Facilities and difficulties experienced in Permanent Health Education, in the Family Health Strategy

ABSTRACT

Permanent Health Education is present in the health services, being the process by which the teams seek improvement, organization and qualification of the actions. It was aimed to analyze facilities and difficulties in the accomplishment of Permanent Health Education, in the Family Health Strategy. This is a qualitative study, which used the research-action technique. Facilities include the use of active methodologies, the integration of the team, the opening of the management and the planning of activities. And as difficulties, the lack of participation of the professionals, work overload, infrastructure, devaluation of some knowledge and incomprehension of the methods used.

KEYWORDS
Continuing education; Family health; Primary Health Care

RESUMO

A Educação Permanente em Saúde está presente nos serviços de saúde, sendo o processo pelo qual as equipes buscam o aperfeiçoamento, a organização e a qualificação das ações. Objetivou-se analisar facilidades e dificuldades na realização da Educação Permanente em Saúde, na Estratégia Saúde da Família. Trata-se de um estudo qualitativo, que utilizou a técnica de pesquisa-ação. Como facilidades tem-se a utilização de metodologias ativas, integração da equipe, abertura da gestão e planejamento das atividades. E como dificuldades, a falta de participação dos profissionais, sobrecarga de trabalho, infraestrutura, desvalorização de alguns saberes e incompreensão dos métodos utilizados.

PALAVRAS-CHAVE
Educação continuada; Saúde da família; Atenção Primária à Saúde

Introduction

Brazilian health services have been developing an understanding of the concept of Permanent Health Education (PHE) - which is considered by the Ministry of Health (MH) as work-based learning, in which teaching and learning are embodied in everyday life - in order to transform the local reality of professional practices and work organization¹.

Thus, the National Program for Access and Quality Improvement in Primary Care (PMAQ-AB), in its first cycle, was attended by 17.202 teams of the Family Health Strategy (FHS), totaling 70.7% of adherence of the municipalities. The professionals were questioned about PHE actions in Primary Health Care (PHC), revealing that 81.1% of the municipalities presented some PHE experience: telehealth, on-site courses, exchanges of experiences, distance learning activities and tutoring, among other educational modalities². These data from the PMAQ-AB help in the knowledge of the dimension of the topic treated in the present study, since more than 14 thousand teams of the FHS of the Country report experiencing some educational activity in their daily life.

When verifying this reality, it is necessary to understand that not all the modalities mentioned previously are part of the role of PHE. However, it is necessary to reflect on the fact that educational activities occur in the daily life of health services. Thus, it is necessary that educational processes are inserted in the day to day of the professionals, so that the services are prepared to provide adequate assistance to the different audiences that need care. In this sense, it is important to think of health work as a key component for such a process to become a reality in the Unified Health System (SUS), since health work is considered a "living work in act"³⁽⁴⁷⁾. Therefore, instruments, knowledge and relationships are essential for the work process to be effective in the production of care and in the organization of health care.

PHE stands out in this understanding, because, according to Ceccim and Ferla⁴, it presents a link between education/work/citizenship, through the overcoming of the teaching-learning process for an education and health policy, reinforcing the political link between health and education. Moreover, in order for PHE to become a reality, some adjustments are necessary in relation to educational processes, such as, for example, overcoming the culture of banking education through the pedagogy of problematization, which, according to Freire⁵, places the individual as protagonist and not as mere spectator of the construction of knowledge.

Likewise, the MH published the Ministerial Cabinet Order nº 1.996, of 20 August 2007, which defines PHE as "a training and development policy for SUS"⁶⁽²¹⁾, since it has the function of articulating the needs of health services and the possibilities of development of professionals, observing the resolving capacities of each service and the social management of health policies. Based on this, the health services undergo, in their daily lives, different experiences regarding the educational process. And these, in turn, represent transformations in practices and relations⁶ of workers.

From this perspective, it is essential to seek elements to improve the educational processes experienced by the PHC health teams. This challenge gives new meaning to PHE in health services and launches elements for the qualification of these services, based on an educational process consistent with professional practice. The educational process provided by PHE is also a political action, in which the actors involved, from their daily practices, elaborate different constructions of care and transformation of reality. In order to qualify the PHE actions, it is interesting to know the facilities and difficulties experienced by the health teams in the PHE process. Thus, the objective of this article includes the analysis of the facilities and difficulties for the accomplishment of the strategies of PHE, in the daily work of the FHS.

Methodology

This is the clipping of a master's degree study entitled 'Permanent Education in Health and its implications in the work process in Primary Health Care', presented to the Post-Graduate Program in Teaching in Health, of the Federal University of Health Sciences of Porto Alegre. A qualitative approach study, which used the action-research technique to achieve its objectives. Therefore, a qualitative research, according to Minayo et al.⁷, deals with a level of understanding that cannot be quantified, that is, it responds to particular questions.

To facilitate the understanding of the process of PHE in PHC, a research-action helped in the search for answers and alternatives to consolidate PHE practices in the work process of health teams. All this being action research an unconventional method of research, that seeks intervention, development and change, predicting the interaction between the researcher and the actors involved⁸.

Participants were health professionals working in the Municipal Health Department (SMS) of Arvorezinha⁹ (RS), involved in the PHE process and working in the FHS or in the matrix support teams, totaling 33 professionals of all levels of training. The data collection used a self-administered questionnaire on the PHE process, being carried out between May and October of 2016.

The municipality is located in the Alta do Vale do Taquari region, about 200 km from the capital, Porto Alegre (RS). According to the Brazilian Institute of Geography and Statistics (IBGE), in 2015, the municipality had 10.585 inhabitants. Of these, 3.952 lived in the rural area and 6.633 in the urban area, which represented a population density of 38.96 inhabitants/km²⁹.

Regarding health care and the structure of the SUS at the municipal level, there were own and contracted services. With regard to self-services, there were two Family Health Units (FHU); three FHS health teams; two teams of support matrix, being a team of the Nuclei of Support to Basic Attention (Naab) and a team of the Nuclei of Support to Family Health (Nasf). Since 2014, the municipality has experienced a strengthening in the process of permanent education among the teams, through the creation of the Municipal Nuclei of Education in Collective Health (Numesc), which is responsible for coordinating, articulating and organizing the educational processes in the MHS.

The research was approved by the Committee of Ethics in Research, through the consubstantiated opinion nº 1.459.159, of March 21 of 2016. Thus, all the participants passed the process of Free and Informed Consent of participation in the research. Also, the funding was carried out by the researchers themselves and there were no conflicts of interest in the execution of the study.

The inclusion criteria were: being a health professional filled in the MHS of Arvorezinha (RS); be over 18 years of age; accept to participate in the research by signing the Free and Informed Consent Form; be involved in the PHE process; and be linked to a primary health care team (FHS or matrix support - Naab or Nasf).

In order to carry out this research-action some instruments were established, such as spaces for discussion, training, planning and evaluation, actions that were carried out in two seminar meetings, as well as a basic questionnaire. The questions contained therein were about the PHE process; the understanding of each one about PHE; the experience; the contributions to the users, the team and the management; the facilities and difficulties in the experience of PHE in daily life; and structuring suggestions. The answers of the questionnaires were grouped according to each category, being identified as Q1, Q2, Q3 and so on, while the seminars are identified as Seminar 1 and Seminar 2.

From this, the first meeting of the seminar was held, previously scheduled with the management and with all the teams, during which both the contracting of the action research and the deepening of the discussions about the questions of the questionnaires were carried out. From these first steps, the other procedures of the research were guided. The difficulties listed by the workers in the different contexts and possibilities of work have leapfrogged the search for alternatives to work with PHE.

In the second meeting of the seminar, the planning of an educational intervention was carried out with the PHC teams of the municipality. All the actors collectively constructed the intervention project and committed themselves to its implementation in the work context of each one. After that, the proposals were consolidated and presented to the teams, which guaranteed legitimacy to the project and boosted its achievement.

After this planning, the Numesc team, together with the health teams, resumed PHE activities, as planned. Topics such as 'Health promotion' and 'Caring for the caretaker' have been worked on. At the end of each of the actions, evaluations were carried out, at the individual and team levels. These evaluations served as a basis for planning the following activities, helping to improve the actions and understanding the function of Numesc and research-action in that reality.

The generated data were analyzed from the thematic analysis process proposed by Minayo¹⁰ that defines such analysis as the discovery of the sense nuclei that compose a communication, whose presence means something for the object of study.

Results and discussions

From the experience of PHE in the context of the city under study, it became important to know how PHE practices occurred, which occurred in the most diverse forms and in the most varied spaces. Together with them, there were factors/situations/moments/conditions that facilitated these practices, transforming them into effective actions of education at work. For a possible discussion and elaboration of a project that resulted in an impact in the daily life of PHE of the health teams, it was necessary to search for elements that would support the accomplishment of the activities, besides others that presented themselves as difficulties, to, this way, seek strength and transform reality. In order to make this possible, the data presented in this section come from the questionnaires answered and validated from the discussion in the seminar meetings.

Initially, it is important to emphasize that some strategies for carrying out the educational activities, here called methods, were mentioned. Thus, the work with active methodologies, with well elaborated themes, was highlighted. In addition, the actors pointed out that some Numesc representatives participated in a specialization in PHE, which facilitated and oxygenated many educational activities, as follows:

Two representatives of Numesc have specialized in PHE; opening of the management for Numesc to work with the teams; meetings taking place in the team meetings themselves causes the majority to participate; working with active methodologies; materials available. (Q5).

Thus, the use of non-conventional teaching-learning methodologies is highlighted, such as active learning methodologies, meaningful learning, pedagogy of implication and problematization. The use of methodologies that prioritize the proactivity of those involved in the teaching-learning process is a substitute for a model that no longer responds to current issues, given that, in the current social context of the Country, information speed and evolution technologies are within the reach of many. Therefore, it becomes necessary a method that places the subject as an actor/constructor of knowledge and no longer as that patient subject, who received the ready information of the teacher, in a model of banking education⁵.

Active learning or teaching-learning methodologies, as some authors express it, are based on the action-reflection-action triad, and their use is remembered in different studies as a strategy to strengthen PHE¹¹, in which there is the active participation of subjects involved, who, in addition to being able to articulate theory and practice, problematize the reality lived by each one¹², to build knowledge and experience a teaching-learning process based on their individualities.

In this sense, there is mention, in the study of Cardoso¹³, of educational actions carried out with the use of active learning methodologies on the theme chosen by the participants, which, are mostly, about programs or policies of the MH.

In this way, the experiences of PHE present elements that facilitate the educational process, especially regarding the use of active methodologies in this context. However, in the researched reality, there was no effective integration of the users with the team in this process of permanent training of the professionals, unlike what happened in the aforementioned study, although the team felt integrated, according to the excerpts from the following questionnaires:

Integration of the team as a whole. (Q2).

The whole group participates actively. (Q21).

Professionals are continuously committed to the implementation of PHE. (Q23).

In this perspective and as a consequence of the integration of the team, there was a potentiation of the will to learn and to make exchanges, since, often, the professionals performed their activities and actions without realizing what they were doing, that is, they did not stop to reflect about the process they lived, according to the following professional report: "Willingness to learn, willingness to exchange. Sometimes, it seems that the professionals do and do not realize what they are doing" (Seminar 1)

Team unity and active participation of all favor this environment and value each member as an individual with potential. Slomp Junior, Feuerwerker and Merhy¹⁴ believe that this integration is a consequence of the encounters that occur among the different actors involved in the PHE, since everyone has the opportunity to express their experiences when these methodologies are used.

Another facilitating element presented by the actors of this research was the fact that there was opening of the management for Numesc to work with the teams, because if the management did not authorize, the teams would not be occupying these spaces, since the PHE was carried out, mainly, in team meetings, creating and maintaining a space for this, according to the following reports:

If the management did not give permission to this, there would be no team meeting and much less PHE. (Seminar 1).

The PHE is held in team meetings, a space was created for PHE. (Seminar 1).

In this sequence, D'Ávila et al.¹² point out that one of the elements that facilitates PHE is the adequacy of a physical space that favors the educational process. In this case, one can overcome the understanding of physical space and also understand the space dedicated to the team meeting as the opportunity to gather the group in a temporal space.

Moreover, there is a preference for active listening of the whole team, based on dialogic practices that foment discussion, through the arrangement of the surroundings in a circle. Other studies also demonstrate that the circle arrangement facilitates the discussion of subjects, predisposes the greater participation of the subjects and generates other possible relations between them^13,15,16, based on principles such as "horizontality, decentralization of power, autonomy, accountability and grouping of teams"^16(2362). These principles corroborate the development of democratic actions that value the participation and contribution of all in the construction of knowledge as an important space for exchanges.

In order for actions to occur, there needs to be organization and planning. However, the Numesc team was limited and few attended or were involved in the planning process, which can be seen in the following report:

It's the group that organizes it and this is seen with good will, they don't do anything out of obligation, but rather because they like it, have pleasure in doing and trying to go beyond. They have good will to do and no obligation. And this goodwill conveys to the team. Thus, the team interacts more. (Seminar 1).

This element can be seen as a facilitator, but it can also be a hindrance to the PHE process, since it is not something inherent to the work, although it is fundamental for PHE to take place in a natural and useful way for all.

Some studies present planning as something important and basic for educational actions to be successful, since the planning of actions contributes to the organization of the team, as the activity is anticipated in advance and respects a certain periodicity¹¹. Corroborating what happens in this reality, Costa et al.¹⁷ present a panorama in which the activities occur, for the most part, in the already formalized spaces of education or organization and planning. They are the team meetings, inserted in the hourly workload of each professional.

In this way, the workers indicate that these meetings represent activities that produce educational actions. This contributes to the development of interdisciplinarity, which, according to Ezequiel et al.¹⁸, is a consequence of PHE, because when knowledge and experiences are placed on the same level, interaction of theory and practice occurs, and vice versa, which causes this process to become dynamic and transform realities, articulating different knowledge, creating other forms of construction of work, extrapolating what is provided in protocols and manuals, reaching the field of health subjectivities¹⁹.

Other experiences, in which the PHE starts from the collective construction of the actors involved, contextualized to the reality experienced by the individuals and incorporated in the daily work^14,20, also involve the resolution of the problems raised by the teams or aspects of the work processes^12,13,16,21. These actions, when constructed collectively, dialogically and horizontally, collaborate in the formative processes for the FHS teams, generating important meanings for the work process, establishing an action-reflection-action relationship or theoretical-practical relationship. All this contributes to the principle that the educational process needs to start from the reality experienced by the subjects, involving them and seeking an improvement in the work process, consequently improving the care provided to the community.

Other elements were highlighted as difficulties or obstacles. They were: the mishaps that the PHE passed in the reality of the FHS of the municipality studied, as the lack of participation of some professionals, the work overload, the lack of infrastructure, the devaluation of the knowledge of the professionals of average level and the difficulties of understanding methods used in educational action.

The actors brought the lack of interest and lack of participation of some professionals as some of the difficulties that caused delays in the educational process. They pointed out that it would be important to arouse the interest of all the professionals, and not only of the professionals that Numesc, according to the following reports:

The accomplishment of PHE is focused on a few professionals, short time to organize PHE (due to work overload), non-involvement of other professionals, lack of medical participation (focusing only on nurses, technicians and CHA [Community Health Agents]). As for time, space for PHE ends up getting very short. (Q5).

Difficulty in bringing professionals together. Not everyone has interest and time. (Q15).

My participation in meetings is, unfortunately, small, due to the demand in the services. (Q31).

Confirming this situation, some studies present lack of support and participation of some professionals, such as physicians¹¹ and pharmacists¹³, even in the presence of these professionals in most health units, composing the teams. Therefore, the major issue in this analysis is the problem of accession, which is seen as an obstacle to the practice of PHE. Since the professional is not occupying the spaces that are his, he stops interacting with the other members of the team, compromising the interdisciplinary articulation and the work with the community.

Another report of a professional presented a difficulty that ended up causing inconveniences in the construction of PHE, as follows:

It is noticed that, at the FHS team meeting, there is a disregard for the present technicians. Unfortunately, still, in the FHS of the municipality, the knowledge is more directed to the medical knowledge. (Q3).

Thus, it is perceived that there is a valorization of biomedical knowledge, devaluing the other knowledge present there. Likewise, Fortuna et al.²¹ demonstrate an obstacle in the process of education at work, which is the devaluation of mid-level professionals - CHA and nursing assistants/technicians. This is because many professionals understand that the theory is superior to the experience, not considering that both are complementary and, separately, none is effective in the construction of knowledge. There is also the technical and social division of labor, the strong hierarquization and verticalized power relations as conditions for this devaluation.

Although, in some places, valuation even occurs, it is necessary to reflect how, in our daily lives, different groups of professionals must be worked to achieve a condition of interdisciplinarity in health services. In this logic, it can be understood that this difficulty of conducting the different ones in the daily life does not represent something new, and that it will only be overcome when the workers take ownership of the spaces of discussion. However, according to Silva and Peduzzi²⁰, health workers occupying these spaces do not usually reflect on the difficulty of carrying out emancipatory activities of education at work. In other areas of knowledge, such as human and social, professionals are prepared to be present in these spaces, empowering themselves with the discussions.

Another element that hampered this process was associated with the PHE design that the professionals presented. In the same sense previously mentioned, in which knowledge is centered on technicality and the biomedical model, some observations and suggestions were made by some professionals to make the PHE process more technical and conducted in a more traditional way, suggesting the use of traditional methodologies.

I suggest a more technical PHE, [...] the kind of work that would be interesting for people focused not only on the disease, but on prevention, which would be our main will as basic care. Focused on the prevention, in some diseases, what we have seen that is more prevalent, more of our day to day. (Seminar 1).

Corroborating this understanding, according to Silva et al.²², this educational process goes beyond technical improvement, enabling transformations, new visualizations, broadening of vision and, mainly, the valorization of the collective knowledge of workers involved in actions. Thus, it is important that the theory-practice relationship can be experienced in the day-to-day services and incorporated into the PHE actions, with the objective of continuous improvement of actions and services.

Another aspect evidenced by the actors was the lack of adequate physical structure, since one of the units of the municipality did not have a meeting room, as depicted by the professional: "Lack of space in the Basic Health Unit, hampering the work of all" (Q27).

Some studies demonstrate that there is a precariousness regarding infrastructure, which makes it difficult to carry out educational activities, just as it is possible to verify the lack of interest in adjusting the institutional resources so that the practices of PHE occur satisfactorily in the services^11,12. All of this integrates the planning process, which must take place strategically and systematically with the team. However, an adequate space for carrying out educational actions at work is essential.

The subjects mentioned, also, the difficulties in relation to the lack of awareness of the population about the importance of PHE, the overload of work and the excess of demand in the teams.

Regarding the awareness of the population about PHE, they mentioned all the professionals who, in their activities, needed to be involved and explain, to the population, the importance of educational activities, with the goal of improving health care. In this way, it would be interesting if there was an involvement of the users in the PHE process. A study by Cardoso¹³ reports that it is possible to note that there are few experiences that integrate users in educational processes at work, because it is more convenient for some professionals that users seek the team only when they are in need of something and not to discuss problems or situations of daily services.

Other situations considered as limitations were verified, pointed out by some professionals and ratified by Ricardi and Sousa¹¹ and Fortuna et al.²¹, as the overload of activities and programs, and the problems experienced by the families under the responsibility of the FHS professionals. These situations hindered the procedures, as they unbalanced the professional agendas, complicating the service to the users, as seen in the following speech:

[...] there is an excess of work demand, the professionals are flooded with assistance - consultations, HV [home visit], groups, among others. (Seminar 1).

It is possible to notice that a possible overload of responsibilities can be due to the lack of planning and the difficulty in the organization of the services, causing problems in attending to the population and, consequently, keeping the professionals flooded in health care, leaving in the background some aspects related to educational processes.

Conclusions

PHE is a strategy that provides subsidies, methods, manners and engenderings for the qualification and organization of health work. In addition, it contributes significantly to the reorientation of processes within the health teams, stressing the different actors in the sense of seeking something more in their daily work. Moreover, it contributes positively to the management and administration of the different spaces in the health field. It is important to emphasize that this study occurred in a specific municipality, with less than 20 thousand inhabitants, a reality similar to that of the great majority of municipalities in the Country in this respect, since, according to IBGE²³, 73% of the brazilian municipalities fit this profile.

From this, some aspects were visualized that facilitated and made possible the accomplishment of educative actions within the health teams of the PHE, as well as some difficulties faced by the professionals in their work routine, with respect to the experience of the PHE in this quotidian. Thus, knowing the facilities experienced by the teams helps to strengthen the PHE process and ensures its effective fulfillment in the daily life of the workers, while the act of making the difficulties aware extends the critical view of health work, creating strategies to overcome them.

To make possible this overcoming, public investments must be made, not only in financial terms, but especially in trained personnel, always prioritizing a policy of PHE. It is necessary, also, to increase the number of researches in this field, in order to guarantee the applicability of such educational process, leading to the conviction of health managers the privileged importance that PHE occupies in the reality of SUS and the way which it can contribute in this process.

From this perspective, transformations in the health field require the integration of different fields and sectors, as well as the empowerment of social actors, based on popular participation actions, qualification of health management and investments in the improvement of professional training. Therefore, it is necessary for the actors to understand the construction of the process that needs to be tried out and experienced, so that health work and all its educational process are responsible for fostering transformations in the daily life of health services.

The health services, the community and the different encounters between all the actors of this process allow educational and health practices. Thus, this article raises awareness that, rather than teaching-learning from work, it is necessary to learn to learn at all moments of life, and that this leads to an expansion of this pedagogy that emerges and is consolidated every day in the health. In this way, it is necessary to include PHE in the daily work, understanding it not only as a merely punctual tool, because education in and for work must permeate all professional activities.

Health workers have an essential role in this comprehension, when they understand themselves as educators, while they value all those involved in the educational process, their knowledge, communication; have an ethical, critical, reflective, human and inseparable position of the process of living. Therefore, it will be possible to overcome the biomedical model and insert educational practices, effectively, in the daily work of health, achieving better results in the practice of PHC.

• Financial support: non-existent

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Publication Dates

• Publication in this collection
  Dec 2018

History

• Received
  18 Aug 2017
• Accepted
  17 Jan 2018