Professional interaction in management of the triad: Permanent Education in Health, patient safety and quality*

Objective: to understand how professional interaction takes place in the hospital organizational structure for the management of Permanent Education in Health, to guarantee patient safety and the quality of nursing care. Method: this is a qualitative study, which used the structuralist aspect of the Grounded Theory as a methodological framework. 27 interviewers participated in the study, who made up four sample groups. Results: six categories and 13 subcategories were presented, representing the studied phenomenon and highlighting particularities of the public health system and the influence of the manager’s support and management priority, the disposition of the organizational structure, the institutional culture, the external encouragement to institution, and the nurses’ initiative and leadership in the professional interaction for the management of the Permanent Education in Health, patient safety, and quality of care triad, revealing the need for cultural change through interdisciplinarity. Conclusion: the professional interaction in the hospital organizational structure requires the creation of new management models with an emphasis on more participative management, in order to improve the care processes in hospital institutions.

In this sense, the following question emerges: How does the professional interaction take place in the hospital organizational structure for management of Permanent Education in Health in order to ensure patient safety and the quality of nursing care?
The study aimed to understand how professional interaction takes place in the hospital organizational structure for the management of Permanent Education in Health in order to ensure patient safety and the quality of nursing care.

Method
This is a qualitative study, which used the structuralist aspect of the Grounded Theory (GT) as a methodological framework.
The scenario selected included hospital institutions under direct public administration in a state in southern Brazil. Among the 13 institutions, three were chosen as the collection scenario, all being large hospitals located in three different regions of the state, as well as the State Health Secretariat (SHS), which were included in the study according to the theoretical sample (7) .
Theoretical sampling is circularly constructed, allowing for the construction of concepts that lead the researcher to new questions or hypotheses to be answered with new data collection. Theoretical sampling cannot be determined before the process of data collection and analysis, since it is guided by data as the understanding of the studied phenomenon progresses. Therefore, the number of sample groups, that is, groups of specific participants, cannot be previously determined (7) .
The participants were intentionally chosen according to the objective of the study and approached in their own work environment. The inclusion criterion was that the participant had a minimum experience of one year at the institution and was involved with the study theme. 27 participants were interviewed, among sector chiefs (professionals responsible for in-hospital care units/professionals working in them with greater involvement in the theme), coordinators, managers and directors at local (hospital) and state (SHS) levels.
As for the participants' training, 22 were nurses and 5 had other graduation degrees (2 physical educators, 1 lawyer, 1 designer and 1 pharmacist). As regards gender, 24 were female and 03, male. Their ages ranged between 30 and 55 years old (14 participants were aged between 30 and 40, 9 between 41 and 50, and 4 were over 50 years old). Their length of service Koerich C, Erdmann AL, Lanzoni GMM.
varied between 5 and 25 years (13 participants had between 5 and 10 years of service, 12 had between 11 and 20 years, and 2 had over 20 years).
The participants were organized into four sample groups guided by the questions and hypotheses raised after analyzing the data, as shown in Figure 1. condition; action-interaction, and consequence (7) .
Data was organized using the NVIVO ® software, version 12. The theory was validated at a meeting of the Patient Safety Committee (Comitê de Segurança do Paciente, COSEP) at the SHS, attended by six nurses with expertise in the study theme (7,9) .

Results
The results show the central category of The central category reveals that the PEH, safety, and quality triad is the guiding line of the professional interaction process in hospital institutions. PEH management was not revealed in isolation, since PEH, patient safety, and quality of care showed a movement of interdependence. In this context, the professional interaction reveals the concern with improving patient care, which means a need to work for safe and qualified care. In turn, this care refers not only to nursing care, but to multiprofessional and interdisciplinary health care centered on the patient, this configuration being essential in the process of breaking the culture of fragmentation in hospital institutions.  practices, as well as difficulty in implementing patient safety protocols.
The second subcategory, Evidencing the relational structure, shows that interpersonal relationships need to be a concern for managers so that the management of PEH, safety, and quality takes place in the practice.
Miscommunication was considered a deficiency in public hospitals, an important obstacle to professional interaction, considering the ideological and behavioral differences among the professionals. Thus, the need for spaces of multiprofessional interaction was emphasized in order to favor interpersonal relationships.
The second category, Specifying that PEH, safety, and quality actions are a management priority, presents

Discussion
The first point to be discussed (which has a strong impact when talking about the management of Permanent Education in Health, patient safety, and quality of care in public hospitals) is the instability and high turnover of managers in this scenario, which results in discontinuity of projects, constant restarts, and consequent demotivation of the professionals (1,10) . In addition to the frequent change of managers, the scarcity of professionals prepared to work in the management of the SUS is a reality and was linked in a study to the deficit in the management training of health professionals and to inefficient permanent education in the field. Furthermore, the manager's difficulty in seeking management models beyond the traditional one, characterized by centralized, hierarchical, and bureaucratic actions, represents the managerial ability incompatible with the needs and complexities of the health care sector (1) .
In order to integrate and enhance safety and quality actions, in some hospitals of this study the support services started to take place in the same physical space. However, the need was clear for a change in the mentality of the professionals to understand that this work requires more than sharing the same physical space, being necessary to work in an integrated way.
Thus, the articulation between the different services in the organizational structure is conditioned to the recognition of the insufficiency of these isolated services in providing comprehensive care to the patient (6) . can be characterized as PEH practices, as they have a continuity character, undergo an evaluation process, and meet organizational objectives (11) .
This context, however, requires the encouragement of effective communication, feedback to the professionals, management support, teamwork, autonomy, and professional initiatives, these being potential actions to reduce resistance to change by the professionals, in addition to contributing to innovation in the health care services (12) .
The organizational structure interferes with the management of the triad because it is directly influenced by the organizational culture, which can be understood as a process that involves a combination of factors such as customs, habits, rules, and formal and informal communication, among others (13)(14) that influence all actions within the institution. This is partly the result of the training of the health professionals, since it occurs in a fragmented way and ends up building strict professional identities, which hinders communication and interaction among them (15) . As well as the mentality and individual cultures established at each level of the organization, interfering with the implementation of improvements (16) .
This structure was characterized in this study by a strong dichotomy between the care dimension and the management dimension, which ends up interfering with the participation and interaction of the professionals in the change processes. A number of studies indicate that this situation causes concerns among nurses, as it directly and negatively influences their work process (2,17) .
Another issue concerns the relational structure, that is, how these professionals usually relate within the organizational structure. In this sense, it is necessary to consider that the emphasis on the relational dimension and interpersonal relationships by the managers reinforces Koerich C, Erdmann AL, Lanzoni GMM.
the orientation that the services are made up of people and that they are essential in all the processes (16) . To this end, the institutions must have collegiate spaces, such as centers and commissions, which can be daily shared by the professionals in order to favor interaction (18) , communication (19)(20)(21) , and teamwork (18) .
The managers' support was revealed in this study as an important encouragement in the implementation of institutional improvement processes since, even though they are not the only ones responsible for the success of the institutional projects, they are responsible for strengthening the interaction of the multiprofessional team, monitoring and demand in order to attain the institutional objectives. Several studies reinforce the support of the manager as paramount in hospital institutions, either for the development of professional skills (22) , of the culture of safety and institutional performance (3,12,19,23) or of the effectiveness of PEH (24) .
In addition, despite the results presenting SHS initiatives to support the triad management in the hospital institutions, the participants reinforced the need for the SHS to monitor and demand actions. In this sense, there is a need for "participative supervision" that helps, empowers, and enables active and critical participation in order to develop professional skills with the potential to transform reality (25) . for improving institutional processes (21) .

Extra-institutional incentives
A study showed that the nursing staff has a better understanding, perception, and attitude towards patient safety when compared to other health professionals (23) .
However, it should be noted that the fact that nurses are more engaged in safety actions does not place them as the main responsible for the success or not of these actions at the institutional level. Building a safety culture is a joint work that involves the multiprofessional team and managers.
Finally, the results show the need for a paradigm shift based on the construction of the culture of PEH, safety, and quality supported by interdisciplinarity.
Interdisciplinary interaction is one of the main challenges for health care. The professionals need to learn to work in an integrated way, to break the disciplinary barriers, and to rethink ways of interaction so that health care is integrative (29) , since the fragmentation of the work process hinders work in interdisciplinary team (2) and interferes with the construction of a new culture (21) .
In this regard, it is worth noting that cultural change in an institution is not a radical replacement of an old model with a new one, but rather a construction process In this sense, instruments like Kanban (33) and SBAR (34) are worth mentioning.
Furthermore, initiatives such as the unique therapeutic project offer opportunities for new ways to conduct the practice, work as a team, and co-Rev. Latino-Am. Enfermagem 2020;28:e3379.
manage (35) . A proposal similar to the therapeutic project was presented in a study carried out in the United States of America, in which hospitals have been investing in new ways of providing care to include other perspectives in a single care plan (36) .
In short, the theory presented reveals that the professional interactions in the management of PEH, patient safety, and quality in public hospitals is a complex phenomenon supported by the triad of Permanent Education in Health, safety, and quality, which is presented as an articulated and interrelated basis. This interaction is enhanced by the priority of management, internal initiatives, and extra-institutional encouragement, and is conditioned to a paradigm shift, whether in the way of thinking and doing health, or in the way of restructuring the work processes in hospital institutions.
The theory identifies the main challenges and institutional initiatives to manage processes to improve public hospital services and sees the importance of managing the triad of PEH, safety, and quality in an integrated manner and with the interaction of different actors working internally, in an interdisciplinary way, and externally to the hospital, in order to obtain different health outcomes.
The study presented as a limitation the fact that it was targeted to managers and, therefore, it did not include all the professionals of the multiprofessional team. However, it has the potential to assist managers in the identification of the critical nodes, as well as in the development of strategies for the management of the PEH, patient safety, and quality triad in public hospitals.

Conclusion
The results reveal that the professional interactions in the hospital setting were motivated by the PEH, safety, and quality triad. In this scenario, the management of