Permanent health education based on research with professionals of a multidisciplinary residency program: case study

Educación permanente en salud desde profesionales de una residencia multidisciplinaria: estudio de caso

Abstracts

This research aims to identify the perception of professional members of a multi-professional residency program on Permanent Health Education. It is a case study research using a qualitative approach, with sixteen members of a multi-professional residency program. The data were collected from January to May 2012, through semi-structured interviews, document analysis and systematic observation, and analyzed according to Thematic Content Analysis. Two categories were identified: Permanent Health Education establishing collective spaces of reflection of practices and Permanent Health Education that promotes integration between disciplines. The members of the multiprofessional residency team were found to be aware that permanent education permeates their training and enables reflection on their clinical practices and multidisciplinary action as producers of health actions.

Continued education; Internship and residency; Professional practice; Health services; Nursing

La investigación tiene como objetivo identificar la percepción de los profesionales integrantes de una residencia multiprofesional sobre la Educación Permanente en Salud. Se caracterizó por el abordaje cualitativo del tipo Estudio de Caso, realizado con dieciséis profesionales integrantes de una residencia multiprofesional. Los datos fueron recogidos en el período de enero a mayo de 2012, por medio de entrevista semiestructurada, análisis documental y observación sistemática y analizada de acuerdo con Análisis de Contenido Temático. Se evidenciaron dos categorías: Educación Permanente en Salud como instituidora de espacios colectivos de reflexión de las prácticas y Educación Permanente en Salud como un encuentro entre disciplinas. Se constató que los integrantes de la residencia multiprofesional notan que la educación permanente permea su formación y posibilita la reflexión sobre sus prácticas y el actuar multiprofesional como productor de acciones de salud.

Educación continua; Internado y residencia; Práctica profesional; Servicios de Salud; Enfermería

A pesquisa objetiva identificar a percepção dos profissionais integrantes de uma residência multiprofissional sobre a Educação Permanente em Saúde. Caracterizou-se pela abordagem qualitativa do tipo Estudo de Caso, realizada com dezesseis profissionais integrantes de uma residência multiprofissional. Os dados foram coletados no período de janeiro a maio de 2012, por meio de entrevista semiestruturada, análise documental e observação sistemática, e analisadas de acordo com Análise de Conteúdo Temática. Evidenciaram-se duas categorias: Educação Permanente em Saúde como instituidora de espaços coletivos de reflexão das práticas e Educação Permanente em Saúde como um encontro entre disciplinas. Constatou-se que os integrantes da residência multiprofissional percebem que a educação permanente permeia sua formação, possibilitando a reflexão sobre suas práticas e o agir multiprofissional como produtor de ações de saúde.

Educação continuada; Internato e residência; Prática profissional; Serviços de saúde; Enfermagem

INTRODUCTION

The increasing demand for qualified and productive healthcare professionals is part of logic of the late capitalism where neoliberal market-based policies prevail. Therefore, the healthcare services establish ways to control their professionals, by linking work with the permanent search for productivity with quality, safety, and especially economy^{( 1 )}. Therefore, a logic of production of healthcare professionals tied to the neoliberal system is established, disseminating a concept of labor targeted at the perpetuation of a hegemonic assistential model of healthcare.

According to this view, the production of health-related knowledge, especially nursing, has been characterized by providing analyzes on this type of model. Thus, there is a concern with the introduction of new forms of organization, more flexible and participatory, seeking to improve the quality of healthcare services and professionals. Permanent Health Education (PHE) is inserted within this perspective of change of the hegemonic assistential model of healthcare. Therefore, in the opposite direction of the current model, it allows the questioning of reality, the development of its goals through proposals and projects that ensure new practices tuned to reality, permeated by current knowledge and connections, by the activities performed by the different social actors and by collective responsibility^{( 2 )}.

The concept of PHE emerged in the eighties and was taken as a priority by the Pan American Health Organization and by the World Health Organization^{( 3 )}. In an attempt to construct a policy that values health workers at the Brazil's Unified Healthcare System (SUS), the Ministry of Health indicated the PHE as a key strategy for the recovery of training practices, as well as pedagogical and healthcare practices ^{( 4 )}. Also, the Integrated Multiprofessional Medical Residency program (RMIS) was created as an instrument to promote changes in healthcare practices. This new type of training also includes educational actions focused on the health care needs of the population, on the multiprofessional team and on the institutionalization of the Brazilian Health Reform ^{( 5 )}.

In this context, it is important to know the possible gaps in the consolidation of PHE at a level that allows the qualification of healthcare professionals that is consistent with SUS principles. Therefore, the present study poses the following question: how do healthcare professionals in a multiprofessional residency program perceive their practice of permanent health education in their daily lives? And it is aimed to identify the perception of professionals that integrate a multiprofessional residency team on permanent health education.

METHODOLOGY

A case study with qualitative approach based on a master's dissertation was used in the present study ⁽⁶. This method allows the expression of different points of view about the object of the study by including many variables in the analysis, providing multiple perspectives of the same phenomenon, which can be scaled by triangulation of data sources (document analysis, observation and interview)^{( 7 )}.

The Case Study is a significant method, since it allows detailed analysis of the development of PHE by the members of a multiprofessional residency program and its implications. Thus, the Case Study aims to capture the circumstances and the conditions of commonplace or daily activities, since they provide information on the experiences of the institution^{( 7 )}.

The setting of this research was the Program of Integrated Multiprofessional Residency program in the Public Health System (RMISPS), developed in a university hospital in a city in the inland of the state of Rio Grande do Sul, Brazil. The subjects of this research were 16 professionals of a RMISPS related to the hospital area, contemplating residents and mentors of the nucleus (equal professions, but different concentration areas) and field (different professionals, equal concentration areas) of the following professions: Nursing, Psychology, Nutrition, Social Work, Speech and Language Therapy, Pharmacy, Occupational Therapy, Dentistry and Physical Education distributed in four concentration areas: Chronic-Degenerative diseases, Mental Health, Mother-Infant and Hematology and Oncology.

The researchers made informal contacts with the subjects during the field observation process, and then formally asked them questions through semistructured interviews with leading questions. Data collection was performed from January to May 2012. At first, document research was carried out with the purpose of obtaining records of evidence of principles of Permanent Health Education in the pedagogical process of the RMIS program. Also, observation of the dynamics of development of nucleus and field seminars and of the activities carried out by RMIS members were perfomed, in a total of 36 hours of observation. The activities of the professional nucleus involve functions and actions inherent to each profession. Field activities, in turn, concern the exercise of interdisciplinarity, which is focused on devices that extend healthcare outside the clinic/hospital, construction of lines of care through clinical protocols, construction of institutional or non-institutional integrated networks, elaboration of integrated management plans, case discussions, team meetings and study groups.

Finally, individual interviews were conducted aimed to enhance the search of data about the object of the study. The inclusion criterion for the semistructured interview was: be a healthcare professional attached to the RMISPS in hospital setting at the time of data collection. The interviews ended when data saturation was reached and also when the objectives were achieved.

For data organization and analysis, Software Atlas Ti 6.2 (Qualitative Research and Solutions), Free Trial version (free of charge) was used. Subsequently, the data were gathered for analysis, consisting in a copy of the documents originated from document analysis, researcher's field diary used in the observation process and transcription of interviews (recorded and transcribed by the researcher. Then, this material was analyzed by Thematic Content Analysis^{( 8 )}, which comprised the stages of pre-analysis, material exploration and treatment of the results obtained. The study met the ethical principles contained in Resolution CNS no 466/2012, and was approved by the Ethics Committee with Human Research (CEP) under No 0147012.4.0000.5346. The research began after approval of the institution, and interviews were conducted only after reading and signing of the free informed consent by the subjects. In order to ensure the secrecy and confidentiality of the participants of the study, letter 'E' was chosen (E1, E2, E3, E4...) because it is the first letter of the word Education in the expression Permanent Health Education, followed by a number that does not correspond to the sequence of participation in the research.

RESULTS AND DISCUSSION

For a better understanding of the present research, the statements obtained were subdivided into analytical categories that are interrelated.

Permanent Health Education as a process that establishes collective spaces for thinking on the practices

The concept of PHE is consistent and brought new aspects when it was adopted as a policy - National Policy of Permanent Health Education (PNEPS), in Brazil, in 2004, defined as a "strategic action for the transformation of practices based on critical thinking on real practices"^{( 4 )}. The healthcare professionals attached to the RMIS report their perception of PHE in accordance with this concept:

To my mind, permanent education concerns thinking about clinical practice (resident E1).

It makes you stop and think about what you are doing, so that you really care about what you are doing (resident E6).

I believe it is an in-house strategy aimed to make the professionals think about their daily practices (resident E10).

These are actions aimed to encourage and promote critical thinking and continuous updating of the healthcare team (mentor E13).

In addition to the above considerations about PHE, the subjects also reported that the planning of PHE actions usually occurred in nucleus and field seminars. The observations in these seminars stressed the importance of thinking about what was planned, both with the users and healthcare professionals involved in the team. Every time an activity was planned, the residents emphasized the importance of the existence of a meaning, a reason to develop the activity. Thus, the preparation of the professional activities involved careful and daily thinking. The PHE concerns the introduction of new ways to conceive, develop and involve the subjects based on reflection about their performance, going beyond technicism and the mere reproduction of practices ^{( 9 )}.

This production of meaning for each activity planned that the residents consider key to the production of health in the RMS comes from the central idea of the National Policy of PHE (PNEPS): significant learning. According to the PNEPS, significant learning concerns the use of a pedagogy that proposes to the healthcare professional/student/worker a more active role in the healthcare process, which is potentially more significant and related to the previous experience of the subject, in contrast with the traditional models ^{( 10 )}. Thus, for the resident, regarded as the coordinator of the process of changes in healthcare practices, significant learning maximizes their consolidation as a political actor in the change process.

It was observed that the residents described the nucleus and field seminars as meetings aimed to the creation of new meanings for their healthcare practices. These new meanings not only affect the user, or the team, but the space where health is produced. This space, where health can be transformed by PHE, would be the space where multiprofessional residency acts.

Critical thinking based on real practices deserved special attention by residents while defining PHE:

It concerns critical thinking about real practices (resident E5).

The professionals and the users are involved, and this critical thinking is like accessing informative material of the department of education, it is critical thinking about real practices (resident E7).

Professional practices based on reflection (thinking) (resident E4).

According to the PHE and the SUS, the workplace provides opportunities for facing and solving problems, and the residents, with a holistic view, should identify the "critical nodes", as stressed in the project of the referred program. Then, they will be able to develop the ability to create innovative strategies, in the management and care fields, which is essential for the necessary changes and consolidation of the SUS.

Therefore, the statements are consistent with the PHE, a key strategy for the changes in the professional activities in the sector, involving critical, reflective, propositive, committed and technically competent professional activity ^{( 11 )}. This can be ensured by promoting discussion, analysis and critical thinking about daily practices and their references with supporters from other areas, activators of processes of institutional change and facilitators of collective organizations ^{( 10 - 11 )}.

According to the PHE, from the analysis of the problematized issues in healthcare services, changes must be implemented to meet the needs of users, healthcare services, management and teaching ^{( 11 )}. The pedagogical project of the RMIS emphasizes that this change in professional practices can be ensured by the residents who identify critical nodes and promote new strategies.

The observations during the seminars corroborate with this purpose, since the members of the RMS demonstrated their concern with the "need for change" in their practice, to obtain greater autonomy and be more able to provide appropriate care to the users. The problematization of reality, the permanent questioning of everyday life, generates the need for changes, since it favors the feeling of discomfort, the perception of dissatisfaction with what was done^{( 2 )}. This discomfort is only noticeable when intensely experienced, i.e. through experience and reflection on daily practices ^{( 2 )}. This process of critical thinking reported by the residents stresses the transformation of the practices:

I think that the moment the professionals think critically about their practice, they are transforming this practice (mentor E2).

It is a proposal that involves teaching and service [...] you have to know the place, understand the problems in order to propose solutions, to be able to make changes (resident E11).

The critical thinking on these practices can be seen in the interviews, as most residents reported regarding PHE as a reflective practice, developed in their daily work. Thus, thinking about other forms of healthcare services to the population implies, among other things, revising the labor relations in the sector, the characteristics of the professionals under training, implying that refer us to the assumptions that have supported their formation and practices^{( 12 )}.

In order to incorporate this reality to the daily practices of RMS, the residents must perceive PHE as a pedagogical proposal that involves learning in their daily professional activities. This pedagogical strategy is embraced by concrete relations, which operate realities and allow the creation of collective spaces for evaluation and reflection on the meaning of daily activities ^{( 10 )}. It should be said that the productive action leads to two transformations: the healthcare professional (worker) produces the care acts, changing reality and at the same time produces him/herself as a subject^{( 13 )}.

Permanent Health Education as integration between disciplines

The implementation of the SUS is a counter-hegemonic movement in the current neoliberal context, both in Brazil and abroad. There are important theoretical reflections on the need for healthcare professionals to think critically about what they do, going beyond their hierarchical technical work, with better interaction, greater autonomy and integration of the team.

The RIMS program is tuned with this view, focusing the formation of professionals that overcome the paradigmatic view, focused only on the objects of intervention of each profession. It seeks the implementation of integration and interdisciplinary action involving all professional areas in this common effort of thinking critically about healthcare practices, promoting the intersection of the different knowledge and practices.

In this program, PHE is more than a proposal for multiprofessional action, as it integrates all the professions that are supposed to act as a multiprofessional and interdisciplinary team. However, besides acting in an inter or transdisciplinary manner, the professions should always interact with each other, and not be considered as separate, non-penetrable areas, from a perspective of "intradisciplinarities"^{( 14 )}.

I believe that permanent health education is a space for exchanges. Today there is much talk about interdisciplinarity! And I don't see any professional working alone. I think they are exchanging experiences. (resident E6).

It is necessary to keep motivating the professionals, the residents, to make them aware of the importance of working in an interdisciplinary way! Discuss multidisciplinarity, arrange multiprofessional meetings to address multidisciplinarity (mentor E14).

The statements of the residents point to the equalization of the words Interdisciplinarity and Multidisciplinarity, stressing their greater concern with re-signifying care practices between the professionals who exchange knowledge. Also, the words multidisciplinarity and interdisciplinarity are represented by the new paradigm of Public Health, having coexisted for at least three decades in the healthcare field, redefining disciplinary knowledge and their logics of political implementation or medical-social intervention in the order of collective life ^{( 15 )}.

Thus, multidisciplinarity results from the sum of "perceptions" and methods established by professionals of different disciplines or practices (normative, discursive). Regarding interdisciplinarity, it is the result of the intercession of some conceptual or methodological aspects, creating a new discipline, characteristic of the modern generation of different fields of knowledge^{( 15 )}.

The PHE contemplates interdisciplinarity and multidisciplinarity by providing interprofessional spaces, through the interaction of professionals of different areas ^{( 16 )}. The activities carried out daily by the resident, which were devised and created according to the perception of each professional, configuring a space where all the actors work together, sharing their knowledge to benefit the user:

Multidisciplinarity is here to stay. It is not possible to work alone any more, and I think this training is really implementing multidisciplinarity here. (mentor E8).

This individual must become aware of interprofessionalism [...] in order to understand the new settings and demands that will arise from our human vicissitudes (mentor E16).

The residency program allows the exchange of experiences with other professionals. And in our practice we were always exchanging our views with the interdisciplinary team.(resident E).

The respondents emphasized that multidisciplinarity is an important strategy in the training of professionals under the SUS. The training issue appears in the pedagogical project of the RMIS, regarding the resident. The latter will have to develop competencies to act in an interdisciplinary way in what concerns the effort of thinking critically about healthcare practices common to all professional areas, under the perspective of a triple alliance "interdisciplinary, inter-sector and interinstitutional".

Thus, it is reasonable to think that, to ensure that the residents internalize this proposal of thinking (critical thinking) + doing (healthcare practice) at the SUS, they need training based on these principles, and mentors and professors must also be committed to this proposal. It can be said that the multiprofessional action was especially perceived when residents planned their actions. Each professional was focused on its own nucleus, but maintaining a dialogue with professionals of other areas, wherever appropriate.

This moment, called "intradisciplinarity", is probably one of the most significant points of the referred RMIS program ^{( 14 )}. The PHE is consolidated by multiprofessional actions, leading to the creation of innovative strategies, which are essential to the consolidation of the SUS.

Under this view, we must consider that health training has an important role in the construction of the PHE, as well as of the SUS, for this training impacts the way healthcare professionals think and act, maximizing the reflection on healthcare processes, and, thus, on the construction of daily practices of the SUS ^{( 17 )}.

FINAL CONSIDERATIONS

Our findings have shown that the members of a multiprofessional residency program are aware that Permanent Health Education permeates their training and allows critical thinking about their practices, as well a multiprofessional action in healthcare.

The multiprofessionality reported by the members of the RMIS is a form of professional practice and expression of PHE. The results indicate that the subjects are concerned with what they can do to improve the care provided to the user, without being limited by their specific professions. Thus, the multiprofessional action is emphasized here.

Also, the members of the multiprofessional residency program perceive PHE as a promoter of collective spaces. These spaces were made available by the meetings at the seminars (nucleus and field) and reported as being responsible for the establishment of reflection about the daily healthcare practices.

The development of projects on PHE is considered key to the exploration of its concept and to raise awareness on its application in the daily activities of professionals who seek healthcare formation and are involved in the construction of a model defined by the SUS. One limitation of the study is that the results cannot be generalized because of the short time span, and also because the research was conducted within the specific context of the RMIS program.

Therefore, further studies are needed to encourage deeper reflection on PHE, particularly regarding the development of methodologies that concern not only the space of a multiprofessional residency program, but all the levels that permeate the formation of healthcare professionals.

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Publication Dates

• Publication in this collection
  Sep 2014

History

• Received
  07 Jan 2014
• Accepted
  02 June 2014