Educational intervention on managerial skills with nurses from Family Health Strategy

Abstract

Objective

To learn how nurses from Family Health Strategy (FHS) perceive an educational intervention on managerial skills.

Methods

This is a comprehensive qualitative intervention research, carried out in six weekly meetings. Fourteen nurses who worked in FHS teams from a municipality in the southern region of Brazil participated. Data were collected after the end of intervention, through a focus group and analyzed according to the Grounded Theory assumptions.

Results

In the component consequences of the paradigm model of Grounded Theory, the category “Improving managerial skills among FHS nurses” emerged, supported by the subcategories “Potentials of intervention to improve managerial skills” and “Benefits of intervention on managerial skills in nurses’ work”.

Conclusion

Nurses perceived the educational intervention as an important continuing education strategy to improve their managerial skills, positively assessed the chosen methodology and the contents worked, considering its applicability in the context of professional practice.

Professional competence; Family health strategy; Pratice management

Resumo

Objetivo

Apreender como enfermeiros da Estratégia Saúde da Família (ESF) percebem uma intervenção educativa sobre competências gerenciais.

Métodos

Pesquisa qualitativa compreensiva do tipo intervenção, operacionalizada em seis encontros semanais. Participaram 14 enfermeiros que trabalhavam em equipes da ESF de um município da região Sul do Brasil. Os dados foram coletados após o término da intervenção, mediante a realização de grupo focal e analisados de acordo com os pressupostos da Teoria Fundamentada nos Dados.

Resultados

No componente consequências do modelo paradigmático da Teoria Fundamentada nos Dados emergiu a categoria: “Aprimorando competências gerenciais entre enfermeiros da ESF”, sustentada por duas subcategorias: Potencialidades da intervenção para o aprimoramento de competências gerenciais e Benefícios da intervenção sobre competências gerenciais no trabalho dos enfermeiros.

Conclusão

Os enfermeiros perceberam a intervenção educativa como importante estratégia de educação permanente para aprimoramento de suas competências gerenciais, avaliaram positivamente a metodologia escolhida e os conteúdos trabalhados, considerando a sua aplicabilidade no contexto da prática profissional.

Competência profissional; Estratégia Saúde da Família; Gerenciamento da prática profissional

Resumen

Objetivo

Comprender de qué forma enfermeros de la Estrategia Salud de la Familia (ESF) perciben una intervención educativa sobre competencias administrativas,

Métodos

Estudio cualitativo comprensivo tipo intervención, realizado en seis encuentros semanales. Participaron 14 enfermeros que trabajaban en equipos de la ESF de un municipio de la región sur de Brasil. Los datos fueron recopilados después de finalizar la intervención, mediante la realización de un grupo focal y analizados de acuerdo con los presupuestos de la teoría fundamentada en los datos.

Resultados

En el componente consecuencias del modelo paradigmático de la teoría fundamentada en los datos, surgió la categoría “Perfeccionando competencias administrativas entre enfermeros de la ESF”, basada en dos subcategorías: Potencialidad de la intervención para el perfeccionamiento de competencias administrativas y Beneficios de la intervención sobre competencias administrativas en el trabajo de los enfermeros.

Conclusión

Los enfermeros percibieron la intervención educativa como una importante estrategia de educación permanente para el perfeccionamiento de sus competencias administrativas, evaluaron de forma positiva la metodología escogida y los contenidos trabajados, y fue considerada aplicable en el contexto de la práctica profesional.

Competencia professional; Estrategia de salud familiar; Gestión de la prática profisional

Introduction

Skills are associated with the human capacity to perform specific tasks. It refers to a set of knowledge, skills and attitudes (SKA), whose knowing how to act implies mobilizing, integrating and transferring resources that can add economic value to the organization, in addition to social value to individuals.(¹)

This concept has been gaining ground in the corporate setting, mainly as a result of changes in the economy, in the globalization process and in the labor market,(²)which makes it necessary to enhance the multifaceted skill integrated to the team and the organization. In this context, nurses’ work must go beyond direct assistance or supervision, as these professionals also assume roles in managing their team’s relationships, regardless of the performance setting.⁽³⁾

In this regard, the Brazilian National Primary Care Policy (PNAB - Política Nacional de Atenção Básica), revised in 2017, defines primary care managers’ actions and recommends their inclusion in the team, including federal financial support, a context in which such a manager is flagged as fundamental in the team organization.(⁴)

It should be noted that, in the context of the Unified Health System (SUS – Sistema Único de Saúde), Primary Health Care (PHC) develops actions that include its principles and guidelines, to the point of interfering with health situations, in the autonomy of individuals and in the determinants of collective health. In this juncture, the Family Health Strategy teams (FHS) develop one of the most important roles, as they establish the link between the service and the community.(⁵)

With regard to nurses’ work in PHC, as well as in FHS, there are several aspects that hinder the development of competent work, especially in relation to the process of managing the teams. Among these aspects, the scarcity of human and material resources, lack of technical-scientific knowledge, deficit in infrastructure, weakness in relationships and interpersonal communication, lack of motivation and lack of confidence stand out.(⁶)

In view of this, it is urgent to implement strategies in the PHC setting that strengthen nurses’ managerial skills. These can be provided through educational actions, based on the precepts of the Brazilian National Policy for Permanent Education in Health (PNEPS - Política Nacional de Educação Permanente em Saúde). This policy proposes a pedagogical process that directs work or training towards reflective analysis, meaningful learning, from the use of active methodologies and that considers scientific and technological advances in this process.(⁷)Thus, permanent educational actions must be conducted in such a way as to foster reflection, by health professionals, on the reality in question and the care models in which they are inserted, as well as the problems they face.(⁸)

It is noticed that the theme that permeates managerial skills for the work process has been increasingly addressed in the field of nursing.(⁹-¹²) However, in Brazil, scientific production on team management in the context of PHC, especially with regard to the development of skills, as one of the possibilities of reference, is still limited.(¹³) The approaches, in this setting, end up being more directed to care management, from academic training, with a greater focus on care analysis of the work process.(¹⁴)

Therefore, this study aimed to understand how FHS nurses perceive an educational intervention on managerial skills.

Methods

This is a comprehensive qualitative intervention research, one of the most instigating and challenging research approaches in the health field, as it seeks to strengthen participants’ participation and autonomy, in addition to giving meaning to the experiences. This is a methodology capable of breaking with vertical and watertight approaches and highlighting elements that enhance action in favor of dialogue and interaction.(¹⁵)

The study was carried out in nine of the 34 Basic Health Units (BHUs) in a municipality in southern Brazil, selected for convenience. Therefore, the criterion used was geographic proximity, all located in the same region of the city, which is characterized by a vast population contingent considering the Brazilian parameters of demographic density.

The invitation to participate in the intervention was made in person to all 24 nurses who worked in FHS teams linked to the units selected at the time of the study and who had worked for at least one year in the current team. In turn, those who were on sick leave or vacation during the period of data collection were also excluded. A total of 14 nurses agreed to participate in the study, allocated in eight BHUs.

The intervention took place based on the elaboration of a plan developed by the authors based on a previous study(⁸) and its content was validated by five expert judges in the field. Afterwards, there were six weekly meetings in which active teaching methodologies were used (problematization, conversation circles, dynamics, reflective activities). These meetings took place in a reserved room at one of the selected BHUs from May to June 2019 according to Chart 1.

Chart 1
Intervention Plan’s programmatic content

Meetings	Objectives
Leadership and self-knowledge	1. Present to participants the main objectives of the intervention based on the points listed by them in qualitative data collection; 2. Enable a space to meet each other and assess themselves as leaders; 3. Differentiate the main leadership styles; 4. Problematize leadership as a nurse’s managerial skill. Pedagogical strategies: dynamics “mirror” and “tower building”, construction of SKA on leadership and video “full ball x withered ball”.
Communication	1. Promote discussions about communication as a managerial skills of nurses; 2. Enable reflections on how communication is used in the work process in FHS. Pedagogical strategies: theater: “It is communicating that one understands”, dynamic “Chinese whispers” and construction of SKA on communication.
Interpersonal relationship and teamwork	1. Reflect on teamwork as an important tool for managing FHS teams; 2. Understand the need for interpersonal relationships as a managerial skill of nurses. 3. Know the main strategies for conflict resolution. Pedagogical strategies: dynamics “boat factory” and “rôtulos”, construction of SKA interpersonal relationships and teamwork.
Decision-making, negotiation and flexibility	1. Reflect on how nurses make decisions, negotiate or exercise flexibility in the context of FHS; 2. Address the main strategies for decision-making, negotiation and flexibility. Pedagogical strategies: dynamics “who will survive?” and “untying knots”, building the SKA’s decision-making, negotiation and flexibility.
Entrepreneurship and creativity	1. Encourage reflection on how entrepreneurship and creativity are being employed in FHS; 2. Understand the meanings of entrepreneurship and creativity in the context of health. Pedagogical strategies: dynamics “free fair” and “brainstorming”, construction of SKA of entrepreneurship and creativity.
Systemic vision, planning and organization	1. Enable reflection and discussion on the need to develop management skills of systemic vision, planning and organization. Pedagogical strategies: dynamics “execution and project planning” and construction of SKA of systemic vision, planning and organization.

No waiver was recorded during intervention. However, among participants, three missed one of the meetings and two missed in two. The meetings lasted an average of three hours and took place in two different shifts, morning and afternoon, making it more flexible and providing opportunities for the participation of a greater number of nurses.

The assessment in relation to content, methodology used and implications for professional practice occurred at the last meeting through a focus group. It is a technique in which information is obtained based on reflections and group discussions, guided by a specific theme.(¹⁶) Due to the difficulty experienced by nurses to move away from their activities/units for a long period to participate in intervention, a single focus group session with a duration of one hour was held. It was coordinated by the main researcher with the help of two observers, who were responsible for recording the audio and recording the field notes during and after its performance.

The following guide questions were used during the focus group: What are you thinking about the content you have worked on in the meetings? What suggestions would you have regarding the content? Regarding the workload used for these contents, would you have suggestions for increase or decrease for any of them? What is your opinion regarding the methodology used in the approach to the themes? What was it like to participate in this intervention? What changes were observed in your professional practice after the beginning of intervention? Do you think that a proposal similar to this could be implemented as a permanent education?

Data analysis was by coding, based on the three interdependent steps proposed in grounded theory (GT), open, axial and selective coding. In open coding, the concepts were identified from comparations between their properties and dimensions. Subsequently, the preliminary codes consisting of the titles assigned for each incident, idea, or event were grouped into conceptual codes. In the axial coding stage, these were grouped giving rise to categories and subcategories, with a view to a denser explanation of the phenomenon. Finally, selective coding consisted of a continuous comparison and analysis of the categories and subcategories constructed, in order to develop, integrate and refine the theoretical matrix and emerge the central phenomenon.(¹⁷)

To facilitate this process, the categories were ordered according to the paradigmatic model in the Strausian perspective.(¹⁷) The whole process of data analysis and coding was carried out by two researchers, which allowed an explanatory coherence between the dimensions that support the theoretical matrix of the paradigmatic components that they consider in their structure: phenomenon, causal conditions, intervening conditions, context, action/interaction strategies and consequences.(¹⁷,¹⁸)

The study was developed in line with national and international ethical guidelines and approved by the Institutional Review Board (Opinion 2,927,009) (CAAE (Certificado de Apresentação para Apreciação Ética - Certificate of Presentation for Ethical Consideration) 93926618.7.0000.0104). All participants signed an Informed Consent Form in two copies. To preserve their anonymity, the abbreviation FG was used to designate “focus group” followed by an ordinal number indicative of the sequence of participants (e.g. FG-6).

Results

The 14 nurses in the study were between 28 and 56 years old, working in FHS between one and two years and 12 of them were female. From the analytical process, the central category entitled “Revealing the need to improve managerial skills for FHS nurses” emerged. This communication presents the category corresponding to the “consequences” component of the paradigmatic model, entitled “Improving management skills among FHS nurses”, supported by two subcategories, as presented in Figure 1.

Figure 1
Graphic representation of the component “consequences” - “Improving management skills among FHS nurses”

Potentialities of intervention for improving management skills

In this first category, perceptions about the potential of the intervention were included, represented by two subcategories “Intervention as a space for exchanging experiences and sharing anxieties” and “Visualizing positive strategies and resources in implementing an intervention”, according to Chart 2.

Chart 2
Presentation of excerpts from the first subcategory

Subcategories	Excerpts from speeches
Intervention as a space for exchanging experiences and sharing anxieties	I think we really needed this stop, to be discussing the work process, because we don’t have a lot of meetings to discuss it. (Nur-1) We see we’re not alone! I see that I have more nurses who are in the same situation as me, with the same difficulties and limitations. This way we don’t get tense! (Nur-3) I felt overvalued. We’re not used to it. (Nur-4) I felt privileged. When I saw the themes I thought “it’s going to be kind of an escape for me”, get out of work a little and sit down with colleagues. The negative is not here! The negative is in getting this far! Here is the point to relax, an escape valve, is a therapeutic time! (Nur-5) You were able to bring all the focus to FHS nurses, in our daily lives, in our reality. Nobody thinks only of nurses! I felt welcomed. (Nur-6) We really think that we are alone, that the problem is only with us, that it is only my team that is not working. (Nur-7) What a pity it’s going to end. I spent the whole week thinking Friday was coming. That I could sit down and exchange experiences, identify myself, because we can’t do that inside the unit. (Nur-7)
Visualizing positive strategies and resources in implementing an intervention	The way they were approached we didn’t keep reading book parts. The dynamics are extremely different and new. We can’t get enough! (Nur-3) Usually when we have training with several meetings, we realize that the number of participants is decreasing each day, because sometimes the theme does not matter, the theme does not meet what we need! So we always prioritize the work, but in this case we prioritize the training. In this intervention, the themes were so pertinent to our performance and the role we played that we were waiting for others and thinking about what it would be like! That’s why there was no waiver. (Nur-4) We built this knowledge during the meetings. We don’t read, we build! (Nur-4) The training and protocol presentations that come from the department are very archaic already, outdated. (Nur-5) You leveled all of us, respected our knowledge, our experience. This methodology is nice because part of this, needs the previous knowledge to come out a new collective concept. Here you listen, you can talk, you have a voice. (Nur-5) If you continued, I think it would add more. I think the manager should always invest in it. The more meetings the better the results we will have in BHU. (Nur-8) I had already discussed this in residency and in graduate studies in people management, but I had never discussed it that way. It’s usually always with slides and a teacher talking. The way it was put here we were able to put into practice more easily. (Nur-8) Regarding time, I think the six meetings were ideal, both in relation to the hours of the day and in relation to the number of meetings. Of course, if you had more themes, we would follow. But everything comes at a time when it gets tired, even when it’s good. So, for this purpose, it was enough. (Nur-9) One thing is to hear someone talk. I have a great facility to sleep and I do sleep. And when you do an activity like this, no matter how simple it is, it sticks in your head, it’s essential. (Nur-9)

Benefits of intervention on managerial skills in nurses’ work

In this second category, the benefits resulting from the intervention proposal were evidenced. The meetings allowed nurses to approach content that was far from the reflective process, but present daily in the work context. Moreover, changes in the work environment were also observed from these meetings, as present in the excerpts of Chart 3.

Chart 3
Presentation of excerpts from the second subcategory

Subcategories	Excerpts from speeches
Evidencing that intervention brought knowledge to practice	All the subjects that were raised in the meetings, we thought we were far away from us, that we were totally unfamiliar with it. But we saw that we just don’t know how to name, and now we have too much training and theoretical knowledge to do better. (Nur-3) The opportunity came to learn, listen, put into practice. For me, in particular, it came at a very important time in my life, it came to impose limits on me. This moment I’m going to bring to life. (Nur-5) As far as how to give feedback, everyone learned how to give a compliment first. There’s something we incorporate forever. (Nur-8) It’s what people do on a daily basis, but we don’t stop to think. We wouldn’t stop! But today I can stop and think, “Is this decision democratic?” This anchors in us! Because it’s exactly the content we needed. (Nur-9)
Seeing changes in the work process after intervention	For me, it added a lot. I changed a lot the vision of my work. Many attitudes I did not even realize I was doing. And today I changed some things, corrected many things. (Nur-1) I began to rethink the issue of communication between the team, between patients, among all of us. You pay more attention and do some of the things we discussed here. I’m rethinking it and there are some changes I’m already trying to make. It’s really been a change. (Nur-4) Today, we had a meeting and even “having” this meeting was better. I’m seeing changes, I appreciate it, thanks for these “glasses”. It’s softer, you can see a better return on top of that demand. (Nur-4) These reflections that we had and these changes that I’m trying to put into everyday life will reflect on the team. We were all tired of the same thing, these “little things”, the lack of communication. We need to try to make the environment lighter, and the team more cohesive, in sync. (Nur-4) I went back to my workplace with the thought of working that way. And for me it got faster, quieter. It didn’t change the problem, but it changed the way we act on it. That meant a lot. (Nur-5)

Although participants mentioned benefits from intervention for professional practice, it is noteworthy that they reported concern with the discontinuity of actions like this, since they consider that municipal management has difficulties in providing opportunities for these moments:

It makes me sad to know how hard it was to have this moment! I think that our entire coordination is made up of nurses who do not have a vision of the need for “let’s value this training” and think that this is a form of management too, a way of optimizing the service! It saddens me to think that I have coordination like this: plastered! (Nur-5)

Discussion

As a limitation of this study, there is the intentional selection of the participating BHU (geographic proximity), given the need to facilitate the participation of professionals and also the fact that the focus group was conducted by the same researcher responsible for intervention. However, the focus group session was not held for the express purpose of assessment, but rather as part of the training process. Thus, it is believed that the results found offer support for reflection in other contexts of nurses’ work in FHS, since managerial skills are still little explored in this work setting.

Studies have shown that suffering at work is increasingly present among health professionals, characterized by emotional exhaustion, depersonalization and reduced personal fulfillment.(¹⁹,²⁰) In this sense, as mentioned by the participants of this study, this type of intervention proposal can also contribute as an effective tool for the exchange of experience and emotional relief among professionals, as it provides a comfortable environment for sharing anxieties and experiences. Furthermore, the formation of collective spaces for meaningful learning in the work environment can serve as an encouragement for reflection on the work process itself.

It is important to highlight that the quality of life at work is preserved in situations where the psychological demands of professionals are met. In turn, in contexts of high stress, characterized by the presence of situations that generate anxiety, overload, fast pace and low social support, the negative repercussions can only be alleviated, as it happens in the daily lives of nursing professionals. In this context, the development and implementation of strategies that promote social support among the nursing staff can contribute to reducing work overload.(²¹)

Nurses felt valued and welcomed during intervention, a relevant aspect for enhancing the expected results from the meetings and, consequently, in the improvement of their managerial skills. They also highlighted the importance of being an intervention exclusively focused on nurses’ needs, which valued and was based on the demands experienced by them in the daily work process in FHS, and that the contents were designed with a focus on professional practice.

In this regard, it is worth noting that the focus on managerial skills is essential for a qualified practice of FHS nurses. Thus, transdisciplinary teaching actions in training should be directed towards the construction of spaces that contribute to the understanding and capacity of the various managerial skills expected for this professional, which are essential to strengthen an autonomous practice in FHS. Therefore, training spaces and training closer to the reality of work are needed, considering that the daily health setting is in constant transformation.(⁸,²²)

A study carried out with 20 clinical nurses from a private hospital in southern Brazil(¹¹)identified some strategies for the development of managerial skills, such as permanent education through specialization courses, updating and improvement, interaction with other professionals, and sharing of practical experience in nursing. It is believed that, especially in the context of PHC, the implementation of strategies that encourage the development of skills can favor team engagement, the development of collaborative activities and the power to resolve the services. However, the need to consider the particularities of the PHC context in planning training actions is highlighted so that new practices are incorporated into the service routine and meet the SUS precepts.

The nurses participating in this study also positively assessed the contents and themes worked, as well as the time allocated to the intervention meetings and the teaching methodologies used in its conduct. This reinforces the thesis that the improvement of managerial skills can be enhanced if added to alternative methods that aim to provide criticality in the teaching process.(⁹,¹⁰)

Problem-solving teaching methodologies provide cognitive learning, with knowledge retention and knowledge transfer.(²³) Problematization, supported by constructivism, which refutes traditional learning, restricted only to the transmission and memorization of knowledge, brings a new perspective to the construction of a critical and active professional.(²³)

As reported by participants, the occurrence of a traditional educational process is insufficient to meet health professionals’ demands, mainly due to its vertical and fragmented teaching characteristic. The professional profile required by the current job market values not only technical knowledge, but also communication, interpersonal relationships, among other skills that integrate managerial skills.(²⁴)In view of this, the use of active methodologies enables the individual to occupy the center of the learning process and increases their responsibility towards training/updating.(²⁵-²⁷)

Although practices aimed at the traditional model still prevail in educational processes, the advances observed are related to the use of technological resources and reflective practices in daily work. In the context of health institutions and the work process, educational and permanent actions aim to awaken workers to changes in practice, modifying their professional performance and the qualification of health services.(²⁸)

However, despite its estimated relevance for improving management and care qualification, the consolidation of educational and permanent actions is still a challenge. The PNEPS needs to be effectively implemented in primary care, as it is premised on a political-pedagogical strategy that takes as its object the problems and needs arising from the health work process and enables qualification and improvement to strengthen political-institutional management processes of SUS. (²⁹) Furthermore, its use can contribute to the development of health workers, which will directly reflect on the care provided.

It is identified that, for establishing the PNEPS, some aspects are considered hindering, such as the lack of tools to help managers operationalizing the educational process, the need for articulation between the different levels of management, the lack of qualified professionals and their adherence to educational activities, the lack of planning by the units, professional turnover and the focus on fragmented work.(²⁸)

Even though the challenges are great, the results of educational processes are noticeable and effective in professional training and consequently in the qualification of care. Continuing education is a powerful tool that makes it possible to act on the micropolitics of work, expanding the spaces for action and articulation between professionals.(⁶) Furthermore, continuing education is an excellent tool for improving the managerial skills of FHS nurses, which may result in the construction of knowledge applicable in practice and changes in the work process of these professionals and their teams, especially in the way they see the work process and their relationships.(²⁸)

From the implementation of permanent education aimed at improving managerial skills among nurses, not only professionals, but also the institutions themselves can provide opportunities for improvements in the work process and, consequently, in the quality of health care for the population.

There is, therefore, a constant need for changes in the performance setting, based on reflections arising from the daily routine of the service itself, in addition to teaching being linked to the changing reality of actions linked to FHS. Thus, it starts with the possibility of encouraging the creation and maintenance of spaces and themes capable of generating self-analysis, self-management and changes in professional and institutional practice.(⁶)

Conclusion

Nurses perceived the educational intervention as an important continuing education strategy to improve their managerial skills, positively assessed the chosen methodology and the contents worked, considering its applicability in the context of professional practice. It is noteworthy that educational interventions are challenging processes, especially in health services, constituting innovative strategies for nursing practice. Thus, initiatives such as the proposal developed in this study can contribute to advances in the positioning of nurses in PHC and need to be provided within the services, with management, in its different spheres, playing an important role in this context.

Acknowledgements

To the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior).

Referências

• ¹
  Fleury AC, Fleury MT. Business strategies and skills training. São Paulo: Atlas; 2009.
• ²
  Correa GC. Definition and development of competences: a paradigm in the strategic process. Rev Estudo CEPE. 2015;39(67):103-16.
• ³
  Carmelo SH, Rocha FL, Chaves LD, Silva VL, Soares MI. Competências profissionais e estratégias organizacionais de gerentes de enfermagem. Cien Enferm. 2016;22(1):75-86.
• ⁴
  Almeida ER, Sousa AN, Brandão CC, Carvalho FF, Tavares G, Silva KC. Política Nacional de Atenção Básica no Brasil: uma análise do processo de revisão (2015–2017). Rev Panam Salud Publica. 2018;42:e180.
• ⁵
  Brasil. Ministério da Saúde. Portaria nº 2.488, de 21 de outubro de 2011. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes e normas para a organização da Atenção Básica, para a Estratégia Saúde da Família (ESF) e o Programa de Agentes Comunitários de Saúde (PACS). Brasília (DF): Ministério da Saúde; 2011 [citaso 2021 Set 26]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2488_21_10_2011.html
  » https://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2488_21_10_2011.html
• ⁶
  Dias RM, Moniz MA. Nursing managerial aptitudes in the family health strategy: perceptions of nursing undergraduates. Rev Fun Care Online. 2019;11(4):1048-52.
• ⁷
  Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação na Saúde. Política Nacional de Educação Permanente em Saúde: o que se tem produzido para o seu fortalecimento? Brasília (DF): Ministério da Saúde; 2018 [citado 2021 Set 26]. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_educacao_permanente_saude_fortalecimento.pdf
  » https://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_educacao_permanente_saude_fortalecimento.pdf
• ⁸
  Peruzzo EP, Marcon SS, Silva IR, Matsuda LM, Haddad MC, et al. Essential management competencies of nurses: actions and interactions in the context of the Family Health Strategy. Rev Bras Enferm. 2020;73(6):e20190511.
• ⁹
  Rosin J, Tres DP, Santos RP, Peres RR, Oliveira JL. Desenvolvimento de competências gerenciais na enfermagem: experiência entre residentes. Rev Eletr Gestão Saúde. 2016;7(1):231-46.
• ¹⁰
  Siqueira CL, Bernadeli AC, Gasparino RC, Feldman LB, Cunha IC, Oliveira RA. Knowledge of responsible technical nurses on management skills: a qualitative study. Rev Bras Enferm. 2019;72(1):49-55.
• ¹¹
  Aued GK, Bernardino E, Peres AM, Lacerda MR, Dellaire C, Ribas EN. Clinical competences of nursing assistants: a strategy for people management. Rev Bras Enferm. 2016;69(1):142-9.
• ¹²
  Lachmann H, Nilsson J. Dual use of instruments for assessing nursing students professional- and clinical competence. Nurse Educ Today. 2021;96:104616.
• ¹³
  Xavier SP, Pereira AP, Moreira MR, Martins AK, Ferreira HS, Machado MF. Competências em promoção a saúde à luz do projeto competencies health promotion (CompHP): uma revisão integrativa. Cien Cuid Saude. 2019;18(1):e43421. Review.
• ¹⁴
  Madureira GC, Santos MF, Santos DS, Batalha EM. Reflexão sobre a enfermagem e o gerenciamento das unidades básicas de saúde. Rev Baiana Saúde Pública. 2016;40(4):848-61.
• ¹⁵
  Mendes R, Pezzato LM, Sacardo DP. Research and intervention in the promotion of health: methodological challenges of researching “with”. Cien Saude Colet. 2016;21(6):1737-45.
• ¹⁶
  Kinalski DD, Paula CC, Padoin SM, Neves ET, Kleinubing RE, Cortes LF. Focus group on qualitative research: experience report. Rev Bras Enferm. 2017;70(2):424-9.
• ¹⁷
  Strauss AL, Corbin J. Qualitative research: techniques and procedures for the development of grounded theory. 2a ed. Porto Alegre: Artmed; 2008. 288p.
• ¹⁸
  Silva IR, Leite JL, Trevizan MA, Mendes IA, Silva TP, Lins SM. Learning through research: from teaching science to the sphere of nursing care. Esc Anna Nery. 2017;21(4):e20160329.
• ¹⁹
  Luz LM, Torres RR, Sarmento KM, Sales JM, Farias KN, Marques MB. Síndrome de Burnout em profissionais do serviço de atendimento móvel de urgência. Rev Fundam Care Online. 2017;1(9):238-46.
• ²⁰
  Figueiroa GB, Peruzzo HE, Gil NL, Back IR, Silva ES, Marcon SS. Síndrome de burnout entre profissionais de um serviço de atendimento móvel de urgência do Paraná. Cogitare Enferm. 2019;24:e61917.
• ²¹
  Azevedo BD, Nery AA, Cardoso JP. Occupational stress and dissatisfaction with quality of work life in nursing. Texto Contexto Enferm. 2017;26(1):e3940015.
• ²²
  Jeffs L, Merkley J, Sinno M, Thomson N, Peladeau N, Richardson S. Engaging stakeholders to co-design an academic practice strategic plan in an integrated health system: the key roles of the nurse executive and planning team. Nurs Adm Q. 2019;43(2):186-92.
• ²³
  Pascon DM, Otrenti E, Mira VL. Perception and performance of nursing undergraduates in evaluation of active methodologies. Acta Paul Enferm. 2018;31(1):61-70.
• ²⁴
  Marques LM. Active methodologies as strategies to develop education in values in nursing graduation. Esc Anna Nery. 2018;22(3):e20180023.
• ²⁵
  Yew EH, Goh K. Problem-based learning: an overview of its process and impact on learning. Health Prof Educ. 2016; 2(2):75-9.
• ²⁶
  Bachur CK, Bachur JA, Candido SS, Machado JP, Daniel AC, Silva CM, et al. The use of active methodologies as teaching strategies of measuring blood pressure. J Hum Growth Dev. 2020;30(3):443-50.
• ²⁷
  Garrison E, Colin S, Lemberger O, Lugod M. Interactive learning for nurses through gamification. J Nurs Adm. 2021;51(2):95-100.
• ²⁸
  Ferreira L, Barbosa JS, Esposti CD, Cruz MM. Permanent health education in primary care: an integrative review of literature. Saúde Debate. 2019;43(120):223-39.
• ²⁹
  Ferreira AS, Abrahao AL. Gerência do cuidado em Enfermagem na Estratégia Saúde da Família: revisão sistemática. 2020;9(5):e68953087. Review.

Edited by

Associate Editor (Peer review process): Alexandre Pazetto Balsanelli (https://orcid.org/0000-0003-3757-1061) Escola Paulista de Enfermagem, Universidade Federal de São Paulo, SP, Brasil

Publication Dates

• Publication in this collection
  06 June 2022
• Date of issue
  2022

History

• Received
  13 June 2021
• Accepted
  15 Oct 2021