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Escola Anna Nery

Print version ISSN 1414-8145On-line version ISSN 2177-9465

Esc. Anna Nery vol.20 no.2 Rio de Janeiro Apr./June 2016

http://dx.doi.org/10.5935/1414-8145.20160034 

RESEARCH

Monitors' perception on education program for interprofessional healthcare work - PET-health

Ana Paula Gossmann Bortoletti1 

Erica Rosalba Mallmann Duarte2 

Alcindo Antonio Ferla2 

Gimerson Erick Ferreira2 

Míriam Thais Guterres Dias2 

1Centro Universitário Internacional. UNINTER. Curitiba, PR, Brazil.

2Universidade Federal do Rio Grande do Sul (UFRGS). Porto Alegre, RS, Brazil.


ABSTRACT

Objective:

This study sought to ascertain the influence of the PET-management programme, as perceived by monitors, on healthcare training and on their personal, academic and professional development.

Methods:

In this exploratory, qualitative, descriptive study, data was collected through open-ended or in-depth interviews of 14 monitors of the PET-management programme and analysed using content analysis.

Results:

The data revealed that these monitors' situation in the field favours learning by problematising and can help produce critical, proactive, autonomous professionals with a more comprehensive view of the healthcare system.

Conclusion:

Measures that strengthen interaction between academia and care settings and foster knowledge production where all the actors involved in health production meet should be continued.

Keywords: Health human resources; Health education; Health policy; Health services

RESUMO

Objetivo:

O estudo teve como objetivo conhecer a influência do PET - Gestão na percepção de monitores, em relação à formação em saúde e a influência do programa em seu desenvolvimento pessoal, acadêmico e profissional.

Métodos:

Trata-se de uma pesquisa do tipo exploratória e descritiva, com abordagem qualitativa. Participaram da pesquisa 14 monitores do PET Gestão. Para coleta de dados, utilizou-se a técnica de entrevista aberta ou em profundidade. A análise de dados se deu mediante a análise de conteúdo.

Resultado:

Os dados demonstraram que a inserção destes monitores nos campos de atuação favorece um aprendizado problematizado, podendo possibilitar a formação de profissionais críticos, proativos, autônomos e com olhar mais amplo sobre as redes de saúde.

Conclusão:

Conclui-se a necessidade de dar continuidade de ações, que fortaleçam o encontro da academia com os cenários de desenvolvimento do cuidado e a produção de conhecimentos onde se encontram todos os atores envolvidos no processo de produção da saúde.

Palavras-chave: Recursos humanos em saúde; Educação em saúde; Política de saúde; Serviços de saúde

RESUMEN

Objetivo:

Conocer la influencia del PET - Gestión en la Percepción de Monitores con relación a la formación en salud y la influencia del programa en su desarrollo personal, académico y profesional.

Métodos:

Investigación exploratoria y descriptiva, con enfoque cualitativo. Participaron 14 monitores del PET Gestión. Se utilizó la técnica de entrevista abierta o en profundidad para la recolección de los datos. El análisis se ha producido mediante el Análisis de Contenido.

Resultado:

La inserción de estos monitores en los campos de actuación favorece el aprendizaje problematizado, pudiendo posibilitar la formación de profesionales críticos, proactivos, autónomos y con una visión más amplia sobre las redes de salud.

Conclusión:

Se necesita la continuación de acciones que refuercen el encuentro de la academia con los escenarios de desarrollo del cuidado y la producción de conocimientos donde se encuentran todos los actores que hacen parte del proceso de producción de la salud.

Palabras clave: Recursos humanos en salud; Educación en salud; Política de salud; Servicios de salud

INTRODUCTION

The health service management discussion has accompanied the various different configurations of Brazil's health systems; it thus began long before the advent of the national Unified Health System (Sistema Único de Saúde, SUS) as we know it today. As the present health system takes shape, discussion is framed by the landmark 1988 Federal Constitution, which instituted the SUS and its guiding principles of decentralisation, comprehensiveness and community participation. These were detailed in another legal framework, but it is the text of the Constitution that has posed challenges for this healthcare system of continental dimensions. There healthcare management takes place in the interweave of those guiding principles, contemplating inter-sector action, a broad, systemic view of individual and collective needs and contextualised implementation of measures in different networks and fabrics1. Actually ensuring that these values are incorporated into work processes and worker capacity-building continues to be a challenge, however, while at the same time it is of prime importance to foster relations at the intersection of the two universes of teaching and service. Altering the present conjuncture entails committing to professional training that discerns individual, collective and institutional processes, so as to favour health production not just as provision of curative care, but using multi-professional and interdisciplinary teams and innovative practices2. One particular, pressing challenge is for teaching institutions to understand management in the context of the day-to-day problems facing health services and systems and, accordingly, also as a field for learning and knowledge production.

It is this panorama, together with on-going epidemiological and demographic changes in Brazil, that heightens the need for new discussions and policy-making in connection with capacity-building, continued professional development and continuing education for health personnel, with primary care as the dimension defining the care process and ordering the health system and work process.

This is the perspective from which the Ministry of Education (MEC) began to discuss the process of changing the guidelines for the distribution of course hours and content in required health education, on the basis of which the national curricular guidelines were to be implemented. This process of change was informed by technical reports and resolutions of the National Board of Education (Conselho Nacional de Educação) proposing and approving national curricular guidelines, in a process extending from 1997 to 20013.

Building on these bases, in 2004 the Ministry of Health (MoH) issued administrative order 198/GM/M instituting the national policy on continuing education in health (is called in Portuguese as Política Nacional de Educação Permanente em Saúde) as a strategy for health sector human resource capacity-building and development4. Then in 2005, jointly with the MEC, the MoH introduced a programme of reoriented professional training in health - Pro-Health (Portuguese named as Programa de Reorientação na Formação Profissional em Saúde, PRÓ-Saúde) and, in 2008, another offering education through work in health named Program for Interprofessional Healthcare Work - PET-Health, each designed to exploit different possible manners of combining education and health5.

The stated purpose of the PET-Health programme is to integrate teaching, service and community as a tool for changing how students are trained on courses in the health field. This programme strengthens academic practice and, on a shared basis, integrates university teaching, research and extension activities with social demands, signalling investment in a concrete, contextualised training process grounded in the social, economic and cultural dimensions of the population and integrating grassroots know-how with scientific expertise, and theory with practice6.

Participation by higher education institutions in the PET-Health takes the form of tutors (faculty), 'preceptors' (health professionals) and 'monitors' (undergraduate students in the health field). Monitors undertake teaching, research and extension activities under the guidance (more directly) of a preceptor and (more indirectly) a tutor. The experience is designed to spread knowledge relevant to primary care, through the activities of initiation to work, in constructive activities with the community and with service personnel.

On that understanding, in 2009 Rio Grande do Sul Federal University (UFRGS) began its series of PET-Health projects in partnership with the Porto Alegre municipal health department (SMS/POA). In order to extend coverage and impact on professional training, the PET projects are coordinated by the health coordination office (Coorsaúde), which covers all courses in the health field, as well as strategic projects with potential to spur institutions towards meeting the challenges posed in the national curricular guidelines and other legal provisions on the education of health professionals7.

From 2012 to 2014, the PRO- PET-Health /UFRGS projects comprised seven subprojects, among them, one on management of measures to integrate teaching and service and continuing education in health called management project of integrated teaching-work actions and continue education (named in Portuguese as Projeto Gestão das Ações de Integração Ensino-Serviço e Educação Permanente em Saúde)8.

The purpose of the management PET (PET-Management) programme was to improve management by systematic, collective construction, in order to introduce innovative, qualified management and healthcare based on the monitoring, mapping and evaluation of actions integrating teaching and services9. That programme arose out of the need to offer students experience of health management, given that most health science courses afford no management-related experience or theoretical knowledge.

For some time now, the MOH has pointed to the urgent need to discuss alignment between health management, vocational training and social oversight. Even though proposals do exist for reformulating health training models by changing pedagogical plans and introducing programmes such as PRÓ-Health and PET-Health nonetheless, capacity-building has remained hospital-centred, theory-centred and focussed on producing curative actions - a far cry from the model of health conceived by the SUS, which is framed by social oversight, shared management and health networks playing leading roles.

With a view to assuring that this scenario changes, it is first necessary to (de)construct and (re)construct the curricula by which these professionals are trained: these should be informed by the principles and guidelines of the SUS, which are directed to humanisation, comprehensiveness and co-management with users.

On this perspective, it is possible to establish the importance of learning about and knowing how to use management not just from the standpoint of administering and managing, but as a tool for comprehensive care. With that knowledge, health personnel and future health personnel can assist and participate in the process of empowering users, to make themselves co-responsible with them for the process of managing and establishing the SUS.

In that context, this study sought to ascertain PET-management project monitors' perceptions of how the experience provided by this programme influenced their training.

METHODS

This exploratory, qualitative, descriptive study was conducted in a health district in the municipality of Porto Alegre, Rio Grande do Sul, where monitors of the PET-Health programme carried out their activities. The sample, chosen intentionally after applying inclusion and exclusion criteria to the population of 20 students who participated in the programme between 2012 and 2014, comprised 14 current and former PET-management monitors, independently of age, sex and course in the health field. Participation lasting less than 30 days was an exclusion criterion.

Data were collected in November 2014, by recorded, in-depth or open interview in which interviewees gave free answers to two questions on their experiences in the PET-management. Each participant was asked to talk about their experiences and how monitoring on the PET- management had contributed to their training.

The resulting information was examined using content analysis, in three stages: prior analysis; exploration of the material and treatment of results; and data inferences and interpretation10.

The study complied with National Council of Health (CNS-Conselho Nacional de Saúde) Resolution Nº 466/2012, and was approved by the university's research ethics committee protocol Nº 33825114.2.0000.5347. The study participants signed a declaration of free, informed consent and their identities were kept confidential.

RESULTS AND DISCUSSION

The results from content analysis of the participants' interviews are presented here. In the interviews, the participating students reflected on their experiences and learning afforded by the PET-management and on how that experience contributed to their personal, academic and professional development. From interpretation of the participants' declarations, three empirical categories were identified: enterprising knowledge, learning in the act and the four-way approach to training, as described below.

Enterprising knowledge

The 'enterprising knowledge' mentioned in this study does not mean entrepreneurial and/or economic learning, but rather the ability to deploy and expand knowledge, to change and innovate, with a view to future self-management. Being enterprising means needing to achieve new things and, at the same time, to put existing ideas into practice in innovative ways, with a view to solving problems11.

To the students, the PET-management afforded new learning, expanded their knowledge about working in healthcare, encouraged critical thinking, mobilised knowledge to meet demands and also allowed them to think about their future in the profession. Their declarations, below, illustrate that outlook:

It helped in my training. For instance, I think the course is very conservative and I think I was able to bring some things from my own experience into the classroom, which maybe would not have been offered by the teachers, because they disagree (E8).

I am managing to see which things are working and which are not. What you can be like, your attitude, even afterwards, when you have graduated [...] (E11).

The declarations suggest the need to reconstruct teaching methods, from theory-centred teaching towards participatory, problematising teaching. The verb 'problematise' is a catalyst to education reform; it encompasses other verbs, such as reflect, plan, analyse, subjectivise, create, recreate, involve, introduce, hold accountable and transversalise12. As these verbs are conjugated in living form during the training they give rise to future professionals capable not only of perceiving problems, but of deploying knowledge and experience to create possible strategies to address all variety of situations.

Investing in the ability to be enterprising during the training process calls for changes in the process of (de)constructing and (re)constructing knowledge, to go beyond the established formalities and thus develop problematising methodologies committed to the human person13.

Training that relates theory and practice by way of hypotheses and solutions is decisive to transforming methodologies centred on knowledge transmission and traditional acritical, directive practices, in favour of forming subjects able to recognise and act on problems in the real world. Such a transformation is not brought about simply by curricular change; it needs to take place in the faculty involved, in how they see the students, which must be as co-participants in a training process where teacher and student share meanings.

In the words of these future professionals, the experiences afforded by the PET-management embodied the move from isolated, systemic knowledge to a broader view of knowledge and its practical application, by interrelating theory and practice and strengthening critical thinking.

The PET-management has that more general vision: you manage to see everything and try to arrange ways for things to go according to the needs of the facility, of each team (E11).

Now I am [...] at the specialised wound care centre. I see what the work there involves, I propose changes to the preceptor. What's good is that she is really open to change (E2).

It is clear that these students attribute considerable importance to the possibility of intervening positively and proactively in day-to-day situations. Teaching that provides for proactivity encourages future professionals to set their own directions, to take decisions, solve problems, confront doubt and risk and, above all, to be enterprising in looking for the best development and learning experiences14.

It has to be understood that the development of skills and critical, creative thinking cannot be fostered in occasional, localised programmes; development of these qualities needs to be rooted in academia, so as to encourage the endeavour for autonomy and the overall competences required of a health professional.

Some monitors thought about the impact the programme had on their choices as future professionals, underlining the importance of learning about and experiencing new fields of knowledge and work, which is fundamental to their making their own choices, as highlighted in their interviews:

I think that in relation to my university course, I really did think of working in that field, who knows one day when I graduate, [but] I changed direction a little. As a person I added in a lot more knowledge (E7).

Today I can even see myself working at a primary health station. Before, I didn't like that (E11).

These quotes show that such attitudes, in addition to permitting new learning, also favour more judicious thinking by students about their futures: in hospital-centred training there is often insufficient contact with primary care, so that they cannot always perceive primary care as a field of professional practice.

Surmounting traditional teaching frameworks and assuring a central role to questioning, thought-provoking methodologies that encourage thinking about new possibilities can collaborate towards students' really becoming the agents of their own choices15. It thus falls to training settings to foster a new collective subject defined by two basic features: development towards being individually and collectively enterprising and collaboration to assure the social cohesion necessary for life in society16.

The study shows that expanding the opportunities for students to experience service realities contributes to forming professionals of a different kind, not just in the field of their profession, but in the universal field of health systems, by fostering a broader outlook, creativity, initiative and critical thinking, in such a way that they can develop as agents of their own history.

Learning in the act

Learning in the act relates to the students' encounter with the realities of the SUS in the various different primary care settings, where thinking and doing take place simultaneously, in such a way as to (de)construct and (re)construct their views of the SUS, and collaborate productively to the students' maturing and coming to take a leading role in their own training. That idea is expressed in the following declarations:

Often the university, well, the course, doesn't offer that many opportunities to learn more about primary care, while the PET opens up that part a lot, so as to really immerse us in it [...] (E1).

She [the preceptor] really showed me the realities, that is, the truth. She showed me what things were like there. I was even shocked, sort of. What is all this!? As a result, I matured (E5).

Note that, in spite of changes to health sciences curricula, these future professionals still see their contact with primary care as scanty and regard such contact as necessary for them to mature critically in relation to the health system.

Introducing students into the realities of health services makes for a constructive sense of strangeness, which can bring them to think critically and develop a more mature understanding of their roles as future professionals.

The students feel that to understand the SUS requires more than just discovering the articles of the Federal Constitution or the framework law. Real understanding of a phenomenon comes from experience gained in context, in the setting where it takes place, that is, in the health system with its workers, users and programmes, as below:

[...] in that experience, of really entering into the practical activity, it defies that parameter. They have all the management programmes, health management, SUS management, that you can look at and they are really good and you see they are really narrow, but in the PET you see that that is not really what happens, at least not that way. Each place organises some way (E12).

Today I understand the SUS differently, because you hear about it one way, you have a theoretical idea of the SUS and then you want to see what it's like in practice, with all the facets of the SUS, the good and bad points (E1).

This learning environment, by constructing thinking from what is experienced, sets up spaces that favour change and the introduction of healthcare framed by the values of the SUS. It is also the place where the conflicts, difficulties, strategies and tactics entailed in occupying spaces in the care system are expressed and explained17.

Practice can thus be said to enrich theory, because the SUS with all its history, politics, actors, ideas and ideals cannot be understood solely on paper. The SUS has to be problematised, to be experienced.

When students are brought into close contact with health services, they bring with them their values and beliefs, prior knowledge and life experience. They come to the services with a background of preconceived ideas, but the experience they share with all the actors involved and the situations they encounter bring them gradually to (de)construct and (re)construct their conceptions of primary care, as follows:

I also saw the difference between me and people who hadn't taken part in the PET. I also still had a very closed mind and even a certain prejudice against the SUS, which we started to break down and to understand that it is not the people providing the services in practice who are at fault. There are a number of culprits, but almost never those in the field, that there is a whole political issue involved (E8).

At the beginning of the course we were always talking about the SUS [...] and that whole story, but we never knew exactly how it worked in practice. [...] There in the hospital it's quite different, [...]. And then we managed to see the realities and learn about other things, because unfortunately we do not get that opportunity to have other experiences, and the PET gave us that (E5).

The world of work is considered to be a school where you can dialogue with all the others there, weaving networks of group conversations among those who inhabit the day-to-day of the healthcare services and teams, exploring that power that resides in production activities when they are pedagogical acts18.

Prejudice against the unknown is intrinsic to the human person, like a child who will not eat certain foods because of the way they look; that is how it is with regard to health services. Hospital- and theory-centred training often does not make it possible to learn about and understand the SUS authentically. It is assumed here that the involving teachers and students in service production in real scenarios, throughout the health services, can work in favour of change in those scenarios.

In this way, it emerges that, more than just a tool to bring students into closer contact with the care system, the PET-management brings together ideas, practices, knowledge and the actors embedded in care provision settings, permitting a renewal of knowledge about the SUS in each of the actors involved.

Four-way training

In four-way training, represented by the four sides of a quadrilateral, the four dimensions have to be integrated in order to produce comprehensive healthcare. In day-do-day practice they are in constant movement, meaning that each vertex is cut by each of the others, as in a constantly shifting mandala19. When we talk about it, we discuss scenarios involving users, managers, health personnel and teaching institutions, which are the actors that are establishing the SUS. It is important to stress that, in the traditional form, each of the concepts making up this quadrilateral - which figures as a finding in empirical research, but also constitutes a concept in continuing health education - has independence and a specific meaning.

The discussions of the quadrilateral started from the standpoint that quality in training results from an appreciation of criteria that are important to professional technical development, to ordering the healthcare system and to alterity in relation to users19. The interview excerpts below illustrate clearly the encounter between academia and services:

Other things we took part in were the meetings, [...], in everything we do we are having new experiences. Most important was that new view that I had of management [...] few people on my course particularly have it, to the point where I think I am one of the few on my course [on the PET] (E7).

But I think that overall it was good, because I got to know a lot of things. Afterwards I even mentioned that sometimes a professor would say something about primary care, about the district facilities and so on, and I knew and everyone was like... How come, if we didn't get that in class? [...] So that is an added experience (E1).

[...] she gave me some reading, some rather heavy reading, rather, but in the end I even used them in university work, so it was good to have that exchange too between the PET and the course subjects (E1).

From what participants said it can be seen that the PET-managment provides the opportunity for knowledge over and beyond the course curricula, besides favouring unprecedented experiences and prompting the exchange of ideas and values.

The students' encounters with day-to-day health service realities brought very rich resources to bear on learning about care and the organisation of work and management processes17. When the students enter into the health system, not only are they acted on, but as dictated by Newton's third law, of action and reaction, when one object exerts a force on another object, it in turn experiences an equal and opposing force from that second object. In this case, it is not forces clashing, but rather knowledge, values and ideas being exchanged, not only between the health personnel and the students, but also among the faculty and in the social oversight.

It has to be remembered that health personnel often carry out their duties on a logic of production and mechanical care, endeavouring only to attain targets and indicators. Academia's arrival at the services brings students with new ideas and ideals, who ultimately reinvigorate the healthcare teams. This phenomenon is illustrated in the following excerpts:

[...] I observed a lot [...] there in the management to get that view of how it really is there and how often things don't work, not for lack of willingness by the health personnel, but because the workload is very heavy (E12).

Now I am [...] at the specialised wound care centre. There I can see what the work is like there and I propose modifications to the preceptor. What's good is that she is very open to change (E2).

It helped understand [...] how to work on a multidisciplinary basis, not thinking just about what you have to do, but trying to think about the whole, to try to give the patient better care. The PET helped a lot in that view of the group, of not thinking "This is what I have to do and that's all" (E4).

To these monitors, the encounter with the health services and their cohabitants makes it possible to transform the paradigm model of care where the health personnel alone are responsible for the quality of the care response.

The new training policies are gradually transforming the workplaces, where healthcare is still produced according to the hegemonic procedure-centred, technical care model, into settings for citizenship, where service and teaching personnel, users and the students themselves are establishing their social roles in the confluence of their expertises and ways of being in, and seeing, the world17. The students' immersion in these workplaces helps not only to develop them as future professionals, but also to improve them as citizens with skills and knowledge capable of producing health in shared manners and of expanding the collective production of health.

During training, when thinking about the work process and the quality of care, we often fail to think about the people we are caring for. The volume of services provided, alterations in biomarkers and the quantity of high technology services are constantly being seen as indicators of service quality. Comprehensive, quality care involves the care community, with users in a leading role as the central focus of health actions. The excerpts below show that the monitors were able to think about these things in their experiences in the health system:

Social oversight is very important, because no matter how much you are a manager, you always have to ask for social oversight, because that is a guiding principle of the SUS, what social oversight will accept and what it won't, and show the possibilities. So, even if you are a manager, you are not really a manager, because the real manager of the SUS is the social oversight (E9).

I think it opened up my mind. [...] My mind was very closed before going on the PET. I think that I didn't have such a broad view of things, including that thing of looking at people, let's say dealing with people, according to their needs. That was something that it taught me a lot (E8).

These excerpts show that placing these future professionals in the settings where care is produced makes it possible for them to see social oversight as part of the process of producing healthcare, thus assuring comprehensive care by building an understanding of the demands and needs of individuals, groups and communities on a new view of how to do healthcare. This gives the basis for thinking in terms of training that imagines professionals not just for the workplace, but is convinced that the work of healthcare involves listening and that the interaction between health professional and service user is decisive to the quality of the care response19.

In the current scenario where healthcare management is not tied solely to politics, but rather shared by all the actors that inhabit the services, it is extremely significant that the students should have that perception of management as involving social oversight and of how that influences the healthcare process.

All in all, the encounter and the discussions among these four dimensions permits an endeavour to inform and strengthen the guiding principles of the SUS, with a central focus on comprehensiveness throughout the health service system.

FINAL CONSIDERATION

Healthcare systems are becoming increasingly complex in their structural configurations, requiring increasing professional qualification both in the workplace and in training for work.

This study revealed that the PET- management had an effect that extended beyond academic training, to exert a favourable influence on the personal and professional development of programme monitors, pointing to the importance of structuring a kind of training that contemplates the healthcare system as a whole as a field integrated with teaching, and thus affording students different kinds of development.

The programme monitors were seen to regard the primary care system as a liberating field of learning, where students felt free to question, dialogue and intervene in the various settings and with the different professionals in day-to-day service situations. This afforded them active and participatory experimentation with new fields of knowledge, making for the sharing of ideas and values, which strengthened their agency in their choices in both professional, academic and personal dimensions.

These students' placement in these fields of activity was found to favour learning by problematising. This can help form future professionals who are more thoughtful, proactive and autonomous and with a more open view of health systems, who perceive the importance of multidisciplinarity, interdisciplinarity and working collectively as defining characteristics of comprehensive care.

Accordingly, this reveals the need to continue with on-going actions to strengthen the encounter between academia and the settings where care is provided and knowledge is produced, which are the meeting point for all the actors involved in the process of producing healthcare. That encounter can foster shared management, with users and their agency as the central focus in care actions.

To conclude, this study does not exhaust the discussion of this subject, nor does it specify pathways to be travelled in order to achieve the necessary changes in healthcare training. Rather, it signals that the discussions and changes have now begun and indicate the benefits of continuing this movement to favour the preparation of professionals who will strengthen and help establish the SUS and its guiding principles.

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In the article “Monitors’ perception on education program for interprofessional healthcare work - PET-health”, DOI number: 10.5935/1414-8145.20160034, published in Escola Anna Nery Revista de Enfermagem 2016; 20(2):254-260 “Míriam Thaís Guterres” should be read as “Míriam Thais Guterres Dias”.

Received: February 09, 2015; Accepted: March 09, 2016

Corresponding author: Ana Paula Gossmann Bortoletti. E-mail: ana.bortoletti@gmail.com

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