Permanent Education in a neonatal unit from Culture Circles Educación permanente en unidad neonatal a partir de círculos de cultura

Objective: to identify the factors that hinder and facilitate the work of the nursing team in a neonatal unit and to know the demands of Permanent Education described by the nursing team, emerging from the daily care. Method: qualitative study that followed the steps recommended by the “Paulo Freire’s Method” carried out with 29 professionals of the nursing team of a neonatal unit of a university hospital. Three Culture Circles were carried out to identify the generating themes. Results: The themes generated were organized according to the issues covered in the interviews and during the Culture Circles, with four themes being highlighted: lack of routines; training; improvement of coexistence of the team and improvement of management process. Final considerations: The study made it possible to know the factors that hinder and facilitate the routine practice of nursing professionals by identifying the emergent themes of the Culture Circles that favored the critical refl ection of the group, generating subsidies for the collective elaboration of the Permanent Education program in neonatal unit. Descriptors: Education, Continuing; Educational Technology; Neonatal Nursing; Nursing; Neonatology. RESUMEN Objetivo: identifi car los factores que difi cultan y facilitan el trabajo del equipo de enfermería en unidad neonatal y conocer las demandas de educación permanente descritas por el equipo de enfermería, emergentes del cotidiano de la asistencia. Método: estudio cualitativo que siguió los pasos preconizados por el “Método Paulo Freire” realizado con 29 profesionales del equipo de enfermería de una unidad neonatal de un hospital universitario. Fueron realizados tres círculos de cultura para la identifi cación de los temas generadores. Resultados: Los temas generados fueron organizados según las cuestiones abordadas en las entrevistas y durante los círculos de cultura, siendo destacados cuatro temas: falta de rutinas; formación; mejorar la convivencia del equipo y mejorar el proceso de gestión. Consideraciones fi nales: El estudio posibilitó conocer los factores que difi cultan y facilitan el cotidiano de la práctica de los profesionales de enfermería mediante la identifi cación de los temas


INTRODUCTION
Nursing care for the child and for the newborn is something complex that involves, in addition to the adequate execution of nursing techniques, nurses' competences ranging from knowledge about the most frequent pathologies in each period of development to social and emotional needs of children and their family.With this, the nursing team's action requires a continuous updating process that demands a set of pedagogical strategies, considering the demands and emerging needs of the daily process of work in the neonatal unit.
When developed jointly, the pedagogical strategies value the subjectivity and historicity of the human being within that reality, stimulating dialogue and critical reflection, the development of self-esteem, the rescue of life projects, professional growth, motivation for new learning and personal conquests through creative praxis, realizing that each moment has the opportunity to create and recreate new knowledge of oneself and others (1) .
However, for the educational demands materialize, it is necessary that health professionals put to you, the patient and the family as desiring subjects, capable of causing uncertainties and concerns in a dialogical and reflexive movement of reality, seeking to trigger a set of knowledge to intervene in the situations experienced (2) .
This action-reflection-action movement makes each professional subject, dynamic in the issues experienced in the daily work process, and, in a dialogical way, demands arise that express collective thinking, from the perspective of each one.In this sense, Permanent Education can serve as a path for the emancipation and autonomy of the professional, as it promotes a meeting between work and training, that is, it is at work and for the work that the Permanent Education takes place, application and the relevance of established content and technology (3) .
The search for dialogue between peers and constant reflection on daily life makes each professional subject dynamic and reflective.Thus, thinking about the problems or daily difficulties in the work process and making them collective can favor the debate in the team and provoke a rupture in the closed care model, producing new looks and new (re) directions in relation to the work process.
The exercise of a critical educational practice is a form of intervention in the world, committed to the principle of democracy that rejects any form of discrimination, domination and integrates an attitude of innovation and renewal, in the belief that it is possible to change.The choice to develop a Culture Circle aims to provide a participatory experience with emphasis on dialogue, which enables reflection-action in the collective elaboration of a systematized proposal for an emancipatory health education (1) .
Since, in all areas of knowledge, the search for an ongoing educational process has been a constant, the activities of Permanent Education, if effectively developed and directed towards the collective construction of knowledge, are one of the ways to promote and improve the technical-scientific, cultural, political, ethical and humanistic skills of health professionals.
Permanent Education in Health (PEH), while one of the reorganization strategies of the Brazilian Unified Health System (SUS), once incorporated into the culture of the institution, presupposes the development of educational practices focused on solving concrete problems.It refers to the relationship between health professionals and those with other areas, keeping the focus of actions on the user and also considering the need to apply specific professional knowledge important for responsible care (4)(5) .
In this sense, PEH, as work education, needs to be understood as a qualifying guideline for team management, services and health professional development, whose main motivation must be the several problems identified in health service practices, which could only happen from an awareness of this professional as a subject capable of thinking and acting at work (6) .
But for this, it is understood that the management of the process of Permanent Education should be guided by dialogue and argumentation, in the sense of awakening in the professional the critical awareness about the daily life of his work and the world in which he lives that cannot be alienated and inhumane (7) .
With regard to nursing care in neonatal units, the work process is complex, requires physical structure in accordance with technical standards, quality materials, trained and up-todate staff, and the ability to deal with families from different cultures, and even with all these elements, there is still no guarantee of a work process capable of generating quality in the care provided (4) .

OBJECTIVE
To identify the factors that hinder and facilitate the work of the nursing team in a neonatal unit and to know the demands of Permanent Education described by the nursing team emerging from the routine of care.

METHOD Ethical aspects
The project was submitted to the institution's Ethics and Research Committee and approved.All participants were clarified regarding the study objectives and signing the Free and Clarified Consent Term, as recommended by Resolution 466/12 of the National Health Council/MH (Ministry of Health).
Permanent Education in a neonatal unit from Culture Circles Silva LHF, Santo FHE, Chibante CLP, Paiva ED.

Type of study
This is a qualitative study that followed the steps recommended by the Paulo Freire's Method (8) , which is active and marked by dialogicity, following systematized steps, which are: a) Thematic Research -with investigation of the main themes, issues that will constitute the generating themes to be problematized; b) Coding and Decoding -generating themes are coded and decoded, seeking their social meaning, the awareness of the lived; EOC) Critical Unveiling -in which there is the confrontation of reality, where men or exteriorize their world view, exposing limit situations in the dynamics of their reality, or are silent, generating a thematic silence that can express the oppression of the limit situation to which already adapted.At this stage the thematic reduction occurs, where the themes are split, searching for the fundamental nuclei, that is, learning units with sequences established among themselves, turning to it in its totality to better know it (9) .

Methodological procedures
The study was developed from June to October 2013 with 29 professionals from the nursing team whose inclusion criteria were: nursing professionals, nurses, technicians and nursing assistants, both genders, working in the neonatology unit, with employment relationship; and exclusion: vacation professionals, removed and/or displaced from the sector in the period of data collection.

Study scenario
This study was developed at the neonatal unit of a university hospital in the State of Rio de Janeiro.

Collection and data organization
Data production occurred initially through observations recorded in field diaries and, subsequently, individual semistructured interviews prior to the Culture Circles.All interviews were recorded on digital media, identified by the word "participant" followed by the sequence number and transcribed in its entirety by the researcher.
From the analysis of the interviews, all the themes and actions generated that emerged from the interviews were recorded, followed by the elaboration of a first structured list according to the questions presented in the interviews for later appreciation in the Culture Circles, whose meetings with the participants happened in the Nursing rest room of the unit, usually in the afternoon, with an average duration of 40 minutes, as suggested and previously scheduled by the participants, due to the smaller movement in the unit, which favored their participation.
Three Culture Circles were held in which all professionals had the opportunity to participate with an average of 15 people per circle, according to a previous schedule, in order to identify the thematic network, that is, the content needed to understand and analyze the local reality; thematic reduction in which the contents that each one would work within the program were raised; and programming of the activities that would be part of the program of Permanent Education elaborated.

Data analysis
The research itinerary followed three stages: thematic research (extracted from the experience of the professionals.)Phase of the discovery of the vocabulary universe, words or themes extracted from the daily practice of participants in Culture Circles; (the phase of expansion on knowledge and awareness, in which we tried to contextualize and give meanings to the generating themes); and Critical Unveiling (preliminary analysis of the contents extracted from the coding to see the processes, seeking to know the reality of things in depth).

RESULTS
Elements that hinder and facilitate the routine practice of nursing teams in the neonatal unit The identification of the generating themes occurred from the analysis of the interviews and the records of the observations in the field diary.The themes generated were organized according to the questions raised during the interviews.From the analysis of the question "what facilitates or hinders the daily work in the unit" the researcher applied the phases of the research itinerary.

Priority Generator Theme: lack of routines
The theme was generated in the interviews and maintained in all Culture Circles, being coded as: lack of guidelines that normalize the nursing activities.
The nursing team at that time was trying to adapt to the changes resulting from works to expand the unit in the institution and some participants highlighted the importance of the routines for synchrony and focus of teamwork: The specificity of the unit demands a number of exhaustive technical procedures that always place the know-how of the professional in question and allied to the fact of the speed with which the technologies are developed.The routine appears as a guiding and facilitating element and by many considered as a link between the teams.
Critical Unveiling for the theme: indication of the elaboration of a nursing manual for Neonatal Intensive Care Unit.Facilitator is the knowledge that I am getting here, because here it is really being a school, I'm really learning a lot daily.(Participant 20)

I got here and didn't know anything and the nurses were good welcoming me; they explained to me many things, I've learned a lot of things and it made me want to do a neonatal post-doctorate. (Participant 7)
The university has several programs for qualification and qualification of the server, but few are those that privilege the practice, mainly of the service of average level, since examples like the professional master's and specializations are accessible to the servants with superior formation of the institution, without burden.
However, according to what the participants described in the Culture Circles, training can happen at any time:

Then, I was in training for a month during the day and then she oriented me how to buy the book, to handle with the incubator, not only her but the whole team. Then I started to buy books, to read articles because I was interested, but I did a training that was very good. (Participant 5)
Critical Unveiling of the generating theme: elaboration of a training program that privileges the practice associated with scientific knowledge.

Priority Generator Theme: improving team coexistence
The issue of coexistence as a generating theme emerged in the interviews and was ratified in all Culture circles, being associated to the themes: lack of integration among nursing teams, appreciation of nursing professional knowledge, lack of meetings, bad mood, who does and take pleasure in working, humanizing.It was coded by the team as a need for good relationship and integration during the activities.This was identified in the participants' statements:

As facilitator we can find team integration, once you have an integrated team with everyone involved being a facilitator. (Participant 25)
The multi professional team also facing the same area is a great facilitator because everyone who works with me supports me and I support them because this is all an exchange.Everyone has a single focus.This is a great facilitator.(Participant 18) Therefore, the priority generator theme, improving team coexistence, is necessary to draw up a program of Permanent Education.
Critical Unveiling of the generator theme promotes actions that favor dialogue and integration of team members at times inside and outside the work environment.
Generator Theme: improving management process The theme was identified in the interviews and remained during the discussions in the Culture Circle.The lack of staff to work included the lack of staff, the lack of communication with other sectors and services of the hospital, the devaluation of the nursing service, the excess of people in the sector, the lack of meetings with the group by part of the management and information about what happens outside the sector.
It was coded as difficulty of management of the nursing service, in sectoral level, of the management and direction by lack of routines and goals to be followed and reached to improve the service, as described in the speeches: Regarding the number of staff, the university hospital has a deficit in all sectors.As it is a public agency of the Federal Government, it follows the rules for the replacement of professionals and currently has a staff of about one hundred professionals in temporary contracts of a maximum of two years, which causes constant changes in the teams, generating adaptive stress.
Understanding that the management process should be embedded in the program of Permanent Education, the topic generator to improve the management process was considered a priority.
Critical Unveiling of the generating theme: indications of creating a schedule of meetings with the teams of the sector involving levels of management of the nursing board.To keep staff updated on institutional policies.

DISCUSSION
The Permanent Education Committee of the institution has been working with the Standard Operating Procedure (SOP) with the logic that it presents technical and normative guidelines elaborated, taking into account the reality of the place, which can be considered as an information technology and, therefore, constitutes a strategic character for the global dissemination of knowledge (10) .
It can be said that, in the face of the pillars of education for the 21 st century, the routines, if emerging from the daily practice, constitute a learning to know, since there is participation of professionals in the construction of knowledge so that, learning to do (11) , is the basis of another pillar.Thus, the lack of routines emerges as a generative theme, requiring the collective construction of routines in the Permanent Education program.Practical activities, when privileged in educational actions, favor shared and systematic reflection (12) .Learning to do, although dissociable from knowing, should not be an action restrictive to the world of work, but must also build the modes of its tools of making (9) .
In this sense, it is important to establish an articulation between the nursing managers and the Permanent Education sector in the institution to plan educational actions and the methodologies used in each of them, in order to boost results and encourage employees who benefit from these actions, for the increasing improvement of the assistance quality (13) .
Training, when associated with knowing, is the generating theme for the Permanent Education program and attends the pillar of education for the 21 st century, learning to do, or learning to learn to do (10) .In an analysis of the pillars for education in the 21st century, living together is the very essence of Paulo Freire's work, since it is centered in dialogue and its existence requires two dialogues.The actions of Permanent Education are characterized by the collective reflection of problems and demands, from which the needs for political and educational intervention can be planned (10) .
Educational approaches to Permanent Education and studies of organizations help to understand work-based learning and exchanges that facilitate or prevent changes in organizations.This line of understanding is made, because organizations operate through routines and norms that need to be incorporated in the analysis of this educational process (14) .
Hospitals are institutions with histories internalized by their professionals and health work is delimited by public regulations.Health work represents an explicit and implicit learning context in which the analysis of the accepted or questioned assumptions will promote changes or perpetuate routines and, as long as the Permanent Education is oriented by groups of same interest, it is normal not to discuss the routines (15) .
Permanent Education can operate different levels of learning, level I -when it seeks to extinguish or acquire habits; level II -when reflecting on critical situations or on different practice among professionals, raising awareness of the need for change; and level III -when from the reflection, interprets the context of the organization that allows the possibility of changes (16) .
Culture Circles happened in the unity of the quotidian of the practice and aimed to reflect on the generated themes until they were significant to the contextualization of the reality.Indicated actions and actions already carried out by the nursing team for the construction of the Permanent Education program for the neonatal unit of the university hospital were identified in the generating themes.
The circle was a space for meeting and discovering the other as a subject, with aspirations, feelings and experiences that need to be revealed through dialogue in the group, participation in discussions, exchange of knowledge and experiences.In addition, it promotes dialogicity in the process of building a collective, shared and contextualized knowledge (17) .
Permanent Education in Health is about transforming the work process, that is, it is part of the reflection on what is happening in the service and what needs to be transformed."It is education at work for work and for work, when it is intended to improve the health of the population" (18) .
The implementation of the permanent nursing education program for the institution's neonatal unit had the purpose of contributing to the educational process of the unit's nursing professionals, promoting the continuous improvement of the work process in the provision of child and family care.Thus, Permanent Education, in addition to providing technical updating for health professionals, also makes it possible to critically analyze the work process, identifying its bottlenecks, and developing appropriate strategies for overcoming it.
In-service training is a strategy that enables opportunities for self-knowledge, through personal and reflexive analysis, capable of awakening in the professional the concern and interest in changing the daily practice.However, for this to occur, the educational process must be continuous, critical and imply a praxis capable of overcoming the organizational barriers to reach the intimate of each professional, motivating him for better results (10) .
In view of this, Permanent Education, based on dialogic pedagogy, was based on greater interpersonal integration during the meetings in the Culture Circles, thus contributing to the improvement of relationships in the daily work, generating pleasure in it.

Study limitations
Among the methodological challenges of the study, the institutional moment of works in the neonatal unit for physical plant expansion was highlighted, which implied a review of the research itinerary and the achievement of the objectives.In addition, there was a reduction in the nursing team working in the neonatology sector.However, it was agreed in the group to discuss with the heads of the sector a schedule of activities to follow up the discussions raised in the study as a way to develop Permanent Education in the unit, after completion of the works, with the other professionals of the team who were displaced from the sector.Thus, although the study was carried out with part of the nursing staff of the unit, which may be considered a limitation of this research, the results found may support other studies that broaden the discussions about permanent nursing education in neonatal unit and other sectors in the hospital context.

Contributions to the Nursing
The study hopes to provide new research on Permanent Education, aimed at improving the quality of nursing care through an understanding of the context that involves the practice of the nursing team in a neonatology unit.The study provided a space for meeting the nursing professionals of the unit, favoring the interaction that can contribute to the improvement of the relations in the daily work and favor the activities developed in an integrated way, under a more critical and contextualized look in the work process and in the possibilities of collective changes.

FINAL CONSIDERATIONS
This study made it possible to know the factors that hinder and facilitate the routine practice of nursing professionals by Permanent Education in a neonatal unit from Culture Circles Silva LHF, Santo FHE, Chibante CLP, Paiva ED.
identifying the emerging themes of the Culture Circles that favored the critical reflection of the group, providing subsidies for the collective elaboration of the Permanent Education program in neonatal unit.
Four generative themes were highlighted in the results: lack of routines; training; improve the coexistence of the team and improve the management process.It should be emphasized that the study sought to contribute with the service in the organization of Permanent Education strategies for the whole hospital, since the proposal presented could guide other initiatives in the context of Permanent Education in the other units of the institution.
In this sense, the main contributions of the study are the promotion of moments of reflection of the daily practice of nursing professionals, awakening in them the need to express their ideas, their conflicts, their cultures and their contexts through dialogue with the other in a space of continuous and dynamic reflection-action-reflection.With this, the research itself, in its stages, represented a perspective for the development of a Permanent Education program in Nursing.

Facilitator
for me is to be a work based on routines of a specific area, this makes it much easier for me because I'm not a generalist at all, I have to work based on a focus in a certain area so the issue of having routines and being a specialist are the big facilitators.(Participant 18)Currently the lack of a specific routine for everyone to make the same way, the same language to work in the same way, we realize how there are several people with ideas, they bring new ideas and I just have the idea of the team what I work.(Participant12) Theme: training The training was associated with other generating themes, such as: lack of training, priority training, knowledge, knowing what to do and lack of technical ability, specialized team.It was coded as being the need to receive information and practical training, expanding knowledge.Permanent Education in a neonatal unit from Culture Circles Silva LHF, Santo FHE, Chibante CLP, Paiva ED.
Do you understand what we just said?Until we organize everything, we cannot think of courses.(Participant12)And first we have to create a pattern with standards set by the group and have to be on paper, a unit-specific handbook with SOPs with everything from the administrative parts to the practical parts.From this well-structured, well-founded material, we can begin this.I think I can start with study groups or a specific group for each subject.Anyway, we start working on the application, step by step of our work.(Participant 18)