From in-service education to continuing education in a federal hospital^a

ABSTRACT:

Objective

To analyze the implications of in-service education for the exercise of disciplinary power of nurses in the creation of the continuing education service of the Hospital Geral de Bonsucesso (HGB).

Method

Social-historical study, whose sources were written documents and oral statements; Foucauldian discourse analysis was used.

Results

In-service education activities in the HGB went through two periods of discontinuity and were used as an instrument of disciplinary power exercised by hospital nurses, capable of controlling and organizing the institution’s nursing service, providing basis for the creation of the Continuing Education service.

Conclusion and implications for practice

The creation of Continuing Education functioned as a device used by nurses with knowledge and power to execute disciplinary power, capable of subtly disciplining and training employees, avoiding attitudes contrary to the objectives of the nursing service, in an attempt to ensure its control and qualification. When reflecting on educational practices / continuing education it is stimulated the transformation of care based on the needs of Unified Health System (UHS) users, thus contributing to the quality of health services.

Keywords:
Nursing History; Continuing Education in Nursing; Nursing Education; Nursing; Unified Health System

RESUMO:

Objetivo

analisar as implicações da Educação em Serviço para o exercício do poder disciplinar dos enfermeiros na criação do serviço de Educação Continuada do Hospital Geral de Bonsucesso (HGB).

Método

Estudo histórico-social cujas fontes foram documentos escritos e depoimentos orais; utilizada a análise do discurso Foucaultiano.

Resultados

As atividades da Educação em Serviço no HGB passaram por dois períodos de descontinuidade e foram utilizadas como instrumento de poder disciplinar exercido pelas enfermeiras do hospital, capazes de controlar e organizar o serviço de enfermagem da instituição, fornecendo base para a criação do serviço de Educação Continuada.

Conclusão e implicações para a prática

a criação da Educação Continuada funcionou como um dispositivo utilizado pelas enfermeiras detentoras de saber e poder para execução do poder disciplinar, capaz de disciplinar e adestrar os funcionários, de forma sutil, evitando atitudes contrárias aos objetivos do serviço de enfermagem, na tentativa de garantir o controle e a qualificação do mesmo. Ao refletir sobre práticas educativas/ educação continuada estimula-se a transformação da assistência a partir das necessidades dos usuários do Sistema Único de Saúde (SUS), contribuindo, dessa forma, para a qualidade dos serviços de saúde.

Palavras-chave:
História da Enfermagem; Educação Continuada em Enfermagem; Educação em Enfermagem; Enfermagem; Sistema Único de Saúde

RESUMEN:

Objetivo

Analizar las implicaciones de la Educación en el Servicio para el ejercicio del poder disciplinario de las enfermeras en la creación del servicio de educación continua del Hospital Geral de Bonsucesso (HGB).

Método

Estudio histórico-social, cuyas fuentes fueron documentos escritos y declaraciones orales; fue utilizado el análisis del discurso Foucaultiano.

Resultados

Las actividades de Educación en Servicio en el HGB pasaron por dos períodos de discontinuidad y fueron utilizadas como un instrumento de poder disciplinario ejercido por las enfermeras del hospital, capaces de controlar y organizar el servicio de enfermería de la institución, proporcionando la base para la creación del servicio de Educación Continua de la enfermería.

Conclusión e implicaciones para la práctica

La creación de la Educación Continua funcionó como un dispositivo utilizado por enfermeras con conocimiento y poder para ejecutar el poder disciplinario, capaz de disciplinar y capacitar sutilmente a los empleados, evitando actitudes contrarias a los objetivos del servicio de enfermería, en un intento de garantizar su control y calificación. Reflexionar sobre las prácticas educativas / educación continua estimula la transformación de la atención basada en las necesidades de los usuarios del Sistema Único de Salud (SUS), contribuyendo así a la calidad de los servicios de salud.

Palabras claves:
Historia de la Enfermería; Educación Continua en Enfermería; Educación en Enfermería; Enfermería; Sistema Único de Salud

INTRODUCTION

Continuing Education in Nursing is a term known worldwide and used, mainly in the United States of America (USA) and Canada. In Brazil, it results from an evolutionary process of activities that involve training and qualification of nursing professionals in reviewing the procedures and techniques developed by them^1,2, in order to avoid discrepancy between the care provided and new forms of health care³. It is, therefore, an extremely important tool to ensure safe care⁴, as it contributes to the qualification of nursing professionals and to the assistance provided.⁵

In these countries, a point that differs from Brazil to be highlighted is the linking of Continuing Education to the regulation of the profession. This is because the nursing regulatory bodies, in many countries, recognize that it is their responsibility to ensure the updating, not only of licenses, but also of professionals, maintaining the knowledge necessary to practice the profession safely. In addition, they highlight the importance of Continuing Education and professional development for the remodeling of attitudes and understanding of other roles of health professionals, in an interprofessional view, understood as that focused on shared care that will provide a multidimensional approach that characterizes health care as collaborative.⁶ Many states require continuing education credits to maintain the health professional’s license.⁷ Nurses have a responsibility to keep up to date with regulatory issues, understand the provisions of their nursing practice and comply with their duties to renew their nursing license.⁸ There are several ways to obtain these credits: web seminars, magazine articles with continuing education tests, podcasts (digital audio file), participation in conferences, in addition to courses and training, all being considered valuable sources of new information.^7-9

The first term to name this tool was In-Service Education, which historically was present in the health area until its designation became Continuing Education, as it is currently known in Brazil and in other countries, such as Canada and the USA.² National and international scholars define it as a practice associated with the education process at work, aiming at more technically qualified services.^1,10

In Brazil, Continuing Education started to be integrated into a public policy through the National Policy of Permanent Education in Health, approved by the Ministry of Health, through legislation created in 2007, which recommends that the education processes of health workers be done through the problematization of the work process.^11,12

The change in the name reflects changes in the education activities of health professionals, because it adds transformations of its conceptions and concepts, which accompany the historical trajectory of the development of health sciences, which imposes constant theoretical and practical updates on professionals.¹³ To better understand this process, which, over the years, has become a public policy in Brazil, it is necessary to know this trajectory, in order to contextualize the facts that preceded the emergence of Permanent Education.

The Hospital Geral de Bonsucesso – HGB (in native language), setting of the present study, was inaugurated on January 31, 1948, in the city of Rio de Janeiro, and was linked to the Ministry of Health, starting in 1990. In this sense, Continuing Education became essential for the updating of employees, constituting one of the aspects of its institutional mission: offering quality services to the population, with humanized and multidisciplinary care, integrated to the Unified Health System (UHS) and participating in the training and development of human resources.¹⁴

Until the 1970s, educational activities at HGB were developed in the sectors, without the existence of a service of their own. Subsequently, the In-Service Education activities were carried out in a room annexed to the head of nursing. In 2000, Continuing Education in Nursing began, which now has its own physical space and a nurse responsible for the sector, endowed with knowledge, power and autonomy.

The justification for carrying out this study is based on the importance of the activities developed by the Continuing Education Service in Nursing at HGB, which brought to the institution the recognition of its relevant assistance and social role in Rio de Janeiro and Brazil. Thus, recording the historical facts about the hospital service, in different phases, can induce new theoretical reflections about this sector in other institutions as well. In addition, it allows recording the history of the institution and of nursing itself, contributing with historical sources, fundamental to the profession’s memory.

Therefore, the objective of this research was to analyze the implications of In-Service Education for the exercise of the disciplinary power of nurses in the creation of the Continuing Education service of HGB.

METHOD

Qualitative study of a historical-social nature that seeks to understand the facts that occurred in society at a given time. This article is part of the thesis defended in the Post-Graduate Nursing Program at the Universidade Federal do Rio de Janeiro, in November 2016.

The study scenario was the Hospital Geral de Bonsucesso (HGB), former Hospital of the Instituto de Aposentadoria e Pensões dos Empregados em Transportes e Cargas (IAPETC).¹⁴ The study period is from 1970 to 2000, being the starting point the first record of educational activities at HGB and, the final mark, the creation of the Continuing Education in Nursing service. During this period, the HGB had approximately 500 active beds and offered highly complex services such as emergency, maternity, oncology, liver and kidney transplantations.¹⁵

The direct historical sources include written documents belonging to the archives of the Nursing Division, Archive of the service of Continuing Education in Nursing, Archive of the Study Center, the 1981 Report of In-Service Education Activities, the Hospital’s Institutional Goals of 1999, all from HGB, in addition to two oral testimonies. Secondary sources were articles and books relevant to the topic under study.

Data collection was carried out in 2014, through procedures that included: search, document analysis and interviews conducted with the thematic oral history technique, which allows the recording of testimonies, access to “stories within the story” and, thus, they expand the possibilities of interpreting the past.^16:155 The interviews were conducted in places chosen by employees, lasting 26 and 73 minutes. Subsequently, they were transcribed, returned to the employees for validation and use in the research.

The oral documents used in this article had as collaborators the two nurses from HGB who held strategic positions in the process of creating and organizing the service: General Directorate of Nursing (N1) and Coordination of the Service of Continuing Education in Nursing (N2). The interviews conducted became oral sources for triangulating the data with the other written documents enabling the confrontation of the data about the studied reality, looking at it from different angles, thus eliminating biases of unitary views.¹⁷

The selected sources were submitted to internal and external criticism and related to the historical context. For the data analysis procedure, discourse analysis was used, which was divided into phases, these related to subjects, objects, institutions, power, ideology and reflections, resulting in several returns to the collected data, in order to contemplate the rigor of analysis.¹⁸

For the analysis, primarily, to relate the different discourses, their graduations were articulated with economic, political and social practices. In addition, seeking to better understand the historical process that permeated the evolution of In-Service Education at HGB, the discussion of the documentary corpus of this study was based on some concepts by Michael Foucault, such as knowledge and power.

This research was submitted to the Research Ethics Committee, and data collection started after its approval. Employees received the Free and Informed Consent Form, and all ethical procedures were carried out, in accordance with Resolution 466, of December 12, 2012, of the National Health Council, which provides for the participation of human beings in research.

RESULTS

From the In-Service Education to Continuing Education in Nursing

In the HGB, In-Service Education activities are evidenced in the speech of one of the interviewees, which refers to the end of the 1970s. During this period, according to the HGB’s activities report, the sector had the tasks of updating, improving and monitoring the server, in addition to the improving and training of interns of high school and undergraduate levels of nursing courses.

Regarding the physical structure, the service had a room close to where the head of Nursing worked, in which educational activities were carried out:

[...] the activities that were carried out in this period had as a ‘flagship’ the Nursing Residency and the Boarding School and Internship; also, high school level interns. Updating activities were, therefore, still very focused on monthly lectures, in which nurses were invited. So, it worked until 1982, when politics made the sector practically extinct. So, they ended the area, the room and even left us without a single frequent activity [...]. (N1).

In-Service Education over the years has been developed until the creation of a commission was published in Ordinance No. 16, of December 22, 1981, of the Instituto Nacional de Assistência Médica da Previdência Social – IAMPS (National Institute of Medical Assistance for Social Security, in free translation), composed of ten nurses from the HGB. This committee was responsible for developing the nursing routine manual for HGB, which marked the growth of the service, acquiring more space and autonomy in the institution.

As of 1982, there was a greater organization of activities offered to the internal public and, according to the Educational Activities Report of 1981, they were: Update Courses for Nursing Assistants and Update Courses for Nurses: training of the Nursing Process, electrocardiogram; monthly meetings of internees with presentations of group work on the following topics: acute lung edema, burns and fundaments for infection control.

In the course of its organization, In-Service Education went through periods of discontinuity, having its first break from 1982 until 1983, when the sector was reactivated, according to the discourse presented:

[...] we had a large, comfortable room, two tables, a refrigerator [...] Classroom and a technical room. (E2); in 1983, another director, who was a nurse and teacher, took over as head [...] and she then reactivated the sector in the appropriate area together with the school of nursing assistants, which occupied an entire floor of the administration building [...]. (N1).

With regard to the support of the General Directorate of HGB for the development of educational activities, it is observed that it directly depended on the affinity between the person occupying the position of General Director of the Hospital and the Chief Nurse of the Nursing Service, as a collaborator said:

[...] depending on the director, because the director was a political nomination. […] The director was a doctor, not a manager, not an administrator, he had no training, in a way of putting it, no administrative experience at all. He was a good doctor, he had political knowledge, so he became a director. Some of the times, the boss would get something from him [...]. (N2).

The second rupture occurred for approximately 7 years, between 1990 and 1998, with activities resumed only in 1999:

[...] In-Service Education ended, there was no In-Service Education. It was in 1990, I came here, to the Study Center, because I was vice president. [...] but I also stayed with this part of the internship, because there no longer was In-Service Education in Nursing. So, I brought it here in an indirect way [...]. (N2).

According to the same collaborator, the reason for the ending of the sector:

[...] she [the general head of nursing] no longer wanted In-Service Education. At the time, she needed nurses, in short, she decided to end the sector [...]. (N2).

At the end of the 1990s, some changes that occurred at HGB led to the development of educational actions at the institution:

[...] this happened because external policy generated professionalizing of management and the hospital’s internal policy started some divisions. The three divisions within the hospital that started to take a management course were: medical, nursing and administrative. So, based on the professionalization of these managers, which I was part of, there was a proposal, institutional goals for the hospital [...]. (N1).

The institutional goals to which the employee refers was developed in the direction of the doctor Benedito Pinheiro Meireles and was called “Institutional Goals of the Hospital Geral de Bonsucesso: 1999”. The plan was divided into four parts, namely: presentation, description of the offer, physical goals – consultations, outpatient procedures and hospitalization – and organizational goals.

It was from this plan that the Continuing Education in Nursing service was created, changing its name to that. The referred document brought the following missions to nursing: to improve the technical-assistance standards of nursing and motivation for work through a continuing education program, including: installing of the Ethics Committee of Nursing; and improving the control of the materials sterilization center through the revision of routines.

Thus, the service was created in October 2000, presenting a different format from In-Service Education, with its own room for its operation, auditorium for the development of its activities and with a nurse responsible, coordinator of the sector, being accountable for the missions documented in the institutional goals and for the construction and development of nursing at HGB, continuing the scientific activities.

DISCUSSION

In-Service Education, the creation of Continuing Education in Nursing and the use of disciplinary power

At the end of the 1970s, HGB’s Nursing Service Education activities were based on traditional patterns, where there is the classroom and students, working according to what scholars at the time highlighted as their area of ​​expertise. In addition, the statements bring characteristics of the nursing profession in the process of evolving its scientific characteristic.^1,19 The analyzed speeches evidenced statements of a growing development of the sector in terms of organization and of scientific aspects closely linked to the work of nurses who were involved in the service and who had the scientific knowledge and power to boost activities.

It is possible to note that in the educational practice carried out by the nurses of the HGB, the disciplinary power was exercised through traditional teaching techniques such as lectures in the classroom, aimed at the receiving of new employees and training the interns, updating of the employees by the nurses who held the knowledge.

The relationship between educational activities and the expansion of theoretical and practical knowledge promote changes in power relations in institutions, which was perceived in the HGB by the training of professional nursing groups to better think work strategies in the hospital sectors and to give action to their own practice of in-service education, which gradually gains space for action and power, and is viewed with caution by the head of nursing.

It is worth noting that the functioning of the sector depended directly on the performance of the nurses there, who had a certain degree of autonomy, and on the interest, or not, of the head of nursing in maintaining such a service. There was no policy from the general management or the Ministry of Health that regulated HGB Nursing In-Service Education.

So, when the service started a crisis process, in the year 1990, the activities were not completely interrupted, since one of the nurses, when she assumed the vice-direction of the Study Center, took the coordination of the nursing internship to her new sector, a strategy to guarantee the educational activities of nursing partially functioning in another organizational structure. Such a strategy moves an organized service to another space, in order to maintain its functioning until a new policy is favorable to its advance.

It should be added that the return of the activities of In-Service Education, at the time of its first break (from 1982 to 1983), was made possible by the rise of a nurse, also a professor at a public university, to the position of head of nursing at HGB.

Thus, the power conferred to her to occupy a decision-making position was strategic for the resumption of activities, which were linked to educational issues. In other words, the HGB recognized the knowledge/power of this nurse to occupy a specific space, in view of her training as a nurse and teacher. This is because knowledge and power are related to each other, knowledge being the guiding thread of power, so where there is knowledge there is a struggle for power.²⁰

It is worth mentioning that the official speech of one of the collaborators was that the lack of human resources prevented training in the sectors and, for this reason, the activities were carried out in the classroom, in the traditional manner. This attitude expressed the desire to develop strategies that would preserve power, even if unconsciously. A truth regime is evident, very common among nurses involved in educational activities in a hospital. This report is corroborated by the statement that health professionals and, in this case, nurses included, are not used to working in groups, in dialog formats, active participation.²¹

This discursive formation contributes to the construction of agile, obedient, productive and docile subjects, with no reflection and criticism involved in the process, according to a set of activities, most of the time, linked to the mere accomplishment of tasks, which for some time one seeks to overcome in nursing.

Still in this perspective, in 1981, the proposal of the head of the nursing service to the director of the HGB about the official constitution of a Nurses Committee, with the objective of organizing the manual of routines of the nursing service, brought the discourse that the commission would have the task of studying and developing routines, aiming at the organization of nursing care.

The head of nursing asked the service heads to organize the techniques developed in the respective services for the manual, where they would be described and could be consulted and used for training, and, thus, standardize nursing care in that period. In this case, the use of disciplinary power by the head of nursing can be evidenced, since this type of power is an exercise of control and standardization, being a way of managing and controlling employees and, therefore, increasing their productivity.²²

With the completion of the manual, In-Service Education was responsible for the training of nurses and nursing assistants, in accordance with this document, which corresponds to the process of standardization of nursing at HGB.

With regard to political relations, which are fundamental for the quality of the functioning of a service, the chief nurses, when they had good relations with the medical director of the hospital, opened access to negotiations that also included educational activities specific to nursing.

Thus, when assuming the general leadership, in 1983, a collaborator committed to organize and make efforts to develop the activities of In-Service Education in nursing which were defined, but were not yet carried out in its fullness, or at least, as she believed that it should work. Then, she planned and executed educational actions in favor of this objective.

In fact, her speech contributed to the development of the sector, in view of the occupation of a position that gave her power. In addition, it is noteworthy that the choice of the nurse by the head of nursing at HGB to coordinate the service at the time, was due to her previous experience, when she held the position of professor at another institution. Such indication was associated with the knowledge acquired by the nurse who exercised the power of educational discourse, which would allow the organization and development of the sector.

Regarding the second disruption of In-Service Education activities, a discussion about the facts narrated and analyzed is appropriate, since the need for assistance service is legitimate in a hospital unit such as HGB, but strategies could be applied to keep the sector functioning. These strategies could involve shift rotation schedules of the employees, with reduced activities, which would generate some loss, but would maintain the sporadic performance of activities.

However, this was not the option of the chief nurse of the hospital, determining a discontinuity of the sector in the HGB, which would last seven years, from 1990 to 1998. The speech of the head of nursing about the resizing of the service rotation schedules, removing the nurses responsible for educational activities to serve the sectors with an assistance characteristic, demonstrates the priority of this management to activities of care practice to the detriment of activities of an educational nature, privileging the biomedical and technicist model related to the training of nurses.^23-25

According to the events for the creation of the Continuing Education in Nursing service, it is noted that it maintained the practice of traditional education, based on the technical model and still without much space for reflection and criticism, which is commonly found in current literature.^24,25 In the enunciations present in the statements and documents, disciplinary words stand out, strengthening and perpetuating the disciplinary power exercised by nurses involved in educational activities at HGB, such as: control, routine, installing, commission.

Thus, strategies with the objective of standardizing and controlling the service since its creation are evidenced, which meets the assertion that the nurses themselves collaborate in strengthening the disciplinary face of health education by using such terms arisen from the military regime.²¹

Thus, the creation and organization of the HGB Continuing Education service functioned as a device used by nurses with knowledge and power to execute disciplinary power, capable of subtly disciplining and training employees, avoiding attitudes contrary to the objectives of the nursing service, in an attempt to guarantee the order and maintenance of the service, while developing knowledge and practices for a better functioning of the hospital, in modern logic.

It is noteworthy that the nurses who started the service had the power knowledge compatible with the activities inherent to this job, which favored them to play an important role not only in creating it, but also in maintaining it. It is added that there is always a relationship between knowledge and power within the community, which will be present, even if at a minimum level.²⁰

It is worth mentioning that, in this context, the role of the nurse expanded and because the nurses involved in educational activities have knowledge, the power granted them autonomy with regard to decision-making and organization of the service, which was different in other areas that depended on the Study Center for the analysis and authorization of their training demands.

FINAL CONSIDERATIONS AND IMPLICATIONS FOR THE NURSING AREA

According to the analyzed data, it was possible to observe that In-Service Education was used as an instrument of disciplinary power exercised by the head nurse and nurses involved in educational activities, capable of controlling and organizing the institution’s nursing service, providing a basis for the creation of the Nursing Continuing Education service.

The same characteristics of In-Service Education are noted in the creation of Continuing Education in Nursing, which was linked to the exercise of disciplinary power by the nurses of HGB who, even with two periods of discontinuity, maintained strategies for maintaining a training sector exclusive to nursing. The statement of the nurses’ speeches highlighted slogans capable of disciplining and training employees, in a subtle way, avoiding attitudes contrary to the objectives of the nursing service, in an attempt to guarantee order and the maintenance of its power.

In addition, the disciplinary and standardization of the nursing service was brought by the nurses involved in the creation of the Continuing Education in Nursing service through a creative discourse that would contribute to increasing the quality of nursing care provided at HGB, which, in fact, occurred due to the training strategies implemented.

With regard to the limitations of the study, for this research it was necessary to overcome some challenges in the sense of organizing written documents, as some were not found or were not available on the hospital’s electronic network, in addition to some contradictory dates, being necessary to search relentlessly for reliable data.

The study makes it possible to expand the knowledge of nurses’ performance in the area of ​​continuing education, a term used worldwide, bringing the history of the present time, characterized by a moment of advances, ruptures and expansion of the role of nurses in this area and in this institution, demonstrating their knowledge, power and autonomy. Thus, it contributes by bringing the reflection about educational practices not only at HGB, but also in other health institutions of the federal government that have gone through these processes of creation and organization of these services. For the assistance, the contribution is inserted in the possibility of offering subsidies for changes in professional nursing practices, as continuing education envisions proposals for education to health workers, capable of transforming practices based on the needs of UHS users, contributing, thus, for the quality of health services.

ACKNOWLEDGMENTS

To Lawrence S. Bloomberg Faculty of Nursing, for contributing to the study during the Sandwich Doctorate internship conducted by Camila Pureza Guimarães da Silva, from January to April 2015.

• FINANCIAL SUPPORT Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – CAPES (Coordination for the Improvement of Higher Education Personnel, in free translation) – granting of Sandwich Doctorate scholarship, from January to April 2015, to Camila Pureza Guimarães da Silva.
• a
  This article was extracted from the doctoral thesis entitled “Educação Continuada em Enfermagem do Hospital Geral de Bonsucesso: espaço de consolidação do saber/poder da enfermagem”, by Camila Pureza Guimarães da Silva, supervised by Ph.D Professor Maria Angélica de Almeida Peres. Post-graduate Nursing Program. Escola de Enfermagem Anna Nery. Universidade Federal do Rio de Janeiro, 2016.

Referências

• ¹
  Sardinha PL, Cuzatis GL, Dutra CT, Tavares CMM, Dantas CAC, Antunes CE. Educación permanente, continuada y de servicio: desvelando sus conceptos. Enferm Glob. 2013 jan;12(29):307-22.
• ²
  Draper J, Clark L, Rogers J. Managers’ role in maximising investment in continuing professional education. Nurs Manag (Harrow). 2016 fev;22(9):30-6. PMid:26938913.
• ³
  Price S, Reichert C. The Importance of Continuing Professional Development to Career Satisfaction and Patient Care: Meeting the Needs of Novice to Mid- to Late-Career Nurses throughout Their Career Span. Adm Sci. 2017 fev 7;7(2):17. http://dx.doi.org/10.3390/admsci7020017
  » http://dx.doi.org/10.3390/admsci7020017
• ⁴
  Melnyk BM, Gallagher-Ford L, Zellefrow C, Tucker S, Thomas B, Sinnott LT et al. The First U.S. Study on Nurses’ evidence-based practice competencies indicates major deficits that threaten healthcare quality, safety, and patient outcomes. Worldviews Evid Based Nurs. 2018 fev;15(1):16-25. http://dx.doi.org/10.1111/wvn.12269 PMid:29278664.
  » http://dx.doi.org/10.1111/wvn.12269
• ⁵
  Leach LS, McFarland P. Assessing the professional development needs of experienced nurse executive leaders. J Nurs Adm. 2014 jan;44(1):51-62. http://dx.doi.org/10.1097/NNA.0000000000000021 PMid:24316619.
  » http://dx.doi.org/10.1097/NNA.0000000000000021
• ⁶
  Nelson S, Turnbull J, Bainbridge L, Caulfield T, Hudon G, Kendel D et al. Optimizing scopes of practice: new models for a new health care system. Ottawa, Ontario: Canadian Academy of Health Sciences; 2014
• ⁷
  Alexander M. Does mandatory continuing education ensure continuing competence? J Nurs Regul. 2012 jul;3(2):3. http://dx.doi.org/10.1016/S2155-8256(15)30211-8
  » http://dx.doi.org/10.1016/S2155-8256(15)30211-8
• ⁸
  Libner J. Priorities for continuing education regarding regulation: perceptions of RN-to-BSN students and state regulators. J Nurs Regul. 2016 abr;7(1):53-8. http://dx.doi.org/10.1016/S2155-8256(16)31042-0
  » http://dx.doi.org/10.1016/S2155-8256(16)31042-0
• ⁹
  Institute of Medicine. Committee on Planning a Continuing Health Professional. Continuing professional development: building and sustaining a quality workforce [Internet]. Washington (DC): National Academies Press; 2010 [citado em 2019 nov 23]. Disponível em: https://www.ncbi.nlm.nih.gov/books/NBK219809/
  » https://www.ncbi.nlm.nih.gov/books/NBK219809/
• ¹⁰
  Arnemann CT, Lavich CRP, Terra MG, Mello AL, Raddatz M. Health education and permanent education: actions integrating the educational process of nursing. Rev Baiana Enferm. 2018 jul;32:e24719.
• ¹¹
  Cardoso MLM, Costa PP, Costa DM, Xavier C, Souza RMP. The National Permanent Health Education Policy in Public Health Schools: reflections from practice. Ciênc Saúde Coletiva. 2017 maio;22(5):1489-1500.
• ¹²
  Merhy EE, Feuerwerker LCM. Educação Permanente em Saúde: educação, saúde, gestão e produção do cuidado. In: Mandarino ACS, Gomberg E, organizadores. Informar e Educar em Saúde: análises e experiências. Salvador: Editora da UFBA; 2014. v. 1, p. 5-21.
• ¹³
  Campos KFC, Marques RC, Silva KL. Continuing education: speeches by professionals of one Basic Health Unit. Esc Anna Nery. 2018 out;22(4):e20180172. http://dx.doi.org/10.1590/2177-9465-ean-2018-0172
  » http://dx.doi.org/10.1590/2177-9465-ean-2018-0172
• ¹⁴
  Silva CPG, Santos TCF, Peres MAA. Nursing Service at the current Hospital Federal de Bonsucesso (1950-1951): From laic to religious. Esc Anna Nery. 2015 abr/jun;19(2):356-62. http://dx.doi.org/10.5935/1414-8145.20150049
  » http://dx.doi.org/10.5935/1414-8145.20150049
• ¹⁵
  Hospital Geral de Bonsucesso. Relatório de atividades da Educação Continuada. Rio de Janeiro: Hospital Geral de Bonsucesso; 2006.
• ¹⁶
  Alberti V. Histórias dentro da História. In: Pinsky CB, organizador. Fontes históricas. 2ª ed. São Paulo: Contexto; 2006.
• ¹⁷
  Santos KS, Ribeiro MC, Queiroga DEU, Silva IAPD, Ferreira SMS. O uso de triangulação múltipla como estratégia de validação em um estudo qualitativo. Cien Saude Colet. 2020 mar;25(2):655-64. http://dx.doi.org/10.1590/1413-81232020252.12302018 PMid:32022205.
  » http://dx.doi.org/10.1590/1413-81232020252.12302018
• ¹⁸
  Kruse MHL, Dornelles CS, Viana KRF, Bernardi KS, Botega MSX, Pinheiro MS. Estudos culturais: possibilidades para pensar de outro modo a pesquisa em enfermagem. Rev Gaúcha Enferm. 2018 ago;39(0):e2017-0135. http://dx.doi.org/10.1590/1983-1447.2018.2017-0135
  » http://dx.doi.org/10.1590/1983-1447.2018.2017-0135
• ¹⁹
  Adamy EK, Zocche DAA, Almeida MA. Contribution of the nursing process for the construction of the identity of nursing professionals. Rev Gaúcha Enferm. 2020 nov;41(spe):e20190143. http://dx.doi.org/10.1590/1983-1447.2020.20190143 PMid:31778384.
  » http://dx.doi.org/10.1590/1983-1447.2020.20190143
• ²⁰
  Foucault M. Microfísica do poder. São Paulo: Paz e Terra S/A; 2016.
• ²¹
  Sabóia V. Educação em Saúde: a arte de talhar pedras. Niterói: Intertexto; 2003.
• ²²
  Foucault M. Vigiar e punir. Petrópolis: Vozes; 2014.
• ²³
  Fertonani HP, Pires DEP, Biff D, Scherer, MDA. Modelo assistencial em saúde: conceitos e desafios para a atenção básica brasileira. Ciênc Saúde Coletiva. 2015 jun;20(6):1869-78. http://dx.doi.org/10.1590/1413-81232015206.13272014
  » http://dx.doi.org/10.1590/1413-81232015206.13272014
• ²⁴
  Mendonça FTNF, Santos AS, Buso ALZ, Malaquias BSS. Health education with older adults: action research with primary care professionals. Rev Bras Enferm. 2017 jul/ago;70(4):792-9. http://dx.doi.org/10.1590/0034-7167-2016-0349 PMid:28793110.
  » http://dx.doi.org/10.1590/0034-7167-2016-0349
• ²⁵
  Mello AL, Brito LJS, Terra MG, Camelo SH. Estratégia organizacional para o desenvolvimento de competências de enfermeiros: possibilidades de Educação Permanente em Saúde. Esc Anna Nery. 2018 jan;22(1):e20170192.

Edited by

ASSOCIATE EDITOR Cristina Rosa Baixinho

Publication Dates

• Publication in this collection
  03 July 2020
• Date of issue
  2020

History

• Received
  20 Dec 2019
• Accepted
  27 Apr 2020