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Revista Gaúcha de Enfermagem

On-line version ISSN 1983-1447

Rev. Gaúcha Enferm. vol.37 no.2 Porto Alegre  2016  Epub July 07, 2016

http://dx.doi.org/10.1590/1983-1447.2016.02.56984 

Original Article

Courses offered by the Minas Health Channel: perception of primary care workers

Lizziane d’ Ávila Pereiraa 

Roseni Rosângela de Senaa 

a Universidade Federal de Minas Gerais (UFMG), Escola de Enfermagem. Belo Horizonte, Minas Gerais, Brasil.

ABSTRACT

Objective

To analyse how primary healthcare workers perceive the impact of the Health Channel Mines courses in their work process.

Method

This is a descriptive exploratory qualitative study conducted with 38 professionals working in primary health care units of three municipalities in the state of Minas Gerais, Brazil. Data were collected in 2014 by means of semi-structured interviews and subjected to thematic content analysis.

Results

Data analysis revealed the following three categories: interest in training and its contribution to professional practice; factors that alter professional practices; and proposals for improvement.

Conclusion

The study data demonstrated that the Mines Health Channel courses cannot single-handedly change professional practices. Continued and refresher education resources that enable the exchange and articulation of knowledge between the various specialities are needed to transform professional practices.

Key words: Education; continuing; Primary healthcare; Public policies; Nursing

INTRODUCTION

The National Policy on Permanent Education in Health (“PNEPS”) was established in 2004 through Ordinance 198(1), and reformulated in 2007 through Ordinance 1996(2) with new guidelines and strategies for their implementation.

The concept of permanent education in health (“EPS”) is defined in national politics as learning at work, where learning and teaching are incorporated into the work process and the daily routines of health-related organisations. EPS proposes that the education of health workers should be based on addressing the problems of the actual practice(2).

In 2008, the state department of health (SES/MG) created the Minas Health Channel (“Canal Minas Saúde”), which included a permanent distance-learning programme (“PEPD”), to promote information, communication and education in the field of healthcare(3).

The Minas Health Channel is a multimedia network that uses television technology with computer and radio technologies to promote educational strategies and training for healthcare workers and managers of the SUS (the Brazilian unified health system), coverage of events and administrative ceremonies, and to serve as a vehicle of information(4).

In relation to educational strategies, which is the main focus of the channel, the courses are offered on the Moodle distance-learning platform with television and internet multimedia integration. Television is used to air the video classes and the internet is used to complete the activities included in the course(4). State and municipal management agreed to close the primary care units on Thursdays at 3 p.m., which was called “protected time”, so the whole healthcare team could watch the courses provided by the Minas Health Channel and subsequently discuss their daily routines.

The proposal of the Minas Health Channel is to offer courses based on the concept of continued education by means of distance learning to remedy the daily difficulties of the health system and the social, economic, demographic and epidemiological disparities between all 853 state municipalities.

For the EPS to effectively rearrange health-related educational practices, and care management and policies with social participation and control in the healthcare sector, the structure of knowledge must focus on the reality of the actual work scenario (5).

Studies show that distance learning can be successfully used for EPS in the unified health system (SUS) to exploit the potential of the actors involved, establish multidirectional communication, new relationships and interactions, exchange experiences and share knowledge, and provide professionals with mobility and flexibility in their educational without compromising quality(6-7).

Data of the Minas Health Channel show that, since 2008, more than 200 educational actions have been completed to strengthen the SUS/MG, enhance the technical skills of health workers, and improve public health management(8). Therefore, the guiding question for this study was: do the courses offered by the state government through the Minas Health Channel observe the premises of continued education? Do the professionals working in primary care perceive the repercussion of the courses in the organisation of their teams and work process? Can the contents addressed in the courses be applied to their work routines?

The aim of this paper is to analyse the perception of primary care workers on the contribution of the courses offered by the Minas Health Channel to their work process.

The discussions are based on the assumption that the Minas Health Channel courses contribute to the education of health workers in terms of theoretical and technical knowledge, but are insufficient to modify the professional practice within the complex work context of healthcare, thus creating a gap between scientific knowledge and the practice that constitutes professional “thought” and “action”. The justification and relevance of this study lie in the numerous obstacles that permeate continued education, especially the reproduction of hegemonic practices, and the quest to favour and strengthen processes that enable EPS.

Whereas the nursing profession has a greater participation in the courses and is recognised as an active component of primary care, the aim of these courses, as observed in this investigation, is to stimulate thought on the training practices of healthcare and nursing professionals, and consequently improve health services based on a conscious, responsible and quality professional practice.

METHOD

This is a descriptive, exploratory study with a qualitative approach conducted in three municipalities of Minas Gerais, Brazil, with more than 300,000 inhabitants, located in the northern (NOR), southern (SUD) and northern triangle (TN) health regions, and derived from a master’s dissertation in nursing(9). The choice of approach considers the universe of meanings, values, and attitudes that correspond to a deeper scope of relations(10).

The participants of this study were 38 primary care workers who completed the courses of the Minas Health Channel from 2011 to 2013. The criteria for inclusion were professionals certified in three or more courses offered by the Minas Health Channel for primary care workers between 2011 and 2013; professionals registered in the national registry of health establishments (“CNES”), and linked to an establishment that was either a healthcare unit, a healthcare centre or a mixed centre; professionals from a category classified in the National Policy of Primary Care as pertaining to a multidisciplinary team of the family health strategy (“ESF”); and professionals practicing in one of the scenario municipalities.

Compliance with the inclusion criteria was initially identified by analysing the Minas Health Channel database and the CNES in May, 2014, resulting in 65 potential participants. Of these potential participants, the researchers excluded all the professionals who were not working in the municipalities (eight) or in establishments linked to primary healthcare (four), or who were on leave by reason of holidays (one) or sickness (six), as well as the three workers who participated in the pre-test. Five professionals refused to participate in the study.

Data were collected in June by means of an interview with a semi-structured script, which lasted approximately twenty minutes, to obtain the objective and subjective data from the statements of the social actors(10). The topics of the interview were academic background and trajectory in the healthcare service, reason for completing the course, course content and methodologies, perception on the contribution of the courses to their work, factors that enabled or hindered implementation of the course actions in their daily routine, suggestions regarding the courses and reports of concrete situations that were solved using the content and methodologies learned in the courses.

The interview data were analysed using the thematic content analysis technique proposed by Bardin(11), without computer software support, according to the following three stages: Pre-analysis: full transcription, encoding and skim reading of the interview transcripts; Exploration of the material: in-depth reading, clipping, and sorting, and addition of the record units; Treatment of the results, inference, and interpretation: grouping of the record units according to the unit of meaning.

The ethical principles that guided this research are established in Resolution 466/2012(12), and all the participants were notified of the research and signed an informed consent statement. This research was authorised by the SES/MG and the municipal departments of health (“SMS”), and approved by the ethics and research committee of the Universidade Federal de Minas Gerais (Opinion 30514814.3.0000.5149). To protect the identity of the participants, acronyms of the regions (NOR, SUD and TN) were used, followed by the number of the order of the interviews.

RESULTS AND DISCUSSION

Participant characterisation revealed that 32 were women and six were men, with an average age of 39.13. Four were community health agents, three were dentists, 23 were nurses, seven were physicians, and one was a nursing technician.

In relation to education, 55.26% of the participants graduated from a public institution, an average of 13.16 years ago and between two and 43 years ago. Only one community health agent had not yet graduated.

The information analysis process led to three categories: interest in training and its contribution to professional practice; factors that alter professional practices; and proposals for improvement.

Interest in training and its contribution to professional practice

Professional education is a factor the encourages the study participants to search for training opportunities. The participants mentioned five aspects that encouraged them to search for these opportunities among the courses offered by the Minas Health Channel, namely, the need to continue their education after graduation, the idea of qualifying their actions in the work environment, the desire to update their learning, the shortage of educational practices, and the desire to improve their curriculum.

The participants are evidently interested in continuing their education after graduation and in their employability, as well as in acquiring knowledge for their daily work activities.

This quest for knowledge is directly related to rapidly changing technologies and healthcare needs, and to the repercussions of these changes in the work process. Knowledge is dynamic and every day new information must be monitored and considered in the work process of health professionals(13).

Globalisation makes knowledge rapidly obsolete and brings new information to professional practices that force workers to adopt continued education strategies(7).

One of the modalities that mostly interests healthcare workers who use the Minas Health Channel is distance learning due to the flexibility to complete activities and the possibility of conciliating work with studies. Distance learning also reduces or remedies the issues related to cost and time that are common in classroom courses(7).

Our daily routine is really busy and we don´t have time to commute to other locations, so these online courses really help because I can study any time I am less busy, or at home, I can learn on Saturdays or Sundays, whenever I have more free time, I can do the course. (NOR5)

It is important to register that, despite all the flexibility that is characteristic of distance learning, the statements show that distance learning demands personal planning in order to complete the course activities and enable technology insertion.

When asked about how they had heard about the courses of the Minas Health Channel, the professionals mentioned internet searches, recommendations from other professionals, and text message marketing.

Although the creation of the Minas Health Channel determined the existence of a ‘protected time’ for studies, the professionals stated that the municipality only got involved in promoting and encouraging enrolment in the Manchester Protocol course, due to the risk classification monitored by the state and the transfer of funds to the municipalities.

The need for a more synergistic action between the state and the municipalities that guarantees the inclusion of these courses in the management agenda is recognised by the professionals, who also stated that the ‘protected time’ is only active in the municipalities of the southeast and north triangle health regions, and even then, this period is only used for internal meetings and other educational practices carried out by municipalities.

I searched for them myself, but if there was a way, a connection between the municipal department and the state to enable this for us, summon the health units to participate, that would be great, because it would reach more people. (NOR3)

For most of the professionals, their participation in the course is a voluntary and individual act for those who are interested in improving their qualifications. This is a striking contradiction if we consider the collective nature of healthcare work and the standards laid down in the PNEPS, which values collaborative construction based on the epidemiological profile of the population and the organisation process of healthcare in each region.

Individual training does not generally solve solitary problems like in the former social division of work, nor does it help with team interaction or the autonomy of subjects in their work routines(14). It is widely acknowledged that professionals do not merely need to share the same workspace; the key is to guarantee the sharing of knowledge, projects, powers and wills of professionals who work together(15).

It is believed that the significant participation of nursing professionals is related to the importance of this category in the actions carried out in primary care, which involves several activities and dynamics, as well as assistance, planning, organisation, evaluation and health education.

During the interviews, the participants provided examples and benefits of the information they acquire in the courses for their practice activities, namely professional activities guided by theory; improved care provided to users based on the approach and conduction of cases; more organised work, especially in terms of reference and contra reference, criteria definitions and the incorporations of new tools; and better internal team training and healthcare education.

The mental health course really changed my practice, like really, really, especially in relation to listening, to that position we have of damage reduction within mental health as a whole, on the street, outside the unit walls. (NOR6)

However, this incorporation is obviously individual and fragmented by the worker in the subject area of the course, which indicates that the courses offered by the Minas Health Channel are generally programmatic and vertical. Although the courses promote knowledge updating and trigger the search for solutions to daily problems, the courses are not configured as a network of thought and action articulated with the practice needs and demands of these workers.

Health workers frequently have access to educational practices, such as training, meetings and courses, that are fragmented, vertical, punctual and individual in nature(14). With the establishment of the PNEPS, the proposal is that the educational practices provide workers with the opportunity to learn and discuss cases, actions and behaviour in accordance with service needs(14).

The Minas Health Channel gives priority to alternatives that allow collective learning based on practice and work, and becomes a tool to implement EPS.

Factors that alter professional practices

In order to incorporate the knowledge acquired in the courses offered by the Minas Health Channel in the daily routine, the participants reported that they experienced a series of difficulties and facilities.

The appropriation of the tools and content offered in the course requires the mandatory involvement of the participants and of all other work colleagues. In general, the professionals claimed that other members of their work teams were not readily available to discuss or enrol in the courses offered by the Minas Health Channel.

Data show that the participants who attend different courses have to encourage their work colleagues to enrol in the courses of the Minas Health Channel, although their encouragement does not always increase participation in educational activities.

I offered the courses to the technicians, to the agents, but as far as I know, I don’t know of anyone who actually did them. Only when they were forced to do the Protocol of Manchester. (SUD11)

The desire for greater involvement of their co-workers can be interpreted as the need to share the newly acquired knowledge with their team in order improve the work process.

The interviewees understand that the non-participation of their teams in the courses hinders the exchange of knowledge and interaction required to apply and change the ways of conducting care routines. This often produces discomfort among the team members, especially when the new actions are considered unnecessary to improve practice. It also burdens the professionals who were trained since they are the only ones with this specific knowledge.

This presents a huge contradiction; despite the team work in primary care, the participation in courses of the Minas Health Channel is individual. Ideally, the act of learning must occur as a team through the exchange of information that allows the application of learning in the work routines(13).

According to the study participants, when all the team members participate in the course and all the concepts are aligned, the work process becomes easier

If I could make everyone do the course at the same time, I think the team would be more united, more confident to pass the information to users. (NOR7)

Teamwork provides workers with a global and collective work vision, which reinforces the importance of cooperation and sharing tasks to obtain results(13). This joint effort is also essential for the EPS process since it seeks to solve collective problems to transform reality(16).

Although the courses are offered to all the primary care professionals, most of the participants are nurses, which prevents routine care actions from being reconsidered by the entire team. Since EPS targets the work process, educational practices should involve all the members of a team, not merely the nurses, although they are also recognised as agents who effectively contribute to the consolidation of this level of care.

The participants identified that the support of municipal management is also an important intervening factor for the practical incorporation of the content learned in the courses. The absence of a manager who is aware of the proposal can prevent the development of actions with effective results.

The lack of resources, whether human, structural, or of material and consumable goods, was also reported by the study participants as an important variable in the appropriation and application of the learned content and methodologies.

The need to adapt the course content to the reality of healthcare services was also mentioned. As they are offered in all the state municipalities, the course format is generalised and does not observe the specificities of each territory.

This is a contradiction, considering that the EPS processes should be based on problems that are identified in the daily routine of healthcare services in order to improve the work(13). Educational activities that use e-learning tools must be articulated with more local and classroom-based support strategies that allow the knowledge acquired in practice to be reworked.

The statements also revealed how the lack of appreciation of the professionals, absence of a career plan, position and salary, the organisation of the work agenda, the size of the coverage area, and the population’s preference for curative and drug-based actions at the expense of health promotion affect the practical incorporation of content learned in the courses.

These findings are similar to others regarding the aspects that interfere in the EPS implementation process. An article that provides a meta-synthesis of literature on the key concepts and practices related to EPS found difficulties related to material infrastructure, management and human resources that pose a challenge to the implementation of critical-reflective and participative actions that can change work routines(17).

Another author suggests that the factors that limit the construction of an EPS proposal are the non-participation of all professionals of the team, the resistance of some professionals in relation to new ideas, lack of time and financial incentives, excessive demands, and lack of incentive of service managers for workers to update their knowledge(18). Then there are the unstable work ties and low salaries for certain professional categories, which increase the workload, reduce motivation, and limit the available time to focus on studying and discussion groups(16).

Considering the realities experienced by participants in the implementation of the mentioned courses, Minas Health Channel is not configured as an EPS proposal since it does not encourage teams to discuss their work process. This finding reinforces the need to build strategies that improve the supply and the incentive of EPS for state professionals.

Proposals for improvement

The statements provided proposals to improve the supply of courses by the Minas Health Channel to qualify workers and the production of care, and the interest of participants to maintain the courses offered by the Minas Health Channel.

Some statements referred to the need to deepen and update the offered content, and to include new topics and methodologies.

I’m talking about really specific content, for example, one of the things that none of these courses deals with is pharmacology and that is a huge obstacle, because that can be a deficit that lingers from graduation, and if I don’t have access to protocols, guidelines, the issue of pharmacology, it affects performance. (SUD5)

The use of active methodologies that shift learning to the work routine through problem-solving discussions facilitates technical-scientific updating and the construction of team work and communication that are vital to improve performance in primary health care and address the gaps in the implementation of PNEPS(17).

Considering that the foundations that shape educational processes emerge from routine work and the interaction of subjects during the production of health(5), the participants were encouraged to mention the topics that could be included in the Minas Health Channel course portfolio. The topics the participants mentioned were related to key health conditions and life cycles due to the demands they represent in the work routines.

They also mentioned topics related to the fields of care/assistance, namely family approach, interpersonal relationships, wound care, smoking, vaccination, home hospitalisation, and group-oriented concepts and methodologies.

Some of the participants expressed interest in participating in the subjects offered by the Minas Health Channel and the need for synchrony between the topics related to work processes.

I wanted to suggest that we, the team, could suggest some courses, some topics that they could cover that target the topics that we think could be interesting. (SUD1)

These findings reinforce the need to guarantee the precepts of EPS, which aims to ensure the transformation of professional practices and the organisation of work based on the health needs of the population, of management and of social control(5).

EPS should therefore consider the micro politics of live work, which includes the interests and needs of workers and the reality of life production in the region(19).

Another important aspect refers to the need to enhance the service as a privileged locus of the teaching-learning process and allow courses in the workplace, which requires a physical and computer-based structure in health units.

At the unit, we could have some time for updates, but we end up having to do that at home, and I think it is actually for the service as well. (SUD15)

The workplace should be the starting point of the educational process, and therefore provide greater interaction and participation of professionals who are learning inside the environment in which they work(18).

The participants also mentioned the need to provide specific courses for the professional categories. Understanding the importance of the course to the team reaffirms the collective nature of healthcare work, and the specificity of professional fields.

What I want is a broader course for the medical field, because I know they generalise and I think it’s great to generalise for the entire team, but some of the things I would like to study more in the medical field. How the doctor can react, how the doctor can act. (TN2)

A study on the development of permanent education in health units in a medium-sized municipality of southern Brazil also found that most workers want to cover specific medical areas, which could be associated with the inability to understand the work of a multidisciplinary team that is so extensively recommended by the ESF (20).

It turns out that part of the professionals was unmotivated, which affects participation in the courses and in the work context, and suggests the need to discuss incentives and strategies to encourage participation in educational activities.

Another indicated action was the need to ensure meaningful involvement of management in the monitoring of course participants, while allowing them to contact other municipal workers who completed the same course for all the participants to interact and incorporate the new practices in the services or reorganise, adapt and transform hegemonic practices.

I think that at municipal management level the people of the same municipality should interact. I think that if management accompanied us more closely, like arrange meetings with the people who did the course, an example, integrative practices and the things we could work together for the municipality. (SUD17)

In general, the suggestions to improve the courses offered by the Minas Health Channel agree with the findings of another study, in which the main responses included the need for collaboration, the desire to participate as a team, improved primary care facilities and resources, and well-defined topics(20).

Consequently, the teaching-learning process must be based on motivated actions within the scope of a permanent education policy that considers the micro politics of live work.

FINAL CONSIDERATIONS

The results of this study show that the primary care professionals believe that the courses offered by the Minas Health Channel are a means to acquire technical and scientific knowledge and to guide the production of care and associate it with the possibility of personal and professional growth.

It was found that, in general, the acquisition of knowledge affects the production of care according to the individual practices of the professionals who completed the courses of the Minas Health Channel, and therefore induce thought on the work processes according to the proposed activities and interactions. However, the professionals face difficulties that prevent them from applying what they learned to their work routine.

With regard to suggestions for the courses, the professionals mentioned important aspects that should be considered by state and municipal management.

The professionals considered that the courses offered by the Minas Health Channel provided individual theoretical and technical improvements, but are still unable to modify professionals practices, which is the main motto of the PNEPS. The courses are still unable to transcend the oneness of technical and reproductionist practices based on fragmented and one-off training.

Although the Minas Health Channel is presented as a tool to offer courses based on the concept of continued education, the channel has not adopted the guidelines of the PNEPS to construct the offered educational proposals. The starting points of educational proposals based on the EPS design must be the contextualisation of social practices and the active participation of health teams in order to transform praxis through a critical and creative capacity.

Therefore, the Minas Health Channel should be reformulated in order to be included as a continued education tool in Minas Gerais, which can be done by adopting participatory, reflective and problem-solving methodologies.

This study contributes to the nursing professional, especially in terms of the courses offered by the channel, by stressing the importance of educational practices and their potential contributions to the transformation of praxis. However, these proposals must be contextualised according to the reality of the healthcare work that is produced by multi-professional teams.

A limitation of this study is the inclusion criteria, which does not include other healthcare professionals who completed the courses, those who did not finish the course, or those who work in other levels of care. Further investigations should be carried out on this subject to understand the dynamism of this tool that is used as a strategy of the SES/MG to qualify health workers.

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Received: July 08, 2015; Accepted: May 20, 2016

Corresponding author: Lizziane d’Ávila Pereira. E-mail: liz.davila@hotmail.com

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