Implementation of multi-professional healthcare residency at a federal university: historical trajectory

ABSTRACT

Objective

To retrieve the historical trajectory of the implementation of a multi-professional healthcare residency at the Universidade Federal de Ciências da Saúde de Porto Alegre, in partnership with the Santa Casa de Misericórdia de Porto Alegre.

Method

Historical research based on oral history. Interviews were conducted with six professionals of both institutions from October to December 2013. The data were subjected to content analysis.

Results

The oral histories led to three thematic categories, as follows: Strengthening the involved institutions; Professional qualification for intensive care; and Programme implementation.

Conclusions

The historical trajectory of a multi-professional healthcare residency programme revealed the efforts of linking teaching and service to better qualify healthcare professionals and strengthen healthcare teams, and consequently change the hegemonic medical assistance model.

Internship; nonmedical; Specialization; Intensive care units; Nursing

RESUMO

Objetivo

Conhecer a trajetória histórica do processo de implementação da Residência Multiprofissional em Saúde da Universidade Federal de Ciências da Saúde de Porto Alegre, em parceria com a Santa Casa de Misericórdia de Porto Alegre.

Método

Trata-se de uma pesquisa histórica, norteada pela História Oral Temática. As entrevistas com seis profissionais de ambas as instituições foram realizadas de outubro a dezembro de 2013. Foi aplicada a análise de conteúdo como método analítico.

Resultados

Emergiram três as categorias temáticas: Fortalecimento das Instituições envolvidas; Qualificação Profissional para o Intensivismo; e Implementação do Programa.

Conclusões

Conhecer a trajetória histórica de um Programa modelo Residência Multiprofissional em Saúde, evidenciou os esforços para unir ensino e serviço com a finalidade de qualificar profissionais da saúde fortalecendo a equipe para mudar o modelo hegemônico de atenção à saúde médico-assistencial.

Internato não médico; Especialização; Unidades de terapia intensiva; Enfermagem

RESUMEN

Objetivo

Saber la trayectoria histórica del proceso de construcción de la Residencia Multiprofesional Integrada en Salud de la Universidad Federal de Ciencias de la Salud de Porto Alegre, en asociación con la Irmandade de la Santa Casa de Misericordia de Porto Alegre.

Método

Investigación histórica, guiada por la Historia Oral Temática. Entrevistas con seis profesionales de ambas instituciones se llevaron a cabo de octubre a diciembre de 2013. Este estudio utilizó análisis del contenido como método analítico.

Resultados

Emergieron tres categorías temáticas: Fortalecimiento de las instituciones involucradas; Calificación Profesional de Cuidados Intensivos; e Implementación del Programa.

Conclusiones

El conocimiento de la trayectoria histórica de un programa de Residencia Multidisciplinaria en Salud, destacó los esfuerzos para unir la educación y el servicio con el fin de capacitar a los profesionales de la salud para reforzar el equipo y cambiar el modelo hegemónico de atención a la asistencia médica y sanitaria.

Internado no médico; Especialización; Unidades de cuidados intensivos; Enfermería

INTRODUCTION

The healthcare residency programme is a non-degree postgraduate specialisation course. The field of medicine was the first to offer this type of specialisation to academically qualify professionals for in-service practices. The first residency occurred in the United States of America, in 1879, while in Brazil the first residency only occurred in 1945 at the Universidade de São Paulo (USP), and was initially called internship(¹). This mode of teaching was regulated in Brazil on 5 September, 1977 by means of presidential decree 80.281, followed by the creation of the national medical residency commission (“CNRM”)(²).

In Brazil, success of the medical residency led to the expansion of this modality to other areas of health, and the creation of the nursing residency in 1961 by the Hospital Infantil do Morumbi, in São Paulo (SP) to improve paediatric nursing through practice and theory. In 1973, the second specialisation course based on the nursing residency model was initiated to qualify nurses who specialised in surgery at the hospital school of the Faculdade de Enfermagem of the Universidade Federal da Bahia(³).

In 1976, the state department of health of Rio Grande do Sul implemented the first residency in community medicine, named São José do Murialdo. In 1978, this residency was transformed into the multi-professional residency and thus set a precedent in this type of specialisation. This first innovative residency experience united several professional healthcare categories under a single scope of work, and was therefore considered pivotal for the development of this area in Brazil(⁴).

A milestone in the history of healthcare in Brazil is the institutionalisation of the unified health system (“SUS”), which was incorporated into the Federal Constitution of 1988 and conceived during the 8^th National Health Conference (1986). The principles of the SUS include universal access to healthcare; protecting the autonomy of individuals and their physical and moral integrity; enabling the contribution of society; and ensuring the resolvability of services, regardless of level of assistance, and the comprehensiveness of assistance(⁵).

Law 11.129(⁶) of 2005, established the national programme for the inclusion of youths (“ProJovem”), and article 13 of this law regulates the Multi-professional Healthcare Residency (“RMS”) as a non-degree specialisation programme characterised by in-service teaching(⁶-⁷). This kind of specialization has a financial incentive called “scholarships for education through work” that is financed by the ministries of health and education(⁴).

The national commission of multi-professional healthcare residency (“CNRMS”), established by ministerial ordinance 45/2007(⁷), of the ministry of education (“MEC”) and the ministry of health (“MS”), provides the principles and guidelines of the RMS. The CNRMS coordinates programme accreditation, while the MEC provides the technical and administrative support, and helps fund the structure and operation of the CNRMS, with the MS(⁷).

The RMS programmes are considered a strategy to reorient primary healthcare and enable access of skilled youths into the job market according to the principles and guidelines of the SUS and local and regional needs and realities(¹). The aim of the RMS is to provide the collective in-service education of teams, ensure the comprehensiveness of care at all levels of assistance and management, and articulate the RMS and uni-professional medical residencies with medical residencies(⁷). The fields included in the RMS are: biomedicine, life sciences, physical education, nursing, pharmacy, physical therapy, speech therapy, veterinary medicine, nutrition, dentistry, psychology, social services, and occupational therapy(⁷). Currently the RMS receives more incentive from the ministries of education and health since the programme qualifies human resources of several fields to work in the SUS according to the national health policy. In terms of nursing, the RMS programme offers more positions for professional nurses than the uni-professional residencies.

The multi-professionalism of the RMS appears alongside interdisciplinarity in the debate of teamwork regarding the biopsychosocial approach, care, and the introduction of concepts of prevention, and health promotion and protection(⁸). It advocates the valorisation of health professionals by stimulating and constantly monitoring the policy of permanent healthcare education, thus encouraging the qualification and formation of residencies in line with the different government sectors(⁹).

As part of the history of the first classes of residents of a RMS programme of the Federal University of Health Sciences of Porto Alegre (“UFCSPA”) in partnership with a bicentennial Hospital of Porto Alegre/RS, the brotherhood of Santa Casa de Misericórdia de Porto Alegre (“ISCMPA”) became interested in maintaining and divulging historical records based on the following research problem: how did the historical process of planning, organising and implementing the Integrated Multidisciplinary Healthcare Residency (“REMIS”) occur based on the partnership between the UFCSPA and ISCMPA at a teaching hospital?

A search of national and international databases on the subject of RMS revealed a shortage of scientific production. Since this model is exclusively Brazilian, proposed by the ministries of health and education, the search results were restricted to national publications. This model is a strategy to consolidate the national policy of health education. Therefore, the production of knowledge on the construction of a RMS can serve as a model for other institutions that wish to adopt this in-service education model. In addition, the intention is to stimulate a debate on the education of nurses in this interdisciplinary healthcare model.

The aim of this paper is to elicit the historical trajectory of the construction of the REMIS of the UFCSPA in partnership with the ISCMPA.

METHODOLOGY

This study is based on historical research and oral history, according to by Meihy and Holanda(¹⁰). Oral history was used as a methodology and technique to elicit and clarify the historical process of the REMIS. Given the lack of written sources on the trajectory of the reviewed programme, the protagonists of this trajectory were willing to offer their recollections for the record. In view of the scenario of the investigation, it was observed that the greater amount of previously obtained information further extended the research(¹⁰).

Eight professionals participated in the planning and implementation of the REMIS programme in connection with the UFCSPA and/or the ISCMPA. The participants were intentionally and strategically selected since they are witnesses of the facts and experiences of the history. The testimonial nature of this study demands the qualification of those who personally and intensely experienced the researched subject(¹⁰). All the subjects involved in the planning and implementation of REMIS under investigation were invited to participate in the research. Six professionals were available and offered specific data that came to light and enriched the retrieval in question.

The ISCMPA recently completed 211 years since its establishment in 2014. It is commonly referred to as the Complexo Hospitalar Santa Casa because it comprises seven interconnected hospitals that attend different clinical and surgical specialities(¹¹).

The UFCSPA, formerly known as the Faculdade Católica de Medicina de Porto Alegre, is located beside the Santa Casa de Porto Alegre hospitals and initiated its academic activities on 22 March 1961. The faculty was federalized in 11 December 1980 by Law 6.891 and the name was changed to Fundação Faculdade Federal de Ciências Médicas de Porto Alegre. On 10 April 1987, with the creation of Law 7.596, the faculty became a public foundation(¹²). On 11 January 2008, according to Law 11.641, the Fundação Faculdade Federal de Ciências Médicas de Porto Alegre was transformed into Fundação Universidade Federal de Ciências da Saúde de Porto Alegre, and currently offers 14 undergraduate courses in or connected to the field of healthcare(¹³).

The two teaching and services institutions that devised a multi-professional residency programme decided to give emphasis on intensive care for two reasons: 1) the Santa Casa offers nine intensive care units (ICU) with a total of 155 beds in specialized ICUs, namely: clinical cardiology, surgical cardiology, general surgery, oncology, neonatology, neurology, paediatrics, pulmonology and transplants(¹¹); and 2) due to the publication of the Collegiate Board Resolution (“RDC”) 7(¹⁴) that establishes the mandatory delegation of a legally qualified multi-professional team to compose the staff of ICUs, which corroborates the importance of this specialisation(¹⁴).

The basis of the adopted methodology is recorded statements, which demand the adoption of some measures for the interviews, such as avoiding interference so that the respondents can follow their narrative logic, asking open-end questions, and providing a pleasant and trustworthy environment for the respondents. Such measures were observed and the interviews were carried out in specific rooms at the university or hospital. Prior to each interview, the respondents were asked to read and sign an informed consent statement.

The interviews were previously scheduled on days and at times suggested by the subjects, between October and December 2013, at both institutions. After signing of the informed consent statements, the interviews were conducted and recorded using an MP3 recorder. To ensure the anonymity of the subjects the results were presented using the letter “C” followed by a number from one to six, according to chronological order of the interviews.

The interviews were processed using the three procedures proposed by Meihy(¹⁰), namely: 1) transcription - a literal written record of everything that is recorded; 2) textualisation - the questions of the researcher are removed to better understand the statements or the statements of the respondents are adapted to facilitate reading; and 3) transcreation - out-of-text elements are embedded in the statements to create a synthesis of the meanings and sense perceived by the researcher of the respondent’s performance.

Therefore, the transcription process received the most attention since this is the moment when the interviews are written literally with all the possible vices of language, repetitions, and words without semantic relevance. All the interviews received special treatment as specified in the textualisation technique. This treatment included the elimination of questions, the suppression of grammatical errors, sounds, and noises and the correction of other interventions. The narrative was maintained in the first person, in text form, to ensure clarity. In the transcreation stage, the context of the interview the written document was recreated.

All of the collected stories obtained by recording the recollections of the participants during the oral interviews provided insight into the individual and collective motivations that led to the planning of the REMIS project. They were also used to provide the elements and foundations, and strengthen the facts that were being repeated to reconstruct the trajectory of the REMIS. According to the confluence of information, each interview revealed that the collective memory of the history was being substantiated(¹⁰).

In addition to the interviews, data were collected from documents at the location in August 2014 at both institutions, after due prior contact with the person responsible for the material. This stage, however, did not produce many documents. The obtained files were minutes of the multi-professional residency office (“COREMU”), some ordinances, official notifications, designation letters and opinions. The intention was to survey existing documents to cross reference the collected data with the statements of the collaborators. The documents were arranged in Microsoft Excel® spreadsheets to organize the data into a database. The interviews and the documents were subjected to thematic content analysis according to Bardin(¹⁵). This technique was applied in three stages: pre-analysis; exploration of the material; and treatment of results and interpretation. Pre-analysis consisted of skim reading to detect the objective and define the indicators that substantiated the interpretation. During the exploration stage, the data were coded using the registry units. Treatment of the results consisted of categorisation, or classifying the elements according to their similarities and differences, followed by regrouping according to common characteristics(¹⁵).

This research observed the ethical requirements of resolution 466(¹⁶), of the national health council, and was approved by the research ethics committee of the ISCMPA with number CAAE 14533313.5.0000.5335.

RESULTS AND DISCUSSION

All the participants were women aged between 35 and 53. Of these women, two were nurses, two were educators, one was a nutritionist, and one was a speech therapist. All the women had graduate degrees, of which three were specialisations and three had a PhD. Their professional background varied between 9 and 40 years and they had been working at the institution between 3 and 24 years.

After transcribing the statements, a schematic map was built with the full statements to better organise and view the transcribed records. The transcripts were read and re-read to identify the common themes in the responses. After grouping the similar responses, a second thematic map was built without the researcher’s questions and with the themes that emerged from the interviews. A third and final map was created for the transcreation and to present the thematic categories that emerged from the second map, namely: 1) Strengthening the involved institutions; 2) Professional qualification for intensive care; and 3) Programme implementation.

The statements produced the category “Strengthening the involved institutions” since the participants believe that both institutions have a strong tradition in the state of Rio Grande do Sul (RS) and a historic partnership that strengthens their potential when they work together on large projects.

The category “Professional qualification” revealed the demand for qualified professionals for the area of intensive care. The collaborators mentioned that the multi-professional residency, as a new training model that is similar to the medical residency traditionally offered by the two institutions, could benefit other healthcare professions and qualify multi-professional health teams, as established by the national health policy.

In relation to the “Programme implementation”, the statements revealed that the commissions in both institutions were created to hold joint weekly meetings and plan the specialisation programme within the partnership.

The small amount of documents for research is noteworthy. They consisted of eleven records of the programme implementation period (2010-1012). The sources of the documents were categorised into subjects and series, and resulted in five minutes, four ordinances, one opinion and a notice. The topics of these documents were member selection for eight agendas, a selection process for four agendas, and programme execution for two agendas. Therefore, the existing documents reinforce the statements that produced the category “Programme implementation”.

The category “Strengthening” included the subcategories: tradition; partnership; and potentialities. The participants mentioned the historic partnership of the ISCMPA with the university and stressed that their histories were subsequently interconnected.

This category is exemplified in the following statements:

[...] The desire of the institutions, the Santa Casa and the university, the Santa Casa is a university teaching hospital, the university was conceived in here. The Santa Casa has a huge educational history that is intertwined with the actual history of Rio Grande do Sul (C2).

[...] What motivated us was the partnership, create this work partnership with the Santa Casa, being able to work with the Santa Casa (C3).

[...] the partnership between the foundation and the Santa Casa dates back to the origins of the foundation, it was born inside the Santa Casa and this spirit has lingered and it has always been very present in the two institutions”(C5).

An examination of the trajectory of the Santa Casa de Porto Alegre revealed that is was founded in 1897, in the general hospital, by the physicians Protásio Alves, Dioclécio Pereira da Silva, Carlos Frederico Nabuco, and Sebastião Afonso de Leão of the “Curso Libre de Partos”, an open delivery course that qualified midwives. Later, the course in the obstetric service of the hospital was authorised. This venture was so successful that the organisers approached the faculty of pharmacy (founded in 1895) to open a faculty of medicine. This partnership became a reality in 1898, and resulted in the creation of the Faculdade de Medicina e Farmácia de Porto Alegre, which is the origin of the current Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (“UFRGS”)(¹⁷).

A few decades later, the Faculdade Católica de Medicina was created. This event is linked to the construction of the Hospital de Clínicas de Porto Alegre of the UFRGS. The board of the Santa Casa realised that teachers and students would leave and join the new hospital when it was ready. This concern was founded since something similar had occurred in São Paulo. The Faculdade Católica de Medicina was built on some land of the Santa Casa with state and federal funds, and in 1961 it initiated operations with the first university admission exam(¹², ¹⁷).

The faculty was transformed into a private foundation in 1969 through decree-law 781, and was named the Fundação Faculdade Católica de Medicina de Porto Alegre. On that occasion, the Santa Casa ceased to be a maintainer of the faculty and donated the land and properties that were built on this land. In 1980, under law 6.891, the institution came to be named Faculdade Federal de Ciências Médicas de Porto Alegre (“FFFCMPA”), and was linked to the ministry of education and culture(¹², ¹⁷).

The ISCMPA was officially recognized as a hospital-school in 1985, when social services were universalised and accessible to everyone regardless of social or social security status, and any assistance quotas or limits were eliminated. Moreover, an agreement signed with the FFFCMPA secured the transfer of funds to pay for patient expenses(¹⁷).

Considering that the FFFCMPA offered several healthcare courses, on 11 January 2008, according to law 11.641, the institution was transformed into Fundação Universidade Federal de Ciências da Saúde de Porto Alegre (“UFCSPA”), and currently offers the following 14 undergraduate courses in or connected to the field of healthcare: medicine, biomedicine, nutrition, speech therapy, psychology, nursing, physical therapy, pharmacy, food, analytical toxicology, medical physics, healthcare management, biomedical informatics, and food technology(¹³).

In view of the presented scenario, it was observed that the histories of the ISCMPA and the UFCSPA were closely connected. Both histories occurred in an interconnected, living process of mutual communication. The potential of the partnership of these institutions is also remarkable, not only because of the geographic proximity and historical integration, but also because of their structural conditions and the healthcare-oriented vocations that are employed to confront the challenges of healthcare and professional education with determination and dialogue.

The category “Professional qualification” includes the subcategories: lack of qualified professionals for intensive care; new training mode; and culture of medical residency. The respondents stated that the multi-professional residency is a new professional enhancement modality since the medical residency has been around for longer. They also mentioned the multi-professional training that the residency offers for professionals of six areas of knowledge (nursing, pharmacy, physical therapy, speech therapy, nutrition, and psychology), the qualification of patient care by a multidisciplinary team, and the demand for skilled professionals in the job market. The lack of qualified professionals to work in intensive care is exemplified in the statements below.

[...] the institution itself suffers from the shortage of qualified professionals to work in this area (C1).

[...] the institution has a culture and tradition of medical residency and struggles to offer this option for the other areas of health (C1).

[...] Intensive care is a high complexity area and the Santa Casa is a quaternary hospital with a lot of complexity, so what motivated us was precisely the number of patients assisted at the Santa Casa and its mission regarding to SUS (C4).

[...] the Santa Casa needs prepared professionals, and on the other hand because of this demand, because of this consistent number arises the need to offer this space for learning (C5).

[...] it decides to offer a multidisciplinary specialisation course to qualify the care of gravely ill patients (C6).

[...] intensive care was chosen because it has huge potential inside the complex [...] it’s an environment that needs the multidisciplinary team (C6).

The professionals are qualified after completing credit hours and a workload that target quality in assistance. The RMS has an exclusive dedication regime and lasts for two years with 5.760 credit hours. These credit hours are divided into 60 week hours as follows: 80% strategic educational practice and theory and practice activities that target integration, education, management, care, and social participation; and 20% theory. The students must complete all the practice credit hours(¹⁸).

The professional nurses, physical therapists, and doctors who are technically responsible for and coordinate the ICU team must be specialists in the field of intensive care of their area of work, in accordance with RDC No. 7(¹⁴).

In the category “Programme implementation” the collaborators mentioned the creation of a commission. This commission met weekly for a year to elaborate a pedagogical political project within the rules of the bidding process for approval of the multi-professional residency. The following statements exemplify this category:

[...] the group carried out an [exhaustive] consultation with the MEC. So all the guiding documents from the programming, were comprehensive readings. We took them home, read them again and discussed what we would need to include. So it was a year packed with weekly meetings (C2).

[...] the most striking was the short time we had between the approval of the scholarship for the first group and the selection process (C3).

[...] the creation of the program was more or less a year that we did the creation, to write it all down, the project, decide what the activities would be.

[...] I already start to implement when the selection process begins, so it was a couple of months there that we really began to implement I will say that we are in implementation, because until the first group is finished we are still implementing (C3).

[...] A commission was appointed there and here, too, and we met for a year every Friday afternoon [...] (C4).

Currently there is a range of prerequisites that RMS programmes must follow to comply with the law. These requirements include multidisciplinary and interdisciplinary integration based on strategies to organise the services and the teaching-learning process for the implementation of programmes, according to the standards of the technical boards of the CNRMS. Institutions that offer RMS programmes are responsible for organizing the pedagogical project (PP) of the respective graduate programmes in accordance with the current legislation(¹⁹). The PP must be registered in the system, called SisCNRMS, for consideration of the ministry of education and approval of the programme with funding of scholarships.

In addition, there are many actors involved in the structure and functions required to implement the PP of the RMS, including the coordination of the Multi-professional Residency Commission (“COREMU”), programme coordination, the structural faculty-assistance centre (“NDAE”), teachers, mentors, preceptors and resident health professionals(¹⁹).

Although the RMS is a new programme, since 2005 it has been having implementation problems, such as the lack of integration between preceptors and tutors, programme maintenance, increased workload without pay rises, lack of training in the area of education, and other difficulties. It is also important to remember that most of the professionals never had the chance to practice multi-professionalism and comprehensiveness during their academic education(²⁰). This aspect is critical for nursing since the current context of healthcare demands shared work between professionals of the team, especially in dealing with intensive care.

All of the obtained documents referred to the implementation of the programme (2010-1012). These documents were used to assign commissions to implement the REMIS and the REMIS selection process; to compose/designate instances of the REMIS; to compose the NDAE and COREMU; and assign the president of the COREMU and coordinator of the REMIS.

FINAL CONSIDERATIONS

This research retrieved the historical trajectory of the process of building a REMIS, with emphasis on intensive care, of the UFCSPA, in partnership with the ISCMPA, since planning in 2010 to its implementation in 2012. The motivations behind this form of education were the desire to create a non-degree specialization in the RMS modality for a labour market that desperately needs qualified professionals for intensive care, and the tradition, partnership, and potentiality of the two institutions.

The limitation of this study was the small amount of documentary sources. However, the RMS has only recently been regulated and its implementation requires more time to adapt to current needs.

In addition, the RMS are still growing and adapting due to their learning format, while adding a teaching and learning service that can qualify professionals with a focus on multidisciplinary work. It is important to stress the responsibility of educational centres regarding the instruction of healthcare professionals, and the fact that this process should reflect social, political and cultural realities based on the principles and guidelines of the SUS for work in the SUS.

Through the history of this programme, this study reveals the importance of healthcare education by means of non-degree graduate courses based on the RMS model that unite teaching and service to ensure professional qualification. This study can contribute to nursing by encouraging reflection on the importance of training and qualifying nurses, which are fundamental for the interdisciplinary model of healthcare, and by supporting the shift from the hegemonic model of healthcare to medical and assistance-based healthcare. Therefore, nurses should join other healthcare workers to strengthen teamwork and learn to work in an interdisciplinary manner.

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Publication Dates

• Publication in this collection
  2016

History

• Received
  24 Aug 2015
• Accepted
  27 June 2016