Collaborative practices in emergency services in Health: the interprofessionality of the “PermanecerSUS” Program, Health Department of the State of Bahia, Brazil

Abstracts

This article presents and discusses the PermanecerSUS Program a proposal of interprofessional education to the formation in Health. It has a qualitative approach in the perspective of Institutional Ethnography. The discussion focuses on the content registered in the field diary constructed by the researcherethnographer during participant observation sessions carried out at the urgent care units of two hospitals located in the city of Salvador, State of Bahia, Brazil. The results suggest that the program develops competencies such as teamwork, intercommunication and joint solution of problems among students, and integrates education and work. However, the challenges of the PermanecerSUS are based on improving the communication relationship between interns and service professionals and investing in the education of internship preceptors, with perspectives of changes in practices and impacts on the quality of care in health services.

Interprofessional education; Interprofessional collaboration; Teamwork; Collaborative learning

Este artigo apresenta e discute o Programa PermanecerSUS como uma proposta de educação interprofissional (EIP) à formação em Saúde. Possui abordagem qualitativa, sob a perspectiva da Etnografia Institucional (EI). A discussão se respalda no conteúdo registrado no diário de campo construído pelo pesquisador-etnógrafo durante a observação participante em duas unidades de urgência hospitalar, na cidade de Salvador, Bahia, Brasil. Os resultados sugerem que o programa desenvolve competências como o trabalho em equipe, a intercomunicação e a solução de problemas em conjunto entre os estudantes; e proporciona integração educação e trabalho. Entretanto, os desafios do PermanecerSUS estão pautados em proporcionar melhorias na relação comunicacional entre os estagiários e profissionais do serviço e investir na formação dos preceptores do estágio, com perspectivas de mudanças das práticas e impactos à qualidade da assistência nos serviços de saúde.

Educação interprofissional; Colaboração interprofissional; Trabalho em equipe; Aprendizado colaborativo

Este artículo presenta y discute el Programa PermanecerSUS, como una propuesta de Educación Interprofesional para la formación en Salud. Tiene un abordaje cualitativo, bajo la perspectiva de la Etnografía Institucional. La discusión se respalda en el contenido registrado en el diario de campo construido por el investigador-etnógrafo, durante la observación participante en dos unidades de urgencias hospitalarias, en la ciudad de Salvador, en el Estado de Bahia, Brasil. Los resultados sugieren que el programa desarrolla competencias, tales como el trabajo en equipo, la intercomunicación, la solución de problemas en conjunto entre los estudiantes y proporciona integración entre educación y trabajo. No obstante, los desafíos del PermanecerSUS siguen la pauta de proporcionar mejoras en la relación de comunicación entre los pasantes y profesionales del servicio e invertir en la formación de los preceptores de la pasantía, con perspectivas de cambios de las prácticas e impactos para la calidad de la asistencia en los servicios de salud.

Educación interprofesional; Colaboración interprofesional; Trabajo en equipo; Aprendizaje colaborativo

Introduction

The public model of healthcare in Brazil requires professionals qualified to work in teams and prepared to face the challenges of the contemporary health system.

According to Almeida Filho et al. ¹ , some of the main challenges in the area of health education are the fragmentation of teaching in disciplines, the organization of academia/services in departments, the technical division of work, and the importance given to specialization. These aspects diverge from complex thought and comprehensive healthcare, proposed by Morin ² and Lalonde ³ respectively.

According to Batista ⁴ , educating professionals to provide comprehensive care and to practice complex thought translates the understanding that health practice demands a type of work that transcends the individualized activities of each profession and strengthens the importance of the team. This kind of configuration enables cooperation towards the exercise of transformational practices.

However, Frenk et al. ⁵ argue that in almost all countries, education has not been able to overcome inequalities in the field of health. The main reasons for this are curricular rigidity, professional difficulties, lack of adaptation to social needs, the static pedagogy, and the mercantilism that characterizes professions.

In light of this situation, the World Health Organization (WHO) published, in 2010, the document Framework for Action on Interprofessional Education and Collaborative Practice ⁶ , in which it stated that, to comply with the global health agenda, it is necessary to maximize the health professionals’ potential by means of a collaboration among professionals from different fields of knowledge, fostering the development of interprofessional education at universities and research centers.

The WHO ⁶ defines interprofessional education as learning among two or more professions with the purpose of promoting and achieving positive outcomes. Collaborative practice, in turn, is the application of this learning to different actions to the benefit of patients and their families.

To achieve this, Secretaria Estadual de Saúde da Bahia (SESAB - Health Department of the State of Bahia), in partnership with three higher education institutions of Bahia, developed a health education reorientation project based on Política Nacional de Humanização (PNH - National Humanization Policy) ⁷ . The project is grounded on the adoption of humanized practices in the health services, teamwork, and interprofessional collaboration among future health professionals - the pillars of a program named PermanecerSUS .

Therefore, this study aims to present and discuss the PermanecerSUS Program as an interprofessional education proposal in the area of health.

From project to program: PermanecerSUS

In 2007, SESAB, by means of the consolidation of Plano Estadual de Saúde da Bahia (PES-BA - Health Plan of the State of Bahia) 2008-2011 ⁸ , created a line of action to strengthen the management of work and permanent education in the area of health. Among other strategic actions, we highlight the implementation of the embracement device present in the PNH ( HumanizaSUS ) in seven hospital units of the healthcare network through the PermanecerSUS project.

“Commitment 9 - Expanding, qualifying and humanizing the urgent and emergency care network in SUS^(d)BA” ⁹ (p. 131) of PES-BA 2012-2015 eventually transformed PermanecerSUS into a program and included it in maternity hospitals and in urgent and emergency care services of hospitals run by the State of Bahia.

Thus, the creation of the PermanecerSUS Program, in 2008, aimed to provide students of the health area with experience in those spaces and to contribute to improve assistances.

Students currently come from courses in the area of health and other areas, such as Interdisciplinary Baccalaureate in Health, Nursing, Pharmacology, Speech-Language Pathology and Audiology, Physiotherapy, Medicine, Nutrition, Dentistry, Psychology, Social Work, and Collective Health, from different universities and colleges in the State of Bahia. They are governed by an extracurricular internship contract of 20 hours per week (16 hours of practice and 4 hours in permanent education), receive an allowance of R$ 455.00 (approximately US$ 130) and transportation, and are directed to the services in groups comprising five or six members, under the supervision of a preceptor who has an employment relationship with the healthcare unit. Thus, according to the regulatory text of PermanecerSUS, the program’s coordination mixes the internship groups with different areas of knowledge, conceiving an interprofessional practice.

It is important to highlight that interns use their practice to hear what users have to say, distancing themselves from clinical and technical procedures with the aim of seeing, understanding and settling problematic situations that have a direct influence on humanized assistance in the healthcare network.

During the permanent education meetings, students discuss different situations, approaching theoretical, political, and philosophical knowledge but, mainly, sharing their experiences as a healthcare team.

Another particularity is the daily dynamics of the experiences. When students arrive at seven a.m. for the morning shift and at one p.m. for the afternoon shift, they gather at the program’s support room, discuss the assistances provided in the previous day, and outline goals and objectives for the current day. At the end of the shift, they have to record, in the occurrences book, the assistances and referrals they performed.

Still regarding the daily dynamics, we highlight the work developed by students during their practice: they usually stay at strategic places, like the reception desk or a pre-assistance space. First, the intern observes the user’s demand at the place where the assistance record is filled in. Then, the intern performs user embracement by asking the user to provide other data like previous history, social history, and health and disease history. With this information in hand, the intern takes the user to the assistance room with the health professional or indicates another place/health unit that is more adequate to solve the problem. Regarding users whose demand will be met at the health unit where they are, the intern monitors the development, hospitalization and, consequently, the hospital discharge.

Finally, nowadays, PermanecerSUS is present in more than 15 units of SESAB’s assistance network, from primary care to high complexity units. It has already qualified, since 2008, approximately nine hundred students.

Method, venues and research approach

Because we understand health as a transdisciplinary field ¹⁰ that needs objects, practices and research supported by the anthropological sciences ¹¹ , we decided to carry out an ethnographic and qualitative field research under the perspective of Institutional Ethnography.

Institutional Ethnography investigates the occurrence of social relations in the daily experience of institutions. By mapping interconnections between local aspects of daily life and governmental administration processes, researchers attempt to relate previously constructed “texts” to people’s daily action ^12,13 . Thus, Institutional Ethnography enables to perform a critical analysis of the power relations and regulated practices present in health institutions. In addition, it contributes to form a political conscience in individuals, collaborating to enhance critical reflection on daily relationships in the world, which involve power and domination.

We highlight that this study is part of a larger project: “PermanecerSUS: analysis of the effects of its implementation on health workers, users and scholars”, developed from 2011 to 2015 by the research group Life Quality and Promotion of the Institute of Arts, Sciences and Humanities Professor Milton Santos, Universidade Federal da Bahia . Different data collection techniques were used: documentary, semi-structured interview, focus groups, participant observation, and field diary. For this manuscript, we used field notes made during participant observation sessions that took place in the period from September 2013 to January 2014, in the mornings and afternoons of working days, at the adult urgent care unit of two public general hospitals located in the city of Salvador, State of Bahia, Brazil. We refer to these hospitals as Hospital A and Hospital B. These institutions are characterized by meeting both the spontaneous demand and referrals and by having different clinical specialties. Hospital A is exclusive for adults, while Hospital B assists adults and provides services in the areas of urgent pediatric care, obstetrics and high-risk maternity. In each hospital, we had approximately one month and 15 days to conduct the participant observation.

In addition, the reflections brought here are grounded essentially on overheard conversations, experienced situations, informal comments, and on the very development of relationships, recorded in the field diary. According to Weber ¹⁴ , the field diary “is an instrument that the researcher dedicates himself to producing day after day throughout the entire ethnographic experience” (p. 157).

No recording device was used during the participant observation. Our notes were recorded on paper and subsequently transcribed to an electronic document using Microsoft Word^®2013. The construction of the field diary followed the unfolding of the situations; however, our main objective was to analyze the impacts of the PermanecerSUS Program on the education of students - future health professionals. Thus, we focused on some central questions: “How does teamwork happen? Is there collaboration? In what way do students perceive the program’s importance to their education? Is the health user heard? Are the user’s demands satisfied with quality? Does the health professional understand the actions of the PermanecerSUS Program?”

The research was approved under no. 002-11 by the Research Ethics Committee of the Collective Health Institute/ Universidade Federal da Bahia and complied with the requirements of Resolution no. 466/2012 of the National Health Council/Ministry of Health.

Notes on PermanecerSUS and Interprofessionality

Today is the fifth day of observation! When I walked across the emergency room, I noticed an intense flow, stretchers along the corridors and many patients waiting to be hospitalized. I arrived at the PermanecerSUS room and all the interns were together, discussing the assistances of the previous day. One report called my attention: a Physiotherapy student mentioned the difficulty she had in solving a simple issue of patient transfer. There was already a bed for the patient at another unit, but she could not transfer him due to lack of vital signs in the initial record. The professional who was working on that day refused to update the report alleging it was the obligation of the professional who had assisted the patient on the admission day. After some time and with the help of another student, they managed to transfer the patient. (Field Diary - Hospital B)

As we mentioned above, one of the strategies adopted by PermanecerSUS is the discussion of the assisted cases, enabling the understanding of individual events based on possibilities of solution and on the team’s intervention. To Batista ⁴ , this type of proposal reiterates the importance of discussing professional roles, teamwork, commitment to solve problems, and negotiation in decision-making, which are remarkable characteristics of interprofessional education.

During participant observation, we found that students perceive the importance of PermanecerSUS as an inducer of collaborative practices and teamwork, as it values different professions, understands their peculiarities, and integrates them as partners in the construction of the health system. In this sense, Barros and Ellery ¹⁵ argue that the teamwork practice will only be collaborative when there are daily experiences and a greater integration between teaching and work in educational centers. Finally, as an extracurricular internship proposal for professionals’ education, PermanecerSUS reaffirms and awakes in students the need to incorporate, in their practices, comprehensive care for the community. Therefore, it is an alternative that lies between teaching and work.

I have just witnessed a case in the corridor: a woman, approximately 50 years old, arrived complaining about headaches. After being assisted by the doctor, she was instructed to go to the primary care service of her neighborhood to be followed up by the health professional. The patient left the room complaining [in a loud voice] that assistance had been neglected. After being approached by two PermanecerSUS interns who explained about hospital care, the patient understood the state and severity of her pathology and decided to search for assistance in the primary care network. (Field Diary - Hospital B)

Konder and O’Dwyer ¹⁶ found that, in Brazil, one of the great problems of hospitals’ urgent care services is overcrowding. The main causes are structural, political, and management problems, as well as lack of communication among health professionals. We could verify the occurrence of the latter by means of the participant observation report. If the professional who assisted the user had solved her doubts or perhaps referred her to other colleagues, like the PermanecerSUS interns, or if there had been a qualified pre-hearing such as the one provided by Atendimento com Classificação de Risco (ACCR - Risk Classification Assistance) this would certainly have prevented the user’s emotional distress and dissatisfaction.

According to Inoue et al. ¹⁷ , ACCR emerged from the National Urgent Care Policy ¹⁸ . It is a method that classifies users according to the severity of their case, reorients the screening process, and provides assistance according to priorities.

In light of these brief considerations and discussions about ACCR, we found that the assistance flow at Hospital B is different from that of Hospital A:

I stayed close to a line formed by patients waiting to be assisted. After hearing complaints about the delay, I turned my attention to a conversation between two women: one of them, who had arrived alone, complained about a strong abdominal pain. The other woman realized that the first one did not have the assistance record with her and instructed her to talk to one of the PermanecerSUS interns. The intern directed the user to the correct place for the screening procedure and from it to priority assistance. (Field Diary - Hospital A)

In the event above, we observed that users who arrive alone at the service do not receive any directions and have to build their own itinerary inside the hospital’s urgent care service. This may cause setbacks like dissatisfaction, overcrowding, and even complications to the treatment. However, the directions given by the PermanecerSUS intern by means of hearing and embracement enhance user satisfaction and, consequently, improve the assistance flow in the urgent care services.

In this perspective, the studies carried out by Morphet et al. ¹⁹ and Jakobsen et al. ²⁰ have shown that when interprofessional teams are encouraged to work together, they reduce hospital admissions, increase the number of positive assessments received by the assistance, and develop skills and competencies like communication, essential in the health services. Thus, the collaborative practice and teamwork performed in PermanecerSUS as interprofessional education strategies can mitigate the challenges present in the relational dimension among health professionals, managers and users in hospitals’ urgent care services.

On the other hand, some permanent professionals from the urgent care services of Hospitals A and B do not view the PermanecerSUS interns as facilitators and members of healthcare. This suggests lack of understanding about the effectiveness of teamwork, collaborative practice and interprofessionality as tools that aid the dynamism of their work, as it is possible to observe in the events below:

This is my 22^ndday! As it is common when a shift has ended and another will begin, the interns discussed their difficulty to relate to one of the medical coordinators of the urgent care service. One Medicine student was against the group’s unanimous opinion and said he is always well treated. At that moment, a Social Worker student interfered: “You are well treated because, unlike us, you wear a white coat with the Medicine symbol on”. (Field Diary - Hospital B)

Curious about the situation, I approached a Medicine intern and asked him, informally, the reason why he wears a white coat while the other interns wear the blue coats of PermanecerSUS. His answer was that he receives more attention on the part of professionals and users and that the preceptor is not contrary to this practice. (Field Diary - Hospital A)

In addition to the professionals’ non-acceptance of the interns, the two participant observation reports trigger essential issues that diverge from comprehensive care and interprofessional education.

The first issue is the recognition of a healthcare model still centered on the figure of the medical professional, underestimating other professionals who are equally necessary to the health system. In this sense, Koifman ²¹ warns us that the development of Modern Medicine has fostered an autonomous and individualistic work process. Under another perspective, the studies carried out by Silva et al. ²² reiterate the absence of communication between these professionals and the others, an essential aspect for a good interprofessional relationship.

The second issue is the role of the internship preceptor, essential for the educational process and for fulfilling the objectives of PermanecerSUS. Concerning the preceptor, Correa et al. ²³ argue they are excellent technical professionals in the work they perform and one of their functions is to build solutions to the problems that emerge in the field during the healthcare practice. However, one of the problems is pedagogical qualification in the sense of promoting a teaching and learning process that overcomes the knowledge transmission model, promotes reflection on healthcare practices, favors subjects’ emancipation and, above all, is reflected on work processes.

Still regarding the two reports, and bearing in mind this is not the main objective of this study, it is necessary to discuss, even though in a superficial way, the social representation of the medical professional and the use of the white coat.

According to Sêga ²⁴ , “social representations are a way of interpreting and thinking about the daily reality [...] developed by individuals and groups to fix their positions [...]” (p. 128).

Likewise, Moscovici ²⁵ states that social representations are presented by means of symbolic and significant objects. In this case, the white coat and the Medicine Coat of Arms are characterized as such and give power to the PermanecerSUS intern, enabling him to have more access to the health professionals and users in a socially constructed reality where he is the holder of cure and relieves suffering. We believe that this action is one of the program’s challenges, as it contradicts the interprofessional and communication practices with the other professionals in an amplified perspective of health.

Finally, according to Peduzzi ²⁶ , the professions are not static. They are dynamic and need to amplify their scope of practice by acting in accordance with comprehensive care and with the complexity of the agents who constitute the SUS.

Final Remarks

The results of this study indicate that the reorientation proposal for health education developed by the Health Department of the State of Bahia - the PermanecerSUS Program - fulfils a promising interprofessional education experience and maintains the prerogative of health teaching based on the complexity of different types of knowledge, on subjects’ integrality, and on teamwork, developing competencies such as the joint resolution of problems and interprofessional communication, essential for those who will work in the SUS. However, the program faces some challenges: to create alternatives to help interns interact with the service’s professionals, to make the latter understand the effectiveness of interprofessional collaboration and, finally, to rethink the education of the services’ preceptors, redirecting their practices as educators.

Referências

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• (d)
  SUS = Brazilian National Health System.

Publication Dates

• Publication in this collection
  10 July 2018
• Date of issue
  2018

History

• Received
  17 Oct 2017
• Accepted
  08 Apr 2018