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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.45 no.5 São Paulo Oct. 2011
Permanent education in nursing in a university hospital*
Capacitación permanente en enfermería en un Hospital Universitario
Maria Cristina Pinto de JesusI; Mariangela Aparecida Gonçalves FigueiredoII; Sueli Maria dos Reis SantosIII; Arlete Maria Moreira do AmaralIV; Letícia de Oliveira RochaV; Michel Jean Marie ThiollentVI
in Nursing. Associate Professor, School of Nursing, Universidade Federal de
Juiz de Fora. Juiz de Fora, MG, Brazil. email@example.com
IIPh.D. in Nursing. Assistant Professor, Juiz de For a School of Health. Coordinator of the Permanent Education Service at the University Hospital of Universidade Federal de Juiz de Fora. Juiz de Fora, MG, Brazil. firstname.lastname@example.org
IIIPh.D. in Nursing. Associate Professor, School of Nursing, Universidade Federal de Juiz de Fora. Juiz de Fora, MG, Brazil. email@example.com
IVPh.D. in Nursing. Associate Professor, School of Nursing, Universidade Federal de Juiz de Fora. Juiz de Fora, MG, Brazil. firstname.lastname@example.org
VRN. Scientific Initiation Grantee, Professional Training Program, Universidade Federal de Juiz de Fora. Juiz de Fora, MG, Brazil. email@example.com
VIPh.D. in Production Engineering. Associate Professor at Universidade Federal do Rio de Janeiro. Advisor to the Research Project. Rio de Janeiro, RJ, Brazil. firstname.lastname@example.org
Permanent education emphasizes on the interdisciplinarity of the health team, focuses on practice as the source of knowledge and places professionals as active actors of the educational process. The objective of this study was to identify demands and expectations, i.e. factors that interfere in the qualification of nursing workers of a university hospital, and propose capacitation practices from the perspective of permanent education. The investigation process founded on the principles of action-research was performed from 2007 to 2008. Subjects were nurses, nursing technicians and nursing aides. Data collection was performed in training workshops with 114 nursing workers. The results permitted to identify the institutional conditions in which educational actions take place, the possibility of mobilizing workers to identify and solve problems at works, and the need to make changes in training practices. This study provided support for elaborating a proposal of a Center for Permanent Education in Nursing at the institution.
DESCRIPTORS: Education Department, Hospital; Education, nursing; Inservice training; Qualitative research.
La capacitación permanente enfatiza la interdisciplinaridad del equipo de salud, focaliza la práctica como fuente de conocimiento y coloca al profesional para trabajar activamente en el proceso educativo. Estudio que objetivó identificar demandas y expectativas, factores que interfieren en la calificación de trabajadores de enfermería de un hospital universitario, y proponer prácticas de capacitación permanente en perspectiva de educación permanente. El proceso investigativo fundamentado al principio de la pesquisa-acción se realizó entre 2007 y 2008, siendo sujetos enfermeros, técnicos y auxiliares de enfermería. Datos obtenidos en talleres de capacitación con 114 trabajadores de enfermería. Los resultados identificaron las condiciones institucionales en que se efectúan las acciones educativas, la posibilidad de movilización de trabajadores para identificación y resolución de problemas laborales y la necesidad de cambios en prácticas de capacitación. Esta investigación respaldó la elaboración de la propuesta del Núcleo de Educación Permanente en Enfermería para la institución.
DESCRIPTORES: Servicio de Educación en Hospital; Educación en enfermería; Capacitación en servicio; Investigación cualitativa.
Curricular guidelines for health and especially nursing professionals' education appoint permanent education as a requisite for professional nursing practice committed to the population's true health needs(1).
To respond to the transformations occurred in the labor world, permanent education should be considered a strategy for worker qualification. It represents an important change in conception and in training practices and supposes an inversion of the process' logic, incorporating learning into organizations' daily life; it encourages changes in educative strategies, so as to focus on practice as a knowledge source and make professionals act actively in the educative process. Besides, it emphasizes the interdisciplinary team and broadens educative spaces(2).
In Brazilian health policies, permanent education emerges as a strategic action proposal, capable of contributing to the transformation of education processes, pedagogical and care practices and service organization, with articulated work between the different spheres and managements of the health system and training institutions(3).
The permanent education concept adopted in this study refers to a knowledge construction strategy in the technical-scientific, ethical, sociocultural and relational area, involving daily issues at the institution. It seeks articulation with health policy guidelines from the perspective professional training for the health area, using participatory methods that lead to autonomy(4-8).
In the context of the University Hospital (UH), the study scenario, specifically regarding nursing workers' training practice, it is observed that problems exist to put actions in practice, in view of emerging needs for changes in health practices in line with the principles of the Unified Health System (UHS).
Educative actions aimed at these workers are being included in nursing management's activity planning, with a nurse designated to take charge of team training. These actions are articulated with the nursing service only, without any link with a proposal regulated by the human resource sector, in the context of the UH's general management targets. As a priority, training actions have been programmed for nursing auxiliaries and technicians, but do not extend to nurses.
The starting point for this study was nursing management's dissatisfaction with the way training actions were been accomplished, as no actual changes were observed in workers' care practices. Initially, there was the premise that the lack of a formal link between permanent education and other administrative entities at the institution was the main aspect hampering the reversal of training into qualitative changes in the work performed.
The reflections of university hospital workers, faculty and students at the School of Nursing of the federal education institution regarding the need for an administrative entity for permanent education purposes pointed towards the need to review the training process accomplished until then. In that context, it was considered relevant to identify nursing workers' qualification demands and expectations, as well as the possibilities to establish a Permanent Education Center aimed at training these workers.
The following concerns guided this study: what are the qualification needs of nursing workers at the university hospital? What factors interfere in training actions, facilitating or hampering permanent education? How can the establishment of a permanent education center be made feasible with nursing workers' participation?
The knowledge produced based on this research contributed to a better understanding of the reality addressed and to define strategies that are more compatible with nursing workers' qualification needs at the study institution. The researchers hope to contribute in order to stimulate reflections on the relevance of changes in health and nursing professionals' education practices, reflecting in care improvements, besides entailing the possibility of further research in the area.
To identify demands and expectations, factors interfering in the qualification of nursing workers at a university hospital, as well as to propose training practices from a permanent education perspective.
CONSIDERATIONS ON PERMANENT EDUCATION
In Brazil, educative initiatives for health workers were emphasized as a result of the Unified Health System (SUS) and the Brazilian Curricular Guidelines in the 1990's. In 2004, a Permanent Education Policy in Health was established, through Decree GM/MS No. 198/04, as an SUS consolidation strategy to train health workers through a permanent education process. This process aims to transform technical and social practices, focusing on interdisciplinary actions and institutionalized practice aimed at the strengthening of teamwork, active appropriation of technical-scientific knowledge and institutional changes(3).
It is known that reports and discussions on worker education have been present in health since the 1970's, when the World Health Organization (WHO) and the Pan American Health Organization (PAHO) started discussion groups to address issues first referred to as continuing education, and reconsidered as permanent education as from the end of the 1980's(9).
Decree No. 1.996, issued on August 20th 2007, sets guidelines to put in practice the Brazilian Permanent Education Policy in Health and defines directives and strategies to put in practice permanent health education, in line with the operational guidelines and regulations of the Pact for Health(10).
In nursing, the search for competency, knowledge and recycling is essential to guarantee the survival of professionals and the profession. Permanent education's contribution to professional practice is evidenced through attitudes professionals assume in care, including the commitment with themselves, through the motivation to seek self-knowledge, improvement and updating, and foreseeing improvements in care delivery to clients and the community. Permanent education leads to the understanding that individuals should set self-improvement as a target to be aspired to across the lifetime(5).
The importance of recycling, updating and a critical and reflexive attitude towards the situations experienced in health promotion, prevention and rehabilitation is evidenced, in the context of public health and education policies. Developing people not only means giving information for them to gain new knowledge, skills and attitudes and become more efficient in what they do. It mainly means providing basic education for them to learn new attitudes, solutions, ideas, concepts, modify habits and behaviors and become more effective in what they do(4).
Permanent education is understood as the constant search to learn, as one of the actions that permits the development of the change process and aims for professional qualification of nursing and, consequently, the accomplishment of competent, conscious and responsible professional practice(5). It constitutes a route towards the emancipation and autonomy of health workers, as it is at the encounter between the education and job worlds that "learning and teaching are incorporated into the daily lives of organizations and into work. [...] it is based on the problematization of the work process and quality, at each health service, that qualification needs are identified, guaranteeing the application and relevance of contents and established technologies", with a view to dignified and high-quality care(3).
This study followed the ethical precepts of research involving human beings. Approval was obtained from the Institutional Review Board responsible for the study, under Protocol 962.0.2007, Opinion No. 010/20070729/2006.
Action-research was used as a theoretical-methodological foundation, as it permits acting or or solving a collective problem, which participants are participatively and cooperatively involved in(11).
Action-research is an intentional action aimed at making a complex object or phenomenon more intelligible, so as to construct concepts that will feed the reasoning of researchers planning a deliberate intervention in reality. Participation is essential. It can occur to different extents -ranging from representation over cooperation to co-management. Each participant takes part in the action and in reflection on the common activity that needs to be complied with. The goal of action-research is co-management, that is, all members' participation in all decisive activities from the start to the end of the research process. It implies inserting subjects in an understanding, aiming for a profound change at the level of thoughts and actions. To achieve the group aim, attention should be paid to the need for a common language that levels out participants with a view to their involvement in the research process. This phase can take some time, but is essential for participants to gain an acceptable understanding of the research object(12).
Change is the goal of action-research. This change includes the participants' values and takes place in the nature of the research itself, at times when actions and thoughts are reviewed, particularly enriching practical knowledge. Thus, action-research aims for the production of theoretical knowledge, but also contributes to reflections on institutional problems and tensions. It is concerned with the research process and necessarily includes actions. Subjects are seen as autonomous beings and essential agents in their own evolution. The process and product are equally important and their object is a social phenomenon. Researchers interact with the means and participate through their values, taking into account other people's values. Action-research is based on the negotiation among participants with a view to making the process flexible, discerning the globality, complexity and coherence of what is real(12).
Action-research is considered a way to create knowledge in which there are constant relations between theory and practice, between research and action. It aims for a strategic action that demands the actors' participation, "it constitutes a process in which three aspects intermingle, constituting a spiral: planning, action and constant information collection on the group and its own context"(12).
Based on the theoretical-methodological foundations, the following phases were accomplished: participatory survey of nursing workers' training needs in the work context: broad discussion and thematization with participants; definition of principles for the elaboration of a training proposal for different nursing categories, including content production that puts forwards work as an educative principle.
The research was developed at a University Hospital in an interior city in Minas Gerais, Brazil. Subjects were 35 nurses, 70 nursing technicians and nine nursing auxiliaries, totaling 114 professionals who worked in different shifts. Some workers were part of the institution's permanent staff, while others worked on a temporary contract.
All workers who formally accepted to participate in the study were included. Only those workers on a leave of absence for health treatment or worked in another function were excluded.
Data were collected and analyzed between October 2007 and September 2008, using educative workshops as a space for data survey, thematization and content production, and also for the proposal of collective actions aimed at permanent education in nursing.
With a view to motivating participants' manifestation, the following guiding questions were elaborated: in your work environment, what do you like most and what do you like least? What would you add for your work to get better? Specifically regarding permanent education, the following questions were asked: what problems in your daily practice could be solved through workers' training? What facilitates and what hampers workers' training at the University Hospital? What is the goal of a Permanent Education Center?
The first questions were asked to give room for professionals to spontaneously describe the work environment, appointing facilitaties and difficulties in daily reality at the institution. The final questions aimed to identify these workers' training demands, factors hampering training practices and expectations about the changes needed to develop educative activities.
During the data collection and return movement to the workers, the researchers provided theoretical support for the analysis of the reality the professionals evidenced and which would make them reflect on the training proposal to be institutionalized at the university hospital. At that time, considering nurses as triggering elements for changes and for the implementation of training actions, attempts were made to further involve these professionals in the workshops. To arouse reflections, the following guiding questions were presented: how do UH nurses take part in the nursing work process? What are the routes towards permanent education at the UH?
The workers' testimonies and collective production during the workshops were registered, using a digital recorder, posters the participants elaborated themselves and photographs.
The number of study participants evidenced the wealth of meanings. The collected data were considered sufficient to answer the research questions and aims.
For data analysis, the observation, classification and conclusion phases were adopted(12). The observation phase was centered on the discovery of solutions and the meaning of nursing workers' actions, who attempted to diagnose the study question. This phase was based on awareness-raising education, humanistic principles and the premises of health education. For data classification, the units of meaning deriving from interactions with workers during the workshops were grouped. These units were constituted based on the exchange of ideas between workers and researchers. The conclusion phase was centered on understanding the meaning of the events observed and on indications of possible solutions to the problems.
The discussion of results was illustrated using workers' statements, using the letters N, T and A, respectively, for nurses, nursing technicians and auxiliaries, following by the number corresponding to the statement and identified in the text as [N1]; [T1]; [A1], for example, and so on, so as to guarantee anonymity.
RESULTS AND DISCUSSION
The following themes emerged from this research: qualification demands and expectations for nursing work; factors interfering in training practices and training from a permanent education perspective.
Qualification demands and expectations for nursing work
Through the nursing workers' identification of their qualification demands, the importance of and need for technical-scientific knowledge was underlined. Besides, the relevance of including aspects of the paradigm change in professional education and healthcare was highlighted. Participants emphasized professional valuation and autonomy to accomplish activities related to nursing competences, and permanent education as a strategy for knowledge acquisition and updating and for the preparation of multiplying agents to work with users and the health team.
[...] do training, education to improve knowledge [A4].
[...] you need love, respect and responsibility [A1].
Staff policies and valuation of workers at the institution [N17].
The testimonies reveal the prevalent understanding of training as scientific knowledge acquisition to direct care with a view to standardized procedures. The scientific base of care is valued. The need for scientific foundations to accomplish patient care and training was underlined, in the sense of rescuing knowledge. Workers expect to broaden scientific foundations and gain new technical knowledge.
This practice was also observed in a study on health professionals' permanent education, accomplished at public hospitals in São Paulo. Educative activities were directed at task performance and health recovery, with predominantly traditional teaching strategies(13).
During reflections, the nursing workers considered that the training actions put in practice at the university hospital do not relate to the practices' political-social reality.
[...] theory and practice need to go hand in hand [N5].
You lose what you have learned in theory if it is not articulated with practice [N3].
A continuous updating process is needed, as well as changes in line with the pedagogical conception adopted at the UH [N15].
When associating the educative aspects with the work context, the participants consider that the training proposal should be articulated with the reality it is destined for. These workers' stance finds support in a study accomplished at a teaching support hospital in São Paulo, in which nurses report on the importance of and need for educative actions and underline the growing demands for technological renewal and invention, knowledge integration and the need for a new view on health work(14).
Another issue the workers raised is the need to seek distinguished methods for the permanent education process. They indicate that this process should be based on the dialogical and transformative education concept, with a view to improving health professionals' education and qualifying user care.
A work process is needed based on the problem-solving method [N16].
Addressing the inversion of models - prioritizing humanization to the detriment of technology [N18].
Training actions should be based on methods that permit establishing the relation between proposals and reality, i.e. methods that permit a critical view for decision making, choosing those methods that are most in line with the reality of the work process and with users' needs in the care practice context(9).
The change in health services' institutionalized practices is directly related with the change in educative actions. Not only academic knowledge, but also practical knowledge needs to be valued, enhancing shared and systematic reflection, departing from what professionals already know(2).
Factors interfering in training practices
The management of practices and the institutional policy directing nursing work processes at the university hospital were identified as interfering factors that hamper the efficacy of training actions.
The need to discuss the work process is revealed based on problem identification in the work and interpersonal communication spheres.
I consider that there is a lack of communication among the sectors [T3].
Some sectors are disorganized [A5].
Difficulty to integrate the technical team [N10].
Training is needed for the relationship [T4].
In this context, nurses' distancing from their position as nursing team leaders is highlighted, and as strategic professionals for changes to take place.
[...] we get orders from many people, which prevents us from being the nurses we are [N6].
There is a lack of definition on nurses' role and action philosophy [N2].
Nurses assume different functions, including those of other professionals [N8].
The workers' positions revealed nurses' absence and their distancing from some activities inherent in their function with regard to the care work and nursing management process.
There is a lack of supervision by the heads [A6].
The nurse is not integrated in the work process as a whole [N9].
There is no (daily, weekly, yearly) work planning [N10].
It was apprehended that nursing and specifically nurses' work is weakened with regard to the institutional human resource policy, cultural and job market transformations, whether institutionally or in society.
The physical, organizational and service maintenance conditions at the institution were also appointed as factors contributing to the limited efficacy of training actions and/or to the small impact of these actions. Some situations make workers feel dissatisfied, with a lack of motivation for work and knowledge recycling, specifically considering the different job contracts, which grant stability to part of them.
There is the problem of wage differences and contract instability [N7].
The institution does not provide sufficient orientation on the work process [N11].
We perform the work process empirically [N12].
It is highlighted that changes in health work start with the establishment of the SUS. The established healthcare model demands a cooperative work and democratic management process, in which nurses should actively perform in the group they are leading with a view to healthcare delivery. In care delivery, professionals assume attitudes, which include the motivation to seek knowledge, recycling and updating with a view to improving care to users and the community(5).
The work conditions reflect workers' valuation. In this study, the workers mentioned the lack of space for meals, relaxation and healthcare for nursing staff. The need to structure work routines was highlighted with a view to humanization.
The physical structure is crystallized, stuck [N13].
Routines are needed with a view to humanization at the UH [A3].
[...] humanization aiming for quality in human relations [A2].
Talking about humanization in the hospital and healthcare environment means considering the physical, technological, human and administrative structure at the institution, as well as valuing and respecting human beings' dignity(15).
The lack of humanization is also reflected in the lack of adequate physical space for user care.
There is a lack of physical space, producing disorganization [T1].
There is no technology to support the care process [N14].
It was evidenced that some material resources are obsolete, there is a lack of preventive maintenance and fixing equipment takes time, besides the lack of material.
There is a lack of material, there is no preventive maintenance [N4].
[...] when some material is broken, it takes time to fix it [N1].
For educative actions to result in attitudes that enhance changes in the nursing work process, nurses need to get involved in the permanent education process with a view to continuously gaining skills and competences, in view of the epidemiological context and health scenarios' needs. Besides, institutional commitment can facilitate the planning and development of educative actions(6).
Training from a permanent education perspective
During the action-research process, training and quality concepts were evidenced in nursing care. In this respect,training was put forward as a tool to achieve improvements in care and also understood as a way to value workers.
What the professionals' desire is concerned, motivation does exist to get training, to learn, but there are difficulties interfering in the accomplishment of educative actions and largely in the application of what is learned as well. The professionals admit that it is difficult to put in practice what is learned and appoint administrative issues as factors interfering in the accomplishment of actions. It seems that a deadlock is produced, training is accomplished, but no conditions are created in practice for changes based on educative actions, in line with the guiding principles.
[...] people have an enormous will to learn but, in general lines, face difficulties to follow what they have learned [T4].
Support is needed in practice to implement what you have learned [T2].
Addressing work flexibility issues for training [N18].
Enhancing integration, welcoming and humanization at work [N19].
The nursing workers evidenced the need for change and innovations in training practices during reflections:
[...] we have to address health policies, rights and obligations, institutional organization, legal regimen, staff motivation [N7].
These changes go beyond the nursing sphere to the extent that they include technical-scientific and organizational aspects.
To produce results, permanent education actions need to be articulated with organizational change devices, mainly with new staff management styles. They are not limited to making professionals incorporate knowledge, but should make them identify what knowledge they need to learn, what situations should cease to exist and what should be done for the group to adopt the new knowledge, in short, changes in the organization and its contexts are necessary(2).
It should be taken into account that the students need to participate in the educative process to get involved in it. The nursing workers' testimonies indicate that they do not participate in all planning and decision making phases on the training process and on educative actions. They have repeatedly affirmed that training partially depends on workers' interest, desire and involvement.
Further attitude, participation and knowledge exercise by nurses and the team is necessary, leading to credibility [N5].
It is important to value the assessment of the activities performed [N15].
Transforming the work process involves the survey of needs, expectations, problematization and technical support for professionals aware of their commitment to users to perceive the potentials and limits of their practice(14).
As a research product, focusing on the proposition of training practices from a permanent education perspective, a proposal was constructed for the creation of a Permanent Education Center in Nursing at the University Hospital, to be included in the institutional chart, whose actions include recycling and in-service specialization programs, work initiation programs, practicums and experiences, besides support to stricto sensu graduate programs.
The understanding about a Permanent Education Center in Nursing took the form of an administrative entity that facilitates the accomplishment of training actions, marking institutional responsibility. And also as an opportunity to integrate training demands, put them in practice, accomplish them and assess them as a continuous process, with institutional support.
Establishing a well-defined Center, with exclusive nurses; a Multidisciplinary Center for training all UH professionals [N20].
The Center as an integrative element between health schools and the University Hospital [N17].
[...] a permanent education center with a work philosophy, infrastructure (human resources, material and physical area), which articulates work with nursing management regarding nursing service organization [N21].
The nurses' participation permitted the elaboration of guidelines to structure the university hospital's permanent education service, in line with the Unified Health System and current pedagogical requirements. The work dynamics resulting from the action-research facilitated this participation. Participatory studies can be conceived as a way to reestablish the human dimension of health care, as they demand an effective relation among people - health professionals, patients and families(16).
The method used in the research process is highlighted in this study, permitting a broad diagnosis of nursing workers' training demands and expectations, as the starting point for planning actions that are more appropriate to the institution's characteristics and needs.
The collective knowledge construction work evoked a feeling of belonging and valuation in the group, originating in the perception of a space where they are heard. It led to understanding about the importance of involvement and accountability for one's own professional education and the role of nurses, as nursing team leaders, to facilitate educative actions for nursing technicians and auxiliaries.
The group problematized issues they considered relevant and sought achievable solutions, besides reassessing its behaviors. Change proposals based on the structuring of the permanent education service became coherent with the needs of university hospital workers.
The action-research represented an opportunity for reflection on the reality of nursing work, besides permitting workers' mobilization, the perception of problems from stakeholders' perspectives and, at the same time, the triggering of a Permanent Education Center structure. This Center not only enhances permanent education in nursing, but also represents a space for planning, monitoring and assessing the pedagogical proposals related to the demands in the teaching, research and community service context of the University Hospital.
The researchers hope that training practice resulting from the concrete Permanent Education Center in nursing will not remain limited to punctual actions, but will comprise actions in line with the premises and mission of a health institution articulated with a teaching institution.
To advance on theoretical and practical knowledge with a view to putting permanent education in practice, further research is needed, mainly aimed at assessing the impact of educative actions performed, guided by education and health policies.
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Received: 02/03/2010 *
Taken from the Project "Educação Permanente de Trabalhadores de
Enfermagem do Hospital Universitário da Universidade Federal de Juiz
de Fora", 2007-2009.
* Taken from the Project "Educação Permanente de Trabalhadores de Enfermagem do Hospital Universitário da Universidade Federal de Juiz de Fora", 2007-2009.