MULTI-PROFESSIONAL RESIDENCY AS AN INTERCESSOR FOR CONTINUING EDUCATION IN HEALTH

Abstracts

The objective in this study is to understand how Continuing Education in Health is developed in the everyday life of professionals in a multi-professional residency program in health at a teaching hospital in the South of Brazil. Qualitative research with a case study design, involving 16 professionals. The results show that the multi-professional residency program establishes collective spaces, as it permits encounters among subject who develop their actions based on pedagogical training and guided by continuing education. It is concluded that the participants in the residency program can think about other ways of producing health, encouraging the search for transformations of the operating practices to produce new actions in health.

Education, continuing; Internship and residency; Professional practice; Nursing; Case studies

Objetiva-se compreender como a Educação Permanente em Saúde é desenvolvida no cotidiano dos profissionais de uma residência multiprofissional em saúde, de um hospital de ensino no Sul do Brasil. Trata-se de uma pesquisa qualitativa, do tipo estudo de caso, com 16 profissionais. Os resultados mostram a residência multiprofissional como instituidora de espaços coletivos, uma vez que possibilita encontros entre sujeitos que desenvolvem suas ações fundamentadas em uma formação pedagógica e pautadas na educação permanente. Conclui-se que os integrantes da residência têm a possibilidade de pensar outros modos de produzir saúde, incentivando a busca pelas transformações das práticas profissionais para produzir novas ações em saúde.

Educação continuada; Internato e residência; Prática profissional; Enfermagem; Estudos de casos

El objetivo fue comprender como la Educación Permanente en Salud es desarrollada en el cotidiano de los profesionales de una residencia multiprofesional en salud, en un hospital de enseñanza en el sur de Brasil. Investigación cualitativa, del tipo estudio de caso, con 16 profesionales. Los resultados muestran la residencia multiprofesional como instituidora de espacios colectivos posibilitando encuentros entre sujetos que desarrollan sus acciones fundamentadas en una formación pedagógica pautadas en la educación permanente. Se concluye que a partir de eso los integrantes de la residencia tienen la posibilidad de pensar otros modos de producir salud, incentivando la búsqueda por las transformaciones de las prácticas de actuación para pensar en nuevas posibilidades de acciones en salud.

Educación continua; Internado y residencia; Práctica profesional; Enfermería; Estudios de casos

INTRODUCTION

The National Continuing Health Education Policy (PNEPS) proposes a new configuration for the health professionals to produce knowledge and think about education and work.¹ This policy allows the education and development of health professionals to take place in a decentralized, ascending and cross-disciplinary mode, encompassing all places and knowledge to provide for the democratization of the work spaces.²

As a public policy, it is based on significant learning and on the reflexivity of the practices active in the service network and, consequently, in the problematization of the reality. It aims for the construction and reconstruction of knowledge. This, in turn, is constituted in this case through the health professionals' daily experiences, who are stimulated to reflect, act and, thus, again question the health practices through this problematization.²

Hence, in the practice of the PNEPS, the premise is fundamental that the practices of the health professionals respond to the demands of the Unified Health System (SUS). Therefore, the objective of the Multiprofessional Residency in Health (MRS) is to prepare professionals for distinguished action in the SUS, as it presupposed the interdisciplinary construction of the health professionals, teamwork, continuing education and the reorientation of technical care logics.^1-2 What is added to this education modality results in educative actions centered on the health needs of the population, on the multiprofesional team and on the institutionalization of the Brazilian Health Reform, in line with the recommendations of the PNEPS and the principles of the SUS.¹

Hence, the MRS is considered as a space for the development of Continuing Health Education (CHE), which can constitute a potential device to promote the changes the health professionals intended to consolidate the principles of the SUS.² Therefore, the study of the educational space of multiprofessional residency programs is justified because these programs are important in the context of health education and because these studies have clearly increased in stricto sensu graduate programs in Brazil.³

In that sense, the development of this study was based on the following research question: How is continuing health education development in the daily work of the professionals in a Multiprofessional Residency Program in Health? The objective is to understanding how continuing education in health is operated in the Multiprofessional Residency Program in Health.

METHOD

This study is a descriptive, exploratory and qualitative case study. The choice of this type of study is justified by the possibility to analyze the phenomenon in its context, thus addressing the reality in depth, which permits broad and detailed knowledge.⁴ In addition, the research method permits its adoption is several research types, provided that the case under study is specific,⁵ which in this case refers to the MRS.

In that perspective, the relevance of adopting the case study as a research method favors naturalistic generalizations and the manifestation of different viewpoints on the research object. In addition, to answer the research objectives, many variables should be involved and investigated in the analysis, which permits several positions towards the same phenomenon. These variables can be dimensioned through the triangulation of data sources (documentary analysis, observation and interview).^4-6

This study was developed in the Multiprofessional Residency Program in Health at a teaching hospital in the South of Brazil. The participants involved in the research were the professionals who took part in the MRS in the hospital area, including the following professions: Nursing, Psychology, Nutrition, Social Service, Physiotherapy, Speech, Language and Hearing Therapy, Pharmacy, Occupational Therapy, Dentistry and Physical Education and core and field tutors, totaling 16 professionals. They complied with the following inclusion criterion: being a professional affiliated with the MRS, active in the hospital area during the data collection period, which was developed between January and May 2012.

The research participants were informally contacted on the occasion of the field observation process, and formally questioned through a semistructured interview. Initially, a documentary research was developed in the pedagogical project of the MRS, looking for registers that revealed evidence on the principles of CHE. In addition, field observation was developed through the dynamic development of seminars, aiming to discuss and plan the residents' activities. Finally, individual interviews were held with the research subjects, aiming to deepen the search for data on the research problem. Therefore, the interview started by presenting the informants with a fragment of the PNEPS, which permits discussing the proposed theme and, next, the research subjects were asked the following guiding question: "How do you perceive the development of your practices in terms of orientation of the principles of CHE?"

After producing the data, they were analyzed in combination, involving the triangulation of the data the case study recommends. The data triangulation provides the study with more accurate analyses, allowing the researcher to construct a chain of evidences, with a view to enhancing the trustworthiness in the interpretation of the research data.⁴Initially, the field and core seminars were observed, describing the principles of CHE that guided the tutors and residents' actions. At the same time, the pedagogical project of the MRS was analyzed, looking for evidence on the principles of the CHE and, finally, the interviews were analyzed using thematic content analysis, which is systemized in three chronological phases,⁷ which are: pre-analysis, when the interviews were transcribed and the empirical material was organized; exploration of the material, when the empirical material was categorized; and treatment of the results and interpretation, which involved the articulation between the empirical content and the theoretical precepts underlying the study. It is highlighted that, in the pre-analysis and exploration of the material, the software Atlas Ti 6.2 (Qualitative Research and Solutions), version Free Trial was used, offered free of charge to support the coding of the interviews. The analysis of the results was based on the triangulation of the data obtained by reading the content of the interviews, the observations made and the documentary analysis, looking for lines of convergence. The themes that converged with the research objectives were chosen for discussion in this article, supporting the central argument that the MRS is an intercessor space for the development of CHE actions.

Thus, in order to guarantee the secrecy and confidentiality, the participants' identity was preserved through coding by means of the letter E, for the continuing health Education, following by a number that does not correspond to the order of participation in the research. In addition, the participants were identified by the form of affiliation with the MRS: as a resident or tutor.

It should also be observed that the study complied with the ethical principles in National Health Council Resolution 466/2012. Approval was received from the Research Ethics Committee at Universidade Federal de Santa Maria under No. 0147012.4.0000.5346.

RESULTS AND DISCUSSION

The data analysis was based on the reading of the interview content, the observations made and the documentary analysis. The data analysis was based on conceptions of different authors, including Ceccim, Franco, Merhy, who participated actively in the production of knowledge on the CHE, intertwined with other authors who are in accordance with this knowledge production.

The Multiprofessional Residency in Health as the establisher of collective spaces of Continuing Health Education

The Ministry of Health adopted CHE as one of the pillars for the construction of innovative health practices in the democratic system, which are capable of promoting comprehensive and high-quality health care for the citizens who use the SUS.² To fulfill its task, the CHE gains the form of a texture of knots, in which unequal points are linked in health action. Therefore, the CHE does not only offer courses, but mainly encounters among health professionals, users, with opening for dialogue, sharing of texts and concepts.⁸

Based on this understanding of CHE, MRS is signaled as a "possible space of transformation for health professionals articulated as a continuing education device".^9:378 This issue can be evidenced in the testimonies: [...] we experience the residency permeated by continuing education, with the principles of the SUS, it is our day to day. I am unable to think of an action exactly because for us it's what we experience there! (resident E4).

The residency by itself is already a continuing education program (tutor E11).

I believe that much of what the Residency proposes is in line with what the CHE proposes as well (tutor E13).

These testimonies converge in the sense that the MRS constitutes an intercessor space, since it is conceptualizes as an environment of relations that is produced at the encounter among the subjects, in which the product that exists is more than the sum of the stakeholders in this meeting, and translates in the live work of a constantly moving reality, triggering new possibilities of acting in health.¹⁰The MRS uses this intercessor space because it designates the education of professionals as actors of health production, which are not only concerned with the sum of the actions, but mainly with what exists among them, as the result of a singular process, which provides for movements of change.¹⁰

It is observed that some of the interviewees, while reading the selected fragments of the PNEPS, highlighted that it converged with the pedagogical proposal of the MRS. Similarly, the pedagogical project was indicated by the research subjects because it contained concepts in line with the PNEPS. Nevertheless, based on the observations made, it is underlined that the dissemination of this policy comes with bottlenecks, in view of the need to disseminate to disseminate the socialization that involves the PNEPS and its deliberations for the health area, besides the urgency in the dissemination and discussion of this program with the health professionals.¹¹

[...] after reading the fragments, I perceive that we are on the right track. That is what we are developing (resident E7).

The MRS, based on its guiding principles, provides conditions for its members to define the CHE as a structuring pedagogical axis for health actions. Hence, the CHE can be understood as a potential device to promote changes of the management models and care models of the SUS.¹² The following testimonies signal this understanding:

[...] the CHE works on the issue of the transformation of the processes, in the sense of organizing the services according to what the residency proposes (resident E5).

The pedagogical process converges with what the Residency proposes! It reconfigures new possibilities, because of this structural view (preceptor E16).

According to the above testimonies, the pedagogical proposal of the MRS converges with the CHE. That is evidenced as support for pedagogical proposals that permeate the professional education process and the changes of the health service practices. Besides the evidence from the testimonies, the observations made show that the CHE acts beyond an action, it mainly acts in daily health production by all members of the MRS. Nevertheless, it is signaled that the professionals' perception of the MRS as a space for the development of CHE was perceived soon after the reading of the fragment that presented short citations in the PNEPS. Therefore, it is observed that this policy is new in the context of the health policies, and the operation of the CHE needs to be discussed to make it effectively feasible in all health education areas.

In the education processes, challenges are also experienced for the consolidation of the SUS.¹³ There may be a misalignment between what is taught and the students' understanding about the principles and guidelines of the SUS. This can be evidenced in the following testimonies:

My academic background is to graduate and enter the job market, nothing of that is addressed in the residency program (resident E4).

I went to heart about this concept here at the university[residency]. I had never heard about continuing education (tutor E11).

The challenge linked to the discussion of the SUS in professional health education involves the obstacles the CHE faces for its dissemination and operation. Hence, the formation is PNEPS defends is committed to the production of health workers engaged in the principles of the SUS and not just in professionals who possess a monopoly on technical knowledge.¹⁴ It does not mean the rejection of the technique either, as it is known that, in health, technical knowledge cannot be ignored. Nevertheless, the need is repeated for health practices to be monitored by other kinds of educative modalities, such as CHE.¹⁵

Hence, the MRS can be considered a device capable of provoking improvements in the residents' education as, despite the difficulties they presented in the course of their academic education, they highlighted that, when they entered the residency program, they had the opportunity to work engaged in an expanded health concept that is not just focused on biological aspects of the health-disease process, as observed in the following testimonies:

The CHE is truly a strategic proposal to transform educative processes. That is happening a lot here (tutor E8).

What could be perceived in this residency is that it is pure CHE! The residency is strongly focused on the logic of CHE! The resident is brought into this new reality, and new conception of CHE, of teamwork, of multiprofessional, interdisciplinary work (tutor E14).

Based on these testimonies, it is observed that the MRS, departing from an education based on CHE, aims to change the biological logic, which still reflects health education, in which the "supremacy of the fragmented knowledge" impedes the articulation between the parts and the whole and needs to be replaced by a new mode of thinking and knowing "capable of apprehending the objects in their context, their complexity".^16:14 In that sense, the complexity points towards the reflection of daily life, of the act that can be questioned and towards a transformation of the social.¹⁶

Complex thinking permits understanding the development of CHE as a constant work, as it visualizes the intercessor spaces (of the relations) as an environment for the subjects to meet, who allow themselves to doubt, question and problematize the health practices.¹⁰ Thus, it is understood that, in the MRS, the development of CHE occurs when the residents meet with the users, with the health team and with the tutors. It should be observed that the notion of meeting in this case is micropolitical, in which the participants in the meeting are always willing to contribute under intercessor alterities.¹⁷ The meetings are pedagogical and operate against homogenizing practices, with exchanges between the participants' knowledge domains and practices, thus constructing a universe of educative processes in action, in a continuous and intense flow of convocations, de-territorializations and inventions.¹⁸

Based on this encounter, interdependence and interaction exists among the actors for the production of health, with a view to constituting a new collective subject, in view of the creation of a space of "inter" relations, in which the residents can daily invent their autonomy and the production of health acts in an intersubjective relationship. It is highlighted that this encounter with the other is constructed and reconstructed freely to produce meanings that make sense to them as health professionals, to the users and to the health team.¹⁹

In that sense, it is observed that the CHE, developed in the MRS, is constantly active, as it rests on the relations among the health professionals in the intercessor space. In this space, the resident can act as a professional in the production of health freely and autonomously, and can use the CHE as a support tool to help in the subjects' daily life.¹⁹

Continuing Health Education actions that permeate the activity in the Multiprofessional Residency Program: an encounter among subjects

The PNEPS is defined as strategic action that aims for the qualification and transformation of health care, the organization of actions and services, the education processes and the health practices.² The CHE also develops actions that can take place in health care, but the participants in the MRS consider the CHE beyond a strategic action developed in their daily life, as they believe that it takes place in a broader perspective, in the daily activity with the other. Therefore, it is verified that the CHE activities the health professionals developed were evidenced in the encounters with the health users and with the professionals in question through health and service education groups, in accordance with the following testimonies:

Various actions are developed, but I can one group we used to do! [...] we used to talk a lot about health education! That also makes us think about our practices (resident E1).

There's the proposal we need to start developing with the health professional as, for now, we only develop it with the patients, who would be groups of [...] it's not about training, let's say it's about improving [...] (resident E4).

[...] it was a continuing education group because we used to discuss it with the theme, several themes related to our professional activities, we used to discuss some things in view of an expanded clinic, a referral professional (tutor E11).

Based on these testimonies, it can be observed that the residents signal the development of a CHE through health education groups and in-service education, focused on the concern with answering the users' health needs and with working towards objectives with the professionals from the MRS program, such as the expanded clinic and the referral team. Hence, it is highlighted that the CHE, linked to the concept of expanded clinic and the humanization and welcoming proposal, represents effective strategies for the transformations in health work.^2-16

Besides the health education and in-service education groups, the core and field tutoring were appointed as important activities permeated by the CHE, which is evidenced in the following testimonies:

It is a core tutorship where a singular therapeutic project will happen. We will start to work on that here so that, next year, the R1 [first-year residents] are already able to do that in practice there in the network (tutor E8).

[...] the tutorship is linked to these continuing health education issues, which involves both the teaching issues and professionals issues, we in training. [...] There are several others, these are informal spaces in which continuing education also takes place, not only in formal spaces (resident E9).

CHE is always present in the seminars, in the tutorships where professional activity is discussed, in one way or the other it is always present in the residents and tutors' actions (tutor E13).

Among the informal spaces in the testimonies, the tutorships are evidenced as a favorable time for the development of CHE, as tutors and residents dialogue, exchange experiences and define how the health professionals' activities will be planned. In the observations of the tutorships in question, some activities discussed could be highlighted, which are: health activity workshops, reading of scientific articles for debate and theoretical foundation in other studies, or even studies developed based on the theme in question or other related questions, discussion of extension and research projects, participation in events, discussion about the undergraduate program's insertion in the field including the residents' integration, participation in the Pro-Health program, development of distinguished activities to attend to the users' needs; discussion about: National Humanization Policy, expanded clinic, multidisciplinary team, among others. It is also highlighted that the activities planned in the tutorships are based on the field activities, on group work, prioritizing the users, emphasizing their singularity.

Hence, the tutorships are intercessor spaces for the development of CHE, as they permit thinking of the collective, deconstructing the mechanized routine and proposing activities that expand the view on the health world, with production of knowledge that presents a critical reflection, considers the experiences of all participants in the CHE: users, members of the MRS and the service health team.

In that sense, the encounter between professionals-users, professionals-professionals and professionals-residents, in which the care production is developed, serves as a scenario for the pedagogical production, permitting the exchange of cognitive, affective and subjective knowledge.¹¹ These care and pedagogical production scenarios attribute a new meaning to health education, proposing it as a relation beyond teaching-learning, in the sense of cognition and subjectivation, with a view to creating groups with people who are able to assume the protagonist role, with a view to developing the SUS.²⁰

Continuing Health Education permeating the education of the residents through pedagogical encounters

In this category, the testimonies appoint that the CHE guides their education, which happens in the intercessor spaces of the encounters, and not just in the theoretical subjects in the classroom:

There are these formal spaces, for example, the tutorship with appointments, but I believe that what happens most is this natural approximation, this need to discuss a case and that we are able to bring the policy into that case and try to reflect the professional actions as well as a critical act of our practice, knowledge (resident E10).

Based on this testimony, it is perceived that the CHE only happens in the order of the meeting and the interaction conditions among the participants, and not just through a professional order and the work conditions.²¹ Again, it is observed that the residents' activities in the development of the CHE happens through the micropolicy of life work, in view of the resistance to captures, the struggle for creation, the exposure to other forms of health production as opposed to hegemonic knowledge.²¹ In addition, it is observed that, in this research, the residents emphasize that those who are part of the encounters (service professionals, MRS professionals, users) are implied in education guided by the principles of CHE.

The education permeated by CHE also lacks encounters with the other, with the learning in the classroom and with the practical field to develop health production, in accordance with the testimony:

You cannot separate the student from the in-class learning. He needs to go out and do the learning in the field. Where is the learning in the field? It is where he questions what he is learning and it's how he will apply what he learned in the classroom. And the opposite is true, also because there in the workplace, we need to know how to do it. That's how I see continuing education in health (tutor E3).

As presented in the testimonies, the interviewed residents signal the idea that the learning in the classroom, together with the tutor, cannot be detached from learning in the practical field. Regarding this integration, it is highlighted that tutors and residents understand that the resident is competent to act in an interdisciplinary manner in the field of thinking-doing in the professional areas.

In that sense, the residents' education, triggered by spaces in which the health professionals dialogue on the CHE, should be understood as a process, and not only as something punctual, considering that, through this education, the residents may be able to develop competences (knowledge, attitudes and skills) in the health system. Thus, arousing questions on the reality, moving towards the daily, is fundamental for the health professionals to establish proximity between socially constructed knowledge and the experience of the job world.²¹

In that sense, the pedagogical project of MRS signals that the residents are expected to internalize a reflexive critical attitude that takes the form of commitment to the feasibility of activity method, based on the principles of the SUS, guided by the principles of the SUS, which aim for the problem-solving ability of the health actions at the different levels of the care system. In addition, in that pedagogical project, political-pedagogical guidelines are appointed for the education of the residents, which guide the resident in the construction of knowledge, so as to make it capable not only of questioning the daily activities, but also of proposing intervention alternatives. Nevertheless, it is highlighted that the interviewees reveal that the CHE is addressed incipiently in the theoretical subjects:

I think that the concepts are similar to what we intend to do. What we don't have right now is that we are not specifically talking about continuing education, this concept was not targeted, nor this policy specifically, but the proposal is indirectly similar to the concepts of the policy (resident E4).

Based on the observations of the seminars and the field and core tutorships, it can be perceived that the tutors and teachers discussed and offered the theoretical framework of the practical activities the residents would develop in their activity sphere. For those activities, the participants of the MRS admit the relevance of the theoretical foundations to discuss them with the health team, and thus aim for improvements in the quality of the population's health.

The pedagogical project of the MRS is noteworthy, which guarantees that it is the function of the tutor to offer conditions for the integration and exchange of experiences with the professionals from the health services and to encourage the work of the residents through theoretical and theoretical-practical activities. In addition, it is observed that the interviewees appoint that the spaces in which the encounter occurs between the tutors and the residents are devices of theoretical and practical integration, despite arguing that the subjects did not address the reality they experienced, as observed in the following testimony:

[...] in some classes, we have already discussed the CHE. Even if professor class we discussed it, and held some debates that inserted the practice within the theory, trying to articulate both. But I remember very few of them (resident E12).

The pedagogical guidelines of the MRS, in turn, appoint the adoption of methodological strategies that go beyond the subjects offered in the classroom, whose justification can be summarized in the great hour load for theoretical-practical activities. Differently, the testimonies signal distancing between the theory of the disciplines and the practice the residents experienced:

Our theoretical classes are very distant from our practice, from what we experience. I believe that the main space of theoretical and practical education is in a practice field, as this approximation with the theory we live in practice happens mainly in the core tutorship, and in the case discussions the residents themselves promote with the tutors (resident E10).

With regard to this testimony, the documentary analysis of the pedagogical project reveals the presence of evidences that are in line with what the resident presents, as the pedagogical project aims to stimulate the residents to have attitudes of action-reflection-action, making tutors and residents discuss the reality of the health professionals' activities, with a view to gaining individual and collective critical awareness, beyond the biological paradigm. In line with the pedagogical guidelines of the MRS, the guidelines of the CHE aim to (re)organize the health programs, services and practices developed to permit the change of paradigm.

Finally, the education spaces in which the MRS contribute for professionals with distinct educational backgrounds, willing to move among different areas, articulate their specific knowledge in the organization of the work, permit both sharing actions and delegating activities to other health professionals, in a collaborative practice.²² Based on this education, it is expected that the resident, as a future SUS worker, is a professional capable of promoting changes in the health practices, making transformations and innovations to consolidate this system and providing qualified and comprehensive care and management to society, beyond biological care.

FINAL CONSIDERATIONS

This study signals MRS as an intercessor space for the development of CHE actions, as it favors the encounter of the participants in the residency program through the field and core seminars, tutorships, theoretical classes, field activities, constructing relations and interactions among them. Hence, during this moment of relations and interactions, the group discusses and incorporates the CHE into the daily activities of each professional, becoming present in each activity planning, in encounters between health professionals and teachers, users and service professionals.

As regards the residents' education, guided by the principles of the CHE, it is highlighted that this goes beyond a punctual perspective, as it is triggered by spaces in which actors dialogue about continuing education to be able to contribute to competency building for the health professionals to act in the contexts of the SUS. In addition, the residents are expected to gain critical and reflexive attitudes as participatory articulators in the identification of situations as critical knots, creating strategic and innovative alternatives in care and management that are fundamental for the changes that are aimed at the consolidation of the SUS.

In that context, this research helps to expand the dialogue about the CHE problem in the context of the MRS. Hence, it could be observed that challenges remain for this contextualization to truly occur and for the CHE to be disseminated and consolidated as a policy. The challenges stand out that are similar to the challenges of the SUS, mainly regarding the perpetuation of the counter-hegemonic practices, which are still present in the health professionals' education.

In that sense, this study considers the MRS as a strategy for the dissemination of the CHE among the health professionals, including users, teachers and students. It is observed that working in the perspective of the CHE, whose ideology intends to make transformations in the health field, means accepting that the changes in education and health depend on different factors related to the paradigms in force. It is according to this scenario that the MRS, imbued with the perspective of the CHE, can act in changing the health professionals' attitudes, sensitizing them to act differently from the traditional mode. Therefore, other studies are necessary, including a study to verify how the CHE is being assessed within its range and how it is subjectifying the health professionals, focused on in recent calls for health research proposals by the Ministries of Health and Education.

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Publication Dates

• Publication in this collection
  2016

History

• Received
  01 Sept 2014
• Accepted
  12 May 2015