeting and groups already institutionalized, or still in consolidation, as space of exchanges of information and reflections on the acting.Initiatives of nurses were considered new strategies for education in the work, because the involve methods such as simulation and in loco training.
[…] this was the first time that there was [training in loco for new employees] and it was amazing, because they were not so afraid.They [the nurses] the transport monitor, the simulator that shows all the electrocardiogram waves, you know, that laboratory thing.(EE1) In the second subcategory "Highlighting the center of safety of the patient as a management initiative of practice of permanent education", the professionals demonstrate positive expectation regarding initiatives of NSP with space for practices of permanent education in the institution, regarding changes in the practice facing the incipient action in the training sector.The NSP seeks to implement safety protocols of the patient proposed by the Ministry of Health, aiming change of institutional culture.

[…] they already instituted the notification report of any adverse event that happened with the patient, they already notified us, explained how it is used, we have been filling it up, and we already had a result about it […] (EA5)
The education strategy in the work used by NPS results from the observation of the non-adhesion of professionals to traditional practices offered by the institution, which are characterized by the individual instrumentalities and updating.

Exhibiting other configurations for management of the educational practices in work, to reach a care of excellence
The category presents the consequences to the actions for the phenomenon.In the first subcategory "Searching for professional qualification to reach an excellence care" the professionals report that the improvement in the quality of the offered care is an emergency in the institution.They reveal that the significance of relations, interaction and associations of the practices of permanent education is related to the prepare of the staff, security of the patient and professional, to the valorization of the nurse's work and qualified/excellence nursing care to the individual affected by CVD.

This is an emergency to the need of this professionalism, of improving our care, out attention, the basic is what is missing. To show the very routine, without it we will not be able to have a good service. (EG5)
The second subcategory: "Emerging needs of new institutional conformations to favor the management of the practices of permanent education" presents the considerations of the professionals as indicatives for changes needed to the practices of the education in the institution.They consider examples of actions needed to facilitate the management of the practices of permanent education in the institution: greater promotion and encouragement for participation in the educational practices offered in the institution; discussion with care professionals to identify the needs of improvement and search for interesting current subjects to make the learning significant to the professional.They still point out that the practices need to occur in the time and setting of the work, therefore facilitating the relation between theory and practice, as well as the compatible participation of the professional with the logic of the permanent education in health.
[…] permanent education, it will work each time it arises from the necessity, for me permanent education is also this, but I think it will be more successful when it comes from the very need of the people […] (EE8) Professionals highlight that the institution needs to invest in infrastructure, materials and human resourced for permanent education and have an acting sector and effectively focused on practices of significant learning.

DISCUSSION
The results demonstrate the need of updated knowledge in cardiology, regarding the evolution of knowledge to ensure patient's safety.It is possible to affirm that knowledge is present in permanent self-production of the society that develops itself by interactions between individuals, always comprising a cognitive dimension, it is a reconstruction of a previous knowledge (8) .According to the World Health Organization, updating the professional knowledge is related to care quality, and the patient's safety is an important dimension of the care quality, since people have the right to have reduced risks to health damage to an acceptable minimum (9) .
The traditional forms of education, such as bank education, characterized by the act of deposing knowledges, are still present in our days and reveal overcoming conflicts between those involved in the process, since at the same time they develop traditional processes of teaching-learning, they recognize that it is essential to transcend the historical role of the traditional culture trend (10) .According to Morin, the individuals can accommodate emerging knowledges to an old mental structure that they are used to (11) .
Facing the generalist education, the nurse focuses on the domain of the specialization, which is present in the hospital setting it is inserted, in this case a specialized institution, in which the biomedical model is still dominant.However, the nurse seeks to ensure to the patient an integral care that goes beyond cardiovascular pathology.The integral care refers to the recognition of the patient as a human being, who has a life story, feeling and needs.For that it is necessary that the professional of nursing thinks about himself/herself in the situation of this human being, understanding his/her specificities and acting as a mediator in the communication process (12) .
Thus, a great challenge in the education of the nurse relies in the dichotomy between necessity to educate generalist professional and, on the other hand, have competence and visibility to act in specializations that emerge in the setting of health care.In this study about education of nurses, newly professionals demonstrated conditions between theoretical and practical education and professional practice, which shows the need to strengthen pedagogical strategies that promote this approach (13) .
The interaction of the hospital institution with educational institutions is also weak, which affects both development of the practices of permanent education and educational process.Thus, integration between teaching, research and service can also be considered an strategy to improve models of education, permanent education and management of knowledge in health, which needs investments (14) .
Professionals report that it is important to completely know the institution, considering the specificities of each sector and the permanent education, which needs to be institutional.The admission units and the professionals that work there are not only a part of the institution, but the institution, its culture and its incorporated knowledges are present in each one of this care units, as well as in the human beings that work there.Morin states that the part is not only found in the whole, the very whole is, in a certain way, present in the part that is found in it (8) .
The lack of planning of the manager nurses to ensure the participation of the professionals in the educational practices offered by the institution and the need of greater supervision of the staff emerge as management challenges.In study performed with assistant and management nurses, the action of supervision is understood as part of the work process of the nurse and mentioned as way to detect needs that demand educational actions for workers of medium level (15) .Even though in the study only one nurse referred to supervision as a form of interaction and orientation of the staff (15) , in the present investigation most of the nurses use the daily work to discuss professional practice regarding identification of problems.
Nursing supervision is, therefore, considered an important management tool when it is performed with pedagogical and cooperative character, because it allows the monitoring, the evaluation and education of the nursing staff, and it has direct result in a care of excellence (16) .The action of educating the nursing staff is a management practice of the nurse that assumes peculiar characteristics according to the specificities of the acting setting; thus, when nurses educate the staff, they takes a position of facilitator in the acquisition and sharing of knowledge, in the updating of the professional, promoting the capability of selforganization, which contributes to a qualified nursing care (17) .
The involvement of the user, the integral care, the professional initiatives, the interactions between professional sectors were aspects reported as essential to effectuation of practices of permanent education.Thus, interaction of the nursing professionals, through listening and dialoguing, contributes to the logic of permanent education in health, since the focus of educative process of workers relies on the health needs of the users and the intention is the transformation of practices of health and nursing in the perspective of the integrality (18) .
On the other hand, the lack of compromising, interpersonal conflicts and questions inherent to public service and to the hegemonic model are factors that difficult the adhesion to the practices of permanent education.Thus, it is possible to affirm that the health services are adaptive complex systems, because of the self-organization capability of different phenomena that interact with each other and with the setting.In this complex space of relations and interrelations, only the significant learning is capable of motivating the adherence of the workers to the transformation processes of the daily life of work and of the institution (19) .
The participants report that the interaction of the staff depends on the attitude of the professionals involved, openness and availability for a dialogical relation.In this context, permanent education corroborates the discourse of Paulo Freire when he proposes the dialogue as essence of education and practice of freedom that consists in a human phenomenon, which should not be reduced to simple deposit of ideas of a subject to the other, because it represents the encounter of men, to problematize situations and modify reality (20) .The dialogic articulates ideas that seem antagonistic and at the same time complementary, which allows the link of different knowledges (11) .
Regarding the incipient adhesion of the professionals to education practices offered by the institution, the nurses seek strategies for managing permanent education using informal or formal spaces for discussion and orientation in the very work setting, attempting to problematize questions inherent to work process.A study (21) corroborates the results presented here highlighting that there is no institutional planning regarding permanent education, which makes nurses to reach for other moments during work time to participate in the educational process, as formal meetings for discussion of clinical cases and organization of work.Thus, NPS is pointed out by the participants of the study as a space for practices of permanent education.It is an instance of the health service created to promote and support implementation of actions focused on the patient's safety, according to the Resolution 36/2013, that aims to institute actions for patient's safety promotion and improvement of the quality in health services (22) .The need to search for resources to promote practices of permanent education is cited in study (23) that indicates that such process must be based on the conception of dialogical and transformative education, aiming to improve professional performance and nursing care quality, considering that transformations in institutionalized practices are related to changes in educational actions.
Permanent education can approach, in its process, various specific actions of capacitation ot training, however the opposite may never occur.Thus, trainings and qualifications are characterized as practices of permanent education when used as sustainable strategies, which may have a beginning and an end and be focused to specific groups of workers, since they are articulated to a general strategy of institutional changes(4).Thus, education of professionals has close relation with the quality of care offered, and the simulation can favor the complex and continuous process of teaching-learning, because it stimulates learning, since the situation becomes visible/real (24) .
Professionals aim, by educational strategies, professional qualification for an excellence care, which is understood as compelling in the institution.The qualified care or the excellence of the care in the health sector has a direct relation to the patient's safety and represents a challenge in professional practice.Besides other attributions, the nurse is responsible for articulating, integrating and coordinating the staff searching for a work organization that favors care quality and minimizes risks to the patient (25) .Thus, management of the nursing care lacks new approaches related to the advance of new professional acting spaces, to transcend assistance practices, punctual and unidimensional care, and implement horizontal models of decision taking and new approaches of health intervention (26) .
Finally, participants reported the need of new educational models compatible for both needs of the professionals and logic of permanent education in health.Study about necessity and expected results regarding permanent education notifies new formats, contents and senses of the practices of education in work focused to the conception of the permanent education, result that corroborates the founds of this study (15) .Besides, the lack of structure of the services of permanent education in hospital institutions reaffirms the need of a staff responsible for this activity to organize and the quality of assistance to the users (21) .
In the work process in a high-complexity hospital institution, the nurse daily faces needs of updating/improving revealed or noticed in the staff, which require attitude to promote and ensure a staff prepared to offer safe care to the patient.Thus, the management of the practices of education in the work for the nursing staff in the institution is taken by nurses, considering that the care management includes, among other attributions, supervising, orienting and educating.However, despite the initiatives of the professionals being very important for educational practices in work, the institutional support becomes essential.
Even though manager nurses understand the need of new educational models in work that are close to the logic of the permanent education and the initiative of some professionals for effectuating these practices, most of the nurses demonstrate difficulty in taking the management of the practices of permanent education because of fragilities of management competence.Such situation shows the need of greater focus on management formation of the nurse, to overcome the technical dimension and acquire competence to play the role of manager of the care and the education of the nursing staff, thus contributing to the necessary changes in the health services.
The study has as limitation the fact that it was developed in a specific and specialized setting, however its founds were considered, in the validation of the presented model, applicable in realities with analog characteristics.

FINAL CONSIDERATIONS
The understanding of significances attributed by nurses that manage the nursing care to the cardiac patient to the relations, interrelations and associations of the educational practices experienced in a cardiovascular reference hospital in the South of Brazil allowed to reveal the phenomenon Envisioning the management of the practices of permanent education in the emergence of qualified nursing care in cardiology.Such phenomenon emerged in a complex setting of multiple relations and interrelations among human beings that experienced the order, disorder and the institutional organization/self-organization.
Thus, the significance of relations, interactions and associations of the educational practices was related to the preparation of the staff, to the security of the patient and professional, to the valorization of the nurse's work, to the institutional support, to the availability of professionals to dialogue and to the qualified/excellence care to the cardiac patient.In this context, the interaction between professionals allows the problematizing of the very practice and awakening of change initiatives compatible to the logic of permanent education in health.However, despite the permanent education preconizing multidisciplinarity and interdisciplinarity, the disciplinary fragmentation still prevails in health organizations, which indicates the necessity of reflection on this question.
Regarding the results of this study it is evident that the emergence of new practice models of education in the work involve professionals in a dialogical cooperative relation and, respecting traditional focuses, considering however that educational practices, as courses, speeches, punctual and isolated are not the needs of the professionals of health, of the users and of the very institution.
The study presents a new space of action for the nurse that can be used to qualify and optimize the practice in nursing, because it gives more visibility to que management and to the nursing care in the health institutions.

Figure 1 -
Figure 1 -Representative diagram of the theoretical model