Continuing professional development in health for working nurses
Norma Carapiá FagundesI; Anna Gabriella Carvalho Rangel II; Taize Muritiba CarneiroIII; Lívia Magalhães Costa CastroIV; Bárbara dos Santos GomesV.
Doutora em Educação e Mestre em Saúde Comunitária.Universidade Federal da
Bahia. Salvador, Bahia, Brasil. E-mail: firstname.lastname@example.org
II Mestra em Enfermagem. Prefeitura Municipal de Salvador, Núcleo de Epidemiologia. Salvador, Bahia, Brasil. E-mail: email@example.com
III Mestra em Enfermagem. Universidade Federal da Bahia. Brasil. E-mail: firstname.lastname@example.org
IV Mestra em Enfermagem. Hospital da Cidade, Núcleo de Ensino e Pesquisa. Salvador, Bahia, Brasil. E-mail: email@example.com
V Graduanda em Enfermagem. Universidade Federal da Bahia. Bolsista do Programa Institucional de Bolsas de Iniciação Científica e Fundação de Amparo à Pesquisa do Estado da Bahia. Salvador, Bahia, Brasil. E-mail: firstname.lastname@example.org
VI Este artigo é um recorte da pesquisa Análise do trabalho e do processo de educação permanente da enfermeira no contexto do SUS que contou com apoio financeiro da FAPESB /PPSUS e parceria da Associação Brasileira de Enfermagem - Seção Bahia.
Introduction : continuing professional development in health care is especially meaningful in the work of nurses, who are directly engaged in health education activities. Objective: to examine how in-service CPD for nurses is conducted. Method: this exploratory, qualitative study collected information from databases and in discussion groups held between March 2010 and March 2013 in Salvador and at national nursing events, The participants were 63 nurses and CPD specialists. Results: the findings confirm that nurses take more in-service CPD initiatives than any other profession and point to this mode of education as a strategy for fostering participatory management, in which the most successful actions arise from the realities of workers' and users' situations. Conclusion: there is thus a need to invest in training nurses to implement CPD better.
Keywords : Continuing professional development; nurse; in-service training; health services.
The continuing education in health (EPS) constitutes a fundamental strategy for the transformation of work in the health sector SAW, so that it becomes place of purposeful, committed and technically competent reflexive criticism1.
The National Policy of Permanent Education in Health (PNEPS) was established in response to changing needs in the hegemonic education practiced in the health field, founded in a meaningful learning and the creation of learning environments to promote the questioning of practices, with the objective to evaluate, revise and transform work processes 2.
In this perspective, the adoption of EPS comes as a strategy for identifying weaknesses in the care and innovative practices that emerge everyday3, fostering the empowerment and integration of workers through a non-hierarchical logic of knowledge based on complementarity, strengthening the care praxis and pointing towards inter-professionality.
Within the context of nurse's work EPS has a special significance as it promotes a rethinking of practices, participation in decision-making and articulation of the work of members of health teams and nursing teams.
In Brazilian health services, the nurse plays, historically, the leading role of the nursing teamwork and articulates of the health teamwork. To this end, she develops complementary activities of technical and managerial nature that enable the continuity and organization of work, including continuing education. She is, therefore, a professional directly occupied with educational actions, adopting resources for both health promotion and nursing management, integrating the work process with quality of care 4.
Understanding the social dimension of nursing work and the new health care vision require the nurses the assumption of new responsibilities in professional performance, pointing towards a need for changes in the way of producing management, nursing care, education and formal education in and for work.
Given the above, we define the following guiding research question: How is EPS handled in the nurse's working context? Objective is to analyze how EPS is handled in the nurse's working context.
Permanent learning has been adopted in Brazil as human development policy for the Unified Health System (SUS)5.In the present scenario of the world of work, what we see is the need for coexistence between training and work to promote the development of people. In this process, the forms of training in and through their work, such as EPS, become increasingly valued.
The prospect of entering the worker in the restructuring of the complex processes that involve collective work in health is discussed as a resource to strengthen the management of labor. Education on labor has been cited as a management strategy to improve the quality of care and support of the health model recommended by the SUS, through the active participation of workers in discussions, guided by the teaching model of EPS, reveal the complexity and interaction solutions to problems at work everyday 6. This context encourages the enhancement of health work as a source of knowledge, considering this scenario to promote, through contextualized and participatory practices in connection with health care, management and social control, in order to favor building strategies and processes that qualify service7.
In healthcare organizations, educational activities can be referred to as in-service education, continuing or permanent, and translate complementary pedagogical practices and non-hierarchical, essential for complementary health training8-10. These actions are also part of the training at work, differentiating itself by the frequency, the critical insertion and reflection on educational practices.
The EPS stands out as a formative resource that fosters inter-professional practice, since it promotes intense communication and interaction among workers, essential to the effectiveness of teamwork11.
This is an empirical study of descriptive and interpretative character, with a qualitative approach. Initially, the method used was a search and analysis of national and international articles in the SciELO, LILACS, and BDENF databases and Capes periodicals, published from 2007 to 2013. Texts of which are fully available for consultation in version online, in Portuguese, Spanish and English, by combining the keywords: permanent health education, continuing education, continuing education and training or in-service training. The choice of the 2007 post period is due to the publication of the Ordinance GM / MS 1996/2007, which establishes the guidelines for the implementation of PNEPS2.
The literature review was conducted from March 2010 to December 2013 and aimed at familiarizing researchers with the various EPS conceptions existing in the health field and the situations in which this happens and is organized in the nurse's work process in Brazil.
The second stage of information gathering took place in discussion groups with nurses and experts in the field of work in nursing and EPS in the period between March 2010 and March 2013, after the approval of the Research Ethics Committee, under No. 29/2010.
Thus, all ethical and legal aspects established by Resolution No. 196/96 of the National Health Council are considered.
To minimize the chance of the influence of bias, there was a wide online research in national and international journals and this provided an opportunity to the participation of nurses with expertise in different areas and residents in different parts of the country. Selection criteria were presenting expertise on the themes / concepts of research and demonstrating an interest in participating. Participants were randomly distributed in the discussion groups, to ensure groups with varied composition, but similar inclusion criteria. A sample of the lines that formed the analysis was carried out through the identification of the issues that emerged in groups, forming the nuclei of meanings and finally categories.
Sixty-three nurses took part in discussion groups, as can be seen in Figure 1. A total of eight participants speeches were selected to illustrate the content of the analysis categories. Clearly, the EPS theme was integrated in all of the research focus groups. To preserve identities, participants are denoted with the letter E, followed by sequential numbers from the order of the signatures on the attendance list for each of the discussion groups.
FIGURE 1: Number of participants in the second study discussion group
Discussion groups occurred in two national events promoted by the Brazilian Association of Nursing (ABEn), with the presence of nurses in different parts of the country, with the purpose of identifying the various experiences and perceptions on the subject. Besides these, three more were performed in the city of Salvador, Bahia. A first group with the intention to deepen issues related to the work of the nurse and the EPS in primary care / health strategy of the family. The second group was formed in order to obtain more detailed information in the hospital; and a third group with experts on the subject to validation of the results.
All groups were given terms of reference to the main issues addressed by the survey to guide the discussion. Participating in the groups were nurses from the states of Bahia, Mato Grosso do Sul, Piauí, Alagoas, São Paulo, Rio de Janeiro, Paraíba, Goiás, Maranhão, Brasilia and Minas Gerais.
For analysis of the information we used content analysis in the thematic mode, allowing the construction of the following categories of analysis: EPS conceptions; and operation and contributions of EPS.
RESULTS AND DISCUSSION
The reports of the participants showed that nurses hardly understand EPS and most often identified it as capacity building and training, without direct connection with the questioning of work situations and actions that seek changes in health practices.
Nurses are mostly unaware of what continuing education means. (E10)
We pretty much understand continuing education as specialization training. (I12)
The EPS, understood as educational practice guided by critical reflection on issues related to quality of care in everyday services, ensures inter-professional practice and favors the construction of new knowledge and the exchange of experiences. Based on the concepts of education as transformation and meaningful learning, the essence of the EPS is to promote opportunities for discussion among staff to raise problems at work and develop strategies to changes in practices and in the organization of the work process in view of the completeness and expansion the autonomy of the subjects involved, highlighting the link between health care, management and social control8.
To deepen the concept of EPS, members of discussion groups introduced differentiation between permanent education (PE) and continuing education (CE) and underscored some devaluation of the second from the first:
There are dichotomies in nursing [...] that immobilize us. An example [...] is the disqualification of now having continuing education because the buzzword is lifelong learning. (E21)
Studies trying to understand the insertion of educational practices in health work differentiate EC from EP, associating EC with the transmission of uni-professional knowledge restricted to specific courses and training, resulting from individual needs and educational activities geared almost exclusively to technical procedures9.
However, what seems most significant is the intention, the pedagogical aspects, the involvement of the subjects in the educational processes and the need to overcame hegemonic use of the pedagogy of transmission. Without this awareness, this education model can be repeated in the name of any of these three items - continuing education, continuing education and in-service education - which, articulated, are presented as complementary methodologies for vocational training in occupational health context .
Operation and EPS contributions
The changes in the health sector in recent years, with regard to technologies and, in particular, inter-branch working relationships, require a rethinking of the practice. This rethinking is favored, according to participants in a discussion groups when the service management is participatory and action planning meets the specific needs of each team or service, which is the context favored by EPS.
We saw that we would be unable to make a participative management process without making the training together. So we started doing continuing education. (E9)
Recognized as a strategy for participatory management, EPS requires the active participation of workers in decision-making and promote the development of creative potential in the pursuit of improved practices. The promotion of dynamic and reflective discussion environments results in co-responsibility and organizational learning, setting up a technological resource for the management of health work3.12.
The nature of nursing demands the use of tools for resource management to allow for the complex organization of health work. In this perspective, the adoption of EPS as a technology that favors the articulation of inter-professional practice and promote integration may facilitate the performance of management functions nurse.
This is in line with study of nurses in a teaching hospital13. For some participants in the discussion groups, the nurse is the most appropriate professional to coordinate the EPS process, being the professional historically responsible for actions related to health education, not only for the nursing staff, but also for multidisciplinary team. Moreover, it has as one of its main responsibilities coordination of nursing work process and the articulation of the health team actions 14.
The initiative for the development of continuing education actions, institutions, is with the nurses [...] (E3)
I think in continuing education nurses have an important role. It is she who will organize and lead the process. (E9)
To manage education at work, it is necessary for nurses to recognize forms of articulation between the different areas of knowledge to establish the relationship between theory and practice in order to propose feasible interventions and shared with stakeholders. In this sense, the implementation of educational practices in health services should be organized through participatory planning of the actions contemplated in education programs, involving needs assessment, setting goals and objectives, resource feasibility study, determination of programs and evaluation periodic results13.
Thus, it is necessary to review the methods used in health services and nursing for the EPS as a systematic, participatory process, against the backdrop of the workspace in which thinking and doing are key inputs to learn and work. The use of active teaching methods promoting reflection on practice and collective participation from the recognition of the problem to the planning and execution of action promotes the motivation and self-esteem of professionals, creativity in finding solutions and social responsibility5,12,15.
Therefore, it is necessary to invest in nurse training, so that the EPS is incorporated into the daily work, with the support of dialogical methods that intentionally encourage the workers to reflection and commitment to training and the result of the work, facilitating them to build innovative practices that result in improvement of the care provided12.
This scenario favors the adhesion of workers to educational practices in the work, as explained by one participant.
We organized, together with the unit staff, a continuing education activity with the themes motivation, personal development, interpersonal relationships and professional responsibility and it worked. (E23)
From the perspective of the participants, the EPS can provide more autonomy and organization to the nurse's work process:
I see the nurse today, in primary care, participating [...] actively in permanent learning processes. It arises [...] the health team and works with any professional category and any topic. I think that's very new. (E2)
We think work in a very fragmented way. Continuing education can help us to understand the nursing process more comprehensively. (E4)
To produce more satisfactory results, there should be better integration between the participating groups of EPS activities. A study conducted with nurses working in family health strategy corroborates this perception by showing that the EPS reflected in qualification for the planning and organization of work. The emphasis on collective learning through the exchange of information between the teams, was identified as an opportunity for collective evaluation of work processes and favored its reorganization 7.
From this perspective, the education concepts at work, discussed in PNEPS, promote the implementation of EPS supported methodologies in favor of reviewing the work processes defined through strategies for lifting training needs that include the participation of workers and reflect the needs arising from daily work. However, an investment in training of professionals to better understand and define how the PNEPS can get to work in health is needed.
As seen, the discourse of participants shows the nurse as the most appropriate professional to coordinate the EPS process. This perception resonates in the performance of this professional in conducting collective educational activities and coordination of multidisciplinary work processes, praxis that favors their integration and mastery of reality foundation for implementation of the EPS actions7,10,13.
According to the findings, it appears that the EPS is more effective when the service management is participatory and action planning meets the specific needs of teams or services3; when health education practices have a foundation a shared construction guided by inter-disciplinarity, autonomy and citizenship16 . However, these situations are still not found in health services, where activities identified as EPS often originate from evaluated needs, focused on the improvement of technical performance and standardization of behaviors to adapt the worker to the activity performed. Thus they take on an instrumental and vertical character directed almost exclusively to the organization's needs, possibly neglecting the needs of workers and users8.
The study confirms the special meaning of the EPS at nurses' work, since it is this professional who, throughout history, in health services has played the role of coordinator and / or work processes articulator and has been responsible directly for the organization of educational activities in service by continuing education and, more recently, the ongoing education.
Understanding permanent health education to equal training, such as training of human resources, a truly technical-bureaucratic view of management, still influences the field of health. In contrast, there a defense for an EPS able to contribute to the promotion of institutional changes that lead to the break with established models and formulas, and open the new experimental spaces, of not instituted EPS as a management strategy to rethink and qualify the organization of work.
It is concluded that, given the responsibilities assumed by nurses, there is a need for more investment in training these professionals, supporting them to act with EPS, through the adoption of dialogical methodologies that encourage critical reflection on the work and education in job. This commitment should be shared between universities and health services.
The presented perceptions are influenced by the working organization model in the educational practices where the participants operate, possibly reflecting limitations in the study, not to mention the views of other professionals working in the same regions studied.
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