Permanent education in primary health care: perception of local health managers

ABSTRACT

Objectives

To know the health education strategies advocated and developed for workers of primary care, in the view of managers.

Method

The study is characterized as a qualitative, descriptive and exploratory research. A semistructured interview was used to collect data. The sample population was chosen intentionally, with an audience of 26 municipal health managers ascribed to a regional health coordination office, located in the north/northwest of the Rio Grande do Sul State.

Results

The thematic analysis allowed the construction of two empirical categories: educational strategies, compartmentalized, discontinuous and with technicist bases; and the insipience/absence of educational proposals.

Final considerations

The results show a reality that needs to be transformed by all people involved in health work process: teachers and students, users, members of health councils, workers and managers. Realistically, there is a quest for change in services, to qualify the comprehensiveness of health care.

Health management; Health education; Public health; Primary Health Care

RESUMO

Objetivos

Conhecer as estratégias de educação em saúde preconizadas e desenvolvidas aos trabalhadores da atenção básica pelosgestores.

Método

O estudo está caracterizado como uma pesquisa qualitativa, descritiva e exploratória. Para a coleta de dados, utilizou-se a entrevista semiestruturada. A população amostral foi escolhida de forma intencional, tendo como público-alvo 26 gestores municipais de saúde adscritos a uma coordenadoria regional de saúde, localizada no norte/noroeste do Estado do Rio Grande do Sul.

Resultados

A análise temática permitiu a construção de duas categorias empíricas: estratégias educativas, compartimentadas, descontínuas e de bases tecnicistas; e a incipiência/ausência de propostas educativas.

Considerações finais

Os resultados demonstram uma realidade que precisa ser transformada por todas as pessoas envolvidas no processo de trabalho em saúde: docentes e discentes, usuários, membros dos conselhos de saúde, trabalhadores e gestores. Realisticamente, buscam-se transformações nos serviços para que se qualifique a integralidade da atenção em saúde.

Gestão em saúde; Educação em saúde; Saúde pública; Atenção primária à saúde

RESUMEN

Objetivos

Conocer, desde de la perspectiva de los gestores, las estrategias de educación para la salud que son promovidas y desarrolladas para los trabajadores de atención primaria.

Método

El estudio se caracteriza como una investigación cualitativa, descriptiva, exploratoria. Para la recolección de datos se utilizó una entrevista semiestructurada. La población de la muestra se eligió intencional, dirigida a 26 gestores municipales de salud de una coordinación regional de salud, localizada al norte/noroeste del estado de Rio Grande do Sul.

Resultados

El análisis temático permitió la construcción de dos categorías empíricas: las estrategias educativas discontinuas, compartimentadas; y escasez o ausencia de propuestas educativas.

Conclusión

Los resultados muestran una realidad que necesita ser transformada por las personas involucrados en el proceso, profesores/estudiantes, usuarios, miembros de los consejos de salud, trabajadores y gestores. Siendo realistas, buscar los cambios en los servicios, con el fin de calificar la integralidad de la atención sanitaria.

Gestión en salud; Educación en salud; Salud pública; Atención primaria de salud

INTRODUCTION

The structure, the organization of services, the continued development and enhancement of health workers in primary care, represent a major challenge to the implementation and strengthening of the Unified Health System (SUS – Sistema Único de Saúde), because of the importance of work performed by professionals in the implementation of health policies and in generating changes to the care model. The partial and fragmented primary care management models must transcend to a standard that values working conditions, people management, use of technology, integrative work by the multidisciplinary team, with emphasis on planning and especially the implementation of continuing education programs¹.

The management in primary care needs to consider labor relations, in which the participation of the subjects is critical to the effectiveness of services. Thinking of different forms of management includes the observation of health policies, the structure and organization of services, qualitative and quantitative definition of staff, the structuring of continuing education programs, which is the reason for the need to continuously improve and revitalize the work process and consequent qualification of health care¹.

Managing health work, especially human resources, involves several strategies, such as structuring, organizing and including workers in the workplace, as well as a commitment to its continued development, and the Continuing Health Education (EPS) of its supporting pillars. The implementation of EPS needs to be in line with the principles of SUS, committed to solving the problems encountered in the work process and the specificities of health services².

As previously described, the EPS is linked to the development of educational proposals that (re)signify the work process, situation in which the daily work constitutes a source of knowledge, allowing for reflection and discussion of the reality of health services ³. The National Permanent Education Policy in Health (PNEPS) carries democratic and participative management as its principle, thus becoming a useful strategy to improve the educational process. In educational activities concerning the EPS, the key differentiator is the insertion of the workers and users as protagonists, in addition to social control. The educational proposals matching the EPS are, therefore, designed and developed from the needs highlighted in the work process and the use of different educational precepts, especially, significant learning⁴. In PNEPS, meaningful learning is a widespread educational precept that proposes a more active role in the educational process and valuation of previous experiences to the student⁵.

EPS is not an appendix, it lacks understanding by managers as a part of health work management. It is based on institutionalized health practices and its implementation makes reference to the everyday problems of health teams, that seek to generate changes in practices, organization, relationships and the work process⁵. As mentioned above¹, the EPS can contribute to changes in health management, transforming the workspace through critical, reflective, socially committed and technically competent performances⁵. Changes in labor management in primary care, in particular from the work process, therefore, are in line with EPS’ proposal⁶.

The study is justified by the importance EPS represents for management, attention, and training in health and impact that its results can generate in primary care, particularly for what it represents for the subjects involved. The study tried to show how the local health managers perceive the EPS, how they work towards enabling, driving and implementing educational proposals concerning the precepts of PNEPS. The implementation and the development of permanent education is therefore strategic for managers, workers and users. Moreover, the classification of care provided to users of the health services found shelter in continuous development and the improvement of workers. The implementation and effectiveness of the educational activities require the participation of workers, managers, teachers and students, with special attention to social control.

This paper seeks answers to the following question: “What educational strategies have been advocated and developed for workers in primary care, in the view of local health managers?” Subsequently, the objective is to know the health education strategies advocated and developed for workers of primary care, in the view of managers.

METHOD

The study is characterized as a qualitative, descriptive and exploratory research. The sample population was chosen intentionally ⁷, with an audience of 26 municipal health managers ascribed to a regional coordinating body. Data collection took place at the regional health coordination headquarters of each municipality. The interviews were previously scheduled with managers. The data were considered saturated by researched unit when it was established that the types of statements were sufficient and other interviews would not add more elements to the discussion in relation to those existing ⁸. The thematic analysis method was used to assess and interpret the data. The organization’s analysis is chronologically composed of: pre-analysis with material exploration, treatment of results, inference and interpretation. Coding and categorization ⁹.

All managers who, after contact, scheduling the date and time for the interview and exposure of the questions and clarifications related to ethical questions agreed to participate in the survey and signed the Free and Informed Consent Form in duplicate were included. There were no exclusions since all participants joined the study. The data were collected between June and December, 2014. The interviews were conducted from an instrument with semi-structured questions recorded in a system. In the list of questions were some concerning management training, active time in the position, how strategies were defined and the implementation of educational modules. Data collection took place at the headquarters of the municipalities that were included in the study. Interviews, after transcription, were made available to the study subjects, to validate the data and for the subsequent analysis. The ethical guidelines were followed as required by the legislation in force ¹⁰, the research project approved by the Comitê de Ética em Pesquisa da Universidade Federal de Santa Maria (Ethics Committee of the Federal University of Santa Maria) (Term Embodied No. 306040). Study participants are identified in the text by the letter ‘G’, followed by the number that represents the order in which the interviews were conducted.

RESULTS AND DISCUSSION

The survey results come from interviews with 26 local health managers that comprise a certain regional health coordination office, located in the north, northwest of Rio Grande do Sul, Brazil; i.e., 100% of municipal health coordination managers mentioned in the study were interviewed. As for the training of health managers, four are nursing technicians, two nurses, two social workers, one dentist, a doctor, three teachers (math, biology and pedagogy), two directors, one lawyer, one fashion design, one environmental management technician and one techie in environmental management and one farming technician; three managers completed primary school and four high school. The average time that managers were in their respective positions was 25 months, in the period in which the survey was conducted.

Regarding the profile of managers, studies¹¹ point out that although some managers possess higher education, about a third had no training in health or administration. Although a degree in the field is not a requirement to be a health manager, the position incorporates several specificities pertaining to the health management process, especially, knowledge of SUS. The study also highlights¹⁰ that approximately 50% of managers had some sort of training for the position they exercise, confirming that they had no previous experience in the role, and around two-thirds of managers did not know the specificities of SUS and its guidelines, nor the different levels of care, basic, intermediate and tertiary, system regulation and the different levels of complexity¹¹.

Contextually, the inclusion of managers in positions occurs because of partisan political issues, making technical criteria as a secondary issue. Another factor that is superposed refers to temporality in office and the choice of care and health education strategies: the emphasis of actions intended to solve diseases, making health prevention and complications come in second place. It is up to managers to overcome their own professional boundaries and to attempt to meet the weaknesses in infrastructure, the deficient diagnosis and treatment support systems, as well as the absence of care models based on evidence/needs. Another challenge to be overcome concerns the education strategies of workers, the poor working conditions, low professionalism of managers and lack of social control¹².

Thematic analysis⁹ made it possible to know the perceptions of local health managers in relation to the EPS proposals recommended and developed in their respective municipalities. Once the necessary cut was made, two empirical categories were built: in the first, compartmentalized, discontinuous and technically based educative strategies were highlighted; and the second focused on: incipiense, lack of educational proposals.

Compartmentalized discontinuous and technologically based educational strategies

The health managers’ responses show that either there are no educational proposals for workers, or they cannot be found in the planning. The interview excerpts only record the existence of isolated and compartmentalized educational actions. The emphasis on technicality and discontinuity are identified from the information relating to participation in educational activities:

[...] I still consider it flawed. Our workers are not participating as they should. I think they still lack education, educational services. I think it is quite flawed. The offer is insignificant (G4).

[...] We explored certain conditions related to mental health to improve the humanization, fellowship, collegiality (G7).

The girls have some training regarding an accident or incident that happened at work, but there is no specific work being developed (G10).

When requested, we provide lectures, masterclasses (G16).

The respondents’ answers denote that the proposed and developed educational activities distance themselves from the precepts governing the EPS. Reason for which the EPS design links educational activities to the needs of students. The way of exploring these needs includes the diagnosis of educational activities of workers and users, the daily work problems, the intersection with academia, the introduction of new techniques, technologies, work methodologies, especially bringing new meaning and restructuring the work process. The inclusion of specific issues, such as training, should not be disregarded because it may be important to daily activities. The obstacle to educational punctuality is in the uniqueness of the theme work preparedness, often disconnected from the needs of the workers involved in the process and the EPS’ purposes.

The EPS is one of the most fruitful ways to qualify workers of primary care, which contributes to the appreciation and satisfaction of servers and is also a valuable tool in improving the work process¹. Permanent education, therefore, has among its aims, overcoming learning directed at work and the punctual logic of training, improvement and recycling⁶.

A study shows¹that, although there is supply and appreciation of EPS in primary health care, workers’ participation is low, a situation that indicates the need for action to strengthen this participation, involvement and commitment, so that they can link educational activities to the needs of workers and users¹. Low insertion in EPS programs is also seen in hospital settings, showing that involvement with educational activities are sporadic, not very participative and punctual, regarding them as effective in only a very small number of establishments².

The educational actions concerning the EPS have reference in the participation of workers who work actively in the development of proposals concerning the difficulties of daily work and training in health. The process of transforming reality is linked to dialog and collective reflection in the work process¹². The principles governing the proposal of permanent education is committed to the transformation of professional practices and, consequently, services, via (re) organization of the work process⁶.

Excerpts of the responses below enable the observation that the study participants are attempting to transfer the responsibilities for the difficulty to implement educational programs for workers, when they state that:

These strategies are difficult because, usually, today the employees are not easy; it isn’t easy to work with employees today. There are good employees, and there are others that make it difficult to try to get them to do a good job; but we are trying, holding meetings, we had some meetings giving explanations and trying to provide education (G17).

There aren’t many workers with training through lectures and things like that in the city. But those who work in health care here can always find courses. We try to send them to a course at least twice a year (G24).

The EPS management should not, therefore, be up to only one subject, manager or not; the responsibility also belongs to workers, teachers, students and users. The responsibility to formulate and promote EPS management also belongs to Regional Management Collegiate (COGEREs - Colegiados de Gestão Regional), guided by the comprehensiveness of health care. The creation of structures to coordinate and execute training and development policies is therefore needed, as are acts of cooperation with the State and neighboring municipalities, according to its health region¹².

The development of different and innovative means of management is connected to the commitment to change. Although there are different models, participatory management allows the development of actions that will reconfigure the work process in a democratic and innovative way. Health management, therefore, is multifaceted, as it involves technical issues, processes, relationships and, especially, attempt to unite people in favor of common goals ¹³

The PNEPS represent an important improvement strategy of the work process and generation of proactive changes in health management. It is a fact that the EPS proposal as designed allows one to transcend the uniqueness and repetition of educational focused, techical and disconnected educational activities from the needs of daily work. Unfortunately, based on the responses, it is evident that managers are either unaware of, or do not value this important instrument in the revitalization of knowledge, personal improvement, generation of changes, management qualification and care.

The incipience, lack of educational proposals

The category “incipience, lack of educational proposals” denotes that the EPS precepts, as a concept and education policy, were not included in some of the health services surveyed, the answers record lack of knowledge or no interest of managers to establish, in their respective municipalities, systematic educational actions that are in sync with the needs of workers and users. A keener analysis of the data shows that this attitude by managers occurs regardless of training, because none of the surveyed managers started to use the EPS as an educational strategy for the development of workers and the consequent qualification of care and, on the other hand, the renewal of management.

In some health departments, however, there is an interaction with other bodies such as the Regional Health Coordination (CRS) and the university. Anyway, in the view of the managers interviewed, education in health work is linked to the development of partnerships.

[...] We will use the tools we have today. CRS itself helps us a lot, the university is also a partner so we can improve that, and the idea is that we have a qualified team (G1).

CRS offers some training courses. We have been present as much as possible. Most of the time, we can not leave the work here to go participate in a training, as much as we would like to. So, sometimes it’s different in practice, but we are always trying to (G5).

The study shows that there is a shortage/incipience/ absence of EPS projects in the region where the research took place. Therefore, it is recommended that the education projects be elaborated jointly, with the participation of Teaching and Service Integration Committees (CIES - Comissões de Integração Ensino-Serviço), leading to the development of educational proposals concerning the reality, regional particularity or specific need in education and attention. Data analysis refers to the understanding that the reasons for not building educational proposals are linked to lack of PNEPS, lack of planning, attention focused on addressing the disease, with the main objective being to supply the basic needs of consultations, tests and medication ¹⁴.

Studies ¹⁵ show that the difficulties in the implementation of programs for permanent education, relate to the development of courses focused on training, without the participation of workers in the preparation of plans, resulting in possible and disassociated educational activities in the work process; add to this the lack of dialog and the lack of knowledge from workers and managers on what permanent education actually is ¹⁵.

The CIES articulate very little with the parts that compose it, such as managers, workers, teachers, students and even less with social control. Actions are developed in isolation and disconnected from management processes. The effectiveness of the educational proposals, therefore, needs to be socialized among health managers and health service users, so that these are consigned to the needs of all segments and individuals involved in the educational process and so they can collectively seek the qualification of care ¹⁶

The challenge established for EPS, therefore, is to encourage the development of professionals in their context and their responsibility in the ongoing process of education. Therefore, it is necessary to review the educational methods to predict and provide systematic and participatory processes, against the workspace scenario, in which thinking and doing serve as a bassis for the work process ¹⁶.

The incipience and the eventuality in the development of educational proposals are also evidenced interview excerpts listed below, in which managers say that education occurs during scattered periods.

Once a week the health workers gather here and discuss what we are doing here in this area: what is working, what is not working, what we must change, and these trainings are also provided for them during these meetings for them, they discuss it (G6).

In terms of workers, it happens as the service demand arises, but there is nothing specifically planned. But, we will have actions that focus on workers’ health from here on (G8).

The incipience of educational activities concerning ‘professional training’ incur the simplification of targeted pedagogical techniques without the strategic understanding of the political and institutional context. Among the factors that undermine the implementation of the EPS programs, is the lack of institutional support, the lack of educational activities, the lack of sectoral interaction, lack of communication and commitment to change ¹⁷.

The analysis of the responses provided by the study’s participants revealed the possibility of participation in educational activities. Discontinuity, partiality, punctuality and the eventuality of educational activities are not enough to generate the changes according to the needs that are felt and evidenced by workers and service users.

The absence or lack of clarity as to the provision of educational proposals similarly indicate lack of investment appreciation of education as a precursor to changes in the workspace. Transcendence in the ways of transforming management and care is closely linked to educational activities, with innovative and transformative proposals. The lack of effective EPS proposals is also evident when the following is said:

[...] we are trying to organize something to develop training for workers, both from primary care as here, we have a 24-hour clinic, for now there’s nothing there yet (G9).

The EPS, together with other activities, constitutes an important management tool, contributing to the development and worker satisfaction and especially the quality of care to users¹. The EPS is an important health management resource, as their processes are based on institutionalized practices and as a starting point for the problems of teams, with a view to improving their practices, generating organizational, relational, interpersonal changes and improving the work process⁶.

Although education at work, by itself, does not completely solve the problem, the absence of continuous and permanent educational proposals, cause change, due to be committed to the improvement, revitalization and resizing of the health work process. Although some managers mentioned above stress the importance of EPS in the management of their health services, managers highlighted below understand the EPS otherwise:

[...] We were talking about the fact that we sometimes neglect the professionals. But maybe sometimes there is a lack of permanent education for us (G11).

We don’t have a group for the health workers themselves. There’s nothing for the municipal workers (G17).

This year we didn’t have a strategy developed for health workers, we plan to implement it next year, and hold monthly sessions (G20).

The municipality does not have a health strategy for the education of workers (G26).

A study involving a multidisciplinary team composed of nurses, doctors, psychologists, pharmacists, records that the main limiting issues to the deployment of an EPS proposal are physical tiredness, availability, holding more than one job, resistance to change, lack of time, excesses of demands, lack of commitment from professionals, inadequate compensation, lack of incentives. On the other hand, among the facilitators are the challenge of overcoming work challenges, obtaining new knowledge, enabling educational proposals, the correction of the problems highlighted in daily life, interaction with other institutional professionals to exchange theoretical experiments and practice and the work environment itself, linked to constant needs for change, composing actual factors that induce continuous learning¹⁸.

Managers need to anticipate and continuously provide the improvement of the structures, organization and, above all, the processes. With the constant changes in the health field, particularly with regards to the provision of qualified services, it can be said that EPS is the main proactive change strategy to revitalize the attention and, reciprocally, management.

EPS also constitutes the main sustainable strategy for generating institutional changes, but the permanent education process requires planning and research on the needs of the people involved, whether workers or users, as well as the provision of diversified and permanent educational activities. The needs experienced and evidenced in the workspace are the main link between what is needed in education and what is frequently addressed in educational activities.

The EPS is characterized by several meanings: the valuation of work in personal development; the articulation of educational actions with the work process; the articulation of education with care; the integration of educational activities in different dimensions, with the multidisciplinary and interdisciplinary team; the use of educational strategies for transformation of health and nursing practices, and a different view on the comprehensive care of users and the public.

FINAL CONSIDERATIONS

The Permanent Health Education proposal arising from the National Permanent Health Education Policy (Política Nacional de Educação Permanente em Saúde), represents an important step in the revitalization of knowledge in nursing and health. The EPS proposal in this context is anchored in pedagogical theories with a view to the full development of workers, because it proposes the participation of different segments and, above all, constitutes an important strategy to complement/overcome the reductionist, technicist, compartmentalized and reiterative educational proposals, in favor of an innovative and transformative praxis.

Although established by law, it is proposed that the management of EPS occur through the Regional Management Collegiate (Colegiados de Gestão Regional) with the participation of the Teaching and Service Integration Committees (Comissões de Integração Ensino-Serviço). However, research study data show that health managers, in general, are unaware of PNEPS. The study highlights that in the segment researched, local health managers do not know and/or do not value the continuing education strategies that are recommended and/or developed for workers in primary care. It seems that managers do not value the EPS, with one of the most fruitful change strategies in management the work process, with results in improving attention to users.

The meager educational movements currently developed are the result of actions held by health coordination bodies and a public university installed in that region; yet the participation of health workers in these events is exiguous. The study shows that one of the reasons for low participation is related to the small staff and difficulty to be released from work to participate in educational activities. However, there may be other factors involved, among them, the culture of not appreciating educational activities, the understanding that these activities are detached from the realities/needs of those who attend and from the work process.

The institutionalization of an educational culture in workspaces means the reorientation of the work process. However, in the actual study scenario, the work process is tied almost exclusively to care with a view to solving illnesses, with education remaining at a parallel or secondary plan. The implementation of permanent education programs implies rethinking the work process, given that the EPS happens in all places and times, particularly in the workplace, which leads to rethinking and resizing processes and, in them, attention, management and education begin to be congruently developed in the work process.

Permanent education in health is therefore of paramount importance for the development of health workers, which, in turn, in possession of an educational culture, can come to propose and implement perennial educational activities to users, to prevent diseases and injuries and promote health. Among managers, there are people with training in health, in different areas and even secretaries without specific training, making it impossible to show the qualitative differences between educational proposals, which reinforces the understanding that the lack of awareness of PNEPS and its importance to management strategy.

Finally, the study shows a reality that needs to be transformed by all the people involved in the process: workers, teachers and students, users, members of health boards and health managers, who have the prerogative to take over and facilitate the preparation of EPS in their respective municipalities, and/or develop, jointly with the respective health coordinating body, educational institutions and surrounding municipalities, and joint regional EPS actions.

The reality to be transformed includes the restructuring and reorganization of services, seeking to implement health policies in full, developing care strategies that effectively include the prevention of diseases and disorders, as well as health promotion. Reconfiguring the management through structuring, organization with an emphasis on people management, the involvement of managers and workers in generating change towards a more just and egalitarian society. The use of Permanent Health Education is, therefore, imperative for management practices, attention, training, implementation of public policies and social control.

The fact that it is only promoted in one regional health body is considered as a limitation to this study, despite the significant number os interviewees. It is expected that, in the future, new managers can adopt different postures, especially regarding the proper implementation of management strategies and, in a special way, permanent health education. The study, presented here raises challenges, and mobilizes the development of new research, further exploring the theme.

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Publication Dates

• Publication in this collection
  2017

History

• Received
  25 Sept 2015
• Accepted
  14 Feb 2017