Permanent education of health professionals in public hospital organizations

Abstracts

Estudo exploratório-descrito cujos objetivos foram identificar, caracterizar e analisar as atividades educativas desenvolvidas com profissionais de saúde, à luz das concepções de integralidade, trabalho em equipe e educação permanente. A coleta de dados ocorreu em três hospitais do Município de São Paulo, através de entrevista dirigida a informantes-chave, representantes de todas as categorias profissionais. As entrevistas foram gravadas e transcritas, as informações sistematizadas em categorias operacionais e armazenadas em banco de dados. Os resultados mostram que predominaram atividades educativas voltadas às ações de recuperação da saúde, com participação de profissionais de áreas específicas, revelando um distanciamento da concepção de integralidade e de trabalho em equipe. Concluiu-se que as ações de educação dos profissionais de saúde reiteram o modelo clínico de assistência individual, com fragmentação das ações. Recomenda-se que elas sejam repensadas como estratégia integradora de saberes, capazes de promover a integralidade na atenção hospitalar.

Educação continuada; Recursos humanos em saúde; Capacitação em serviço; Unidades hospitalares; Recursos humanos em hospital

ORIGINAL ARTICLE

Permanent education of health professionals in public hospital organizations

Educación en el trabajo de los profisionales de la salud en hospitales públicos

Daisy Maria Rizatto Tronchin^I; Vera Lucia Mira^II; Marina Peduzzi^III; Maria Helena Trench Ciampone^IV; Marta Maria Melleiro^V; Jaqueline Alcântara Marcelino da Silva^VI; Adriana Marques da Silva^VII; Jaqueline Maria de Sousa Soares^VIII

^IPh.D., Professor. Department of Professional Guidance - School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^IIPh.D., Professor. Department of Professional Guidance at School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^IIIAssociate Professor. Department of Professional Guidance at School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^IVFull Professor. Department of Professional Guidance at School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^VPh.D., Professor. Department of Professional Guidance at School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^VINurse, teaching laboratory specialist. Department of Professional Guidance at School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^VIINurse with the State of São Paulo Cancer Institute Octávio Frias de Oliveira. Doctoral student at School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^VIIINurse with the Continuing Education Service at São Luiz Hospital and Maternity (SP), master's student at School of Nursing at University of São Paulo. São Paulo, SP, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

The objectives of this descriptive exploratory study were to identify, characterize and analyze educational activities developed with health professionals based on integrality, teamwork and permanent education. Data collection was carried out in three hospitals of the city of São Paulo, by means of key-informant interviews, representing all the professional categories. Interviews were recorded and transcribed, information was systematized into operational categories and storage in data bank. The results showed that educational activities aiming actions to recover health with the assistance of professionals of specific areas, revealed a distance from the integrality conception and team work. It was concluded that actions aiming education of health professionals emphasizes the individual clinical model, with fragmented actions of professional categories. So, we suggest reconsidering the integrated strategies of knowledge to promote integrality of hospital attention.

Key words: Education, continuing. Health manpower. Inservice training. Hospital units. Personnel hospital.

RESUMEN

Estudio exploratorio-descriptivo cuyos objetivos fueron identificar, caracterizar y analisar las actividades educativas desarrolladas con profisionales de la salud, a la luz de concepciones de integralidad, trabajo en equipo y educación permanente.La colecta de datos ocurrió en tres hospitales del Municipio de São Paulo, a través de entrevista dirigida a informantes-clave, representantes de todas las categorías profisionales. Las entrevistas fueron grabadas y transcritas, las informaciones sistematizadas en categorías operacionales y almacenadas en banco de datos. Los resultados muestran que predominaron las actividades educativas hacia acciones de recuperación de la salud, con participación de profisionales de áreas específicas, revelando un distanciamiento de la concepción de integralidad y de trabajo en equipo. Concluyóse que las acciones de educación de los profisionales de salud reiteran el modelo clínico individual, con fragmentación de las acciones en las categorías profisionales. Estas acciones deberían ser repensadas como estrategia integradora de saberes, capazes de promover la integralidad en la atención hospitalaria.

Descriptores: Educación continuada. Recursos humanos en salud. Capacitación en servicio. Unidades hospitalarias. Personal de hospital.

INTRODUCTION

Studies that focus on macro-tendencies report that in the next decade the changes to the outer environment will continue affecting the dynamics of organizations. For this reason, work management models should be adapted before those changes, hence creating specific demands for service managers, particularly in public health services. Taking into consideration the interfaces between work and school education, it is understood that the referred demands will determine the directions and essential competencies of university education, professional education and education at work in the Unique Health System (UHS).

The decade from 2006 to 2015, referred to as the Human Resources for Health (HRH) Decade, aims at the problem detected in the global scenario and defines guiding principles and goals for Latin America and the Caribbean⁽¹⁾. Therefore, the HRH observatories, in the 7^th Regional Meeting in 2005, in Toronto-Canada, sought to find consensus about strategies and policies to deal with the challenges of the next decade, stressing the need to mobilize political actions, resources and institutional actors to contribute with the development of HRH and the universal access to quality health care services for all⁽²⁾.

The referred document states that the improvement of the technical skills for HRH management and development is related to the need to improve inter-professional education that would allow for improving the organization of services in the team work modality ^(3-4). It is understood that the national public policy for continuing education in health (CEH) is in harmony with that proposal, as it recommends multi-professional interactivity in the management area, health care, social control and educational institutions, by means of education anchored to the work process with a perspective of integrality (comprehensiveness).

The CEH proposal originated in the 1980's from initiative of the Pan-American Health Organization for the development of HRH⁽⁵⁾. In 2003, in Brazil, the Ministry of Health (MH) created the Secretary for Work Management and Health Education with the aim to give a new order to the logic of health workers' education and define the National Policy of CEH implemented by law GM/MS 198/04.

The objective of the CEH policy is to create a teaching-learning network in the UHS for the workers' education and development, based on the health needs of the users/population. To institutionalize that policy, CEH centers were created as devices for inter-institution interactivity, connecting administrators, educational institutions, health service centers, health councils, social groups, student groups and health worker's organizations. Through the centers, efforts were made to join different actors to actively participate in the local health system practice, aimed at the administration and education in the UHS⁽⁶⁾.

The CEH was reaffirmed by law GM/MS 1996/07, which defined their local practice by creating permanent integration committees (CIES, abbreviation in Portuguese) between the health service centers and the educational institutions in both the state and regional levels, coordinated by the Regional Administration Commissions⁽⁷⁾ to adjust them to the guidelines and rules of the Pact for Health⁽⁸⁾. The referred pact reinforces the need to make advancements in the implementation of the CEH policy as the human resource (HR) policy for the UHS, focused on valuing health practice, workers and integrality.

Integrality refers to the combination of actions for health promotion, prevention, and recovery; the broad and contextualized understanding of the population's and users' health needs; and the organization of integrated services in the health care network, combining work actions with inter-professional, inter-disciplinary and inter-sector teams⁽⁹⁾.

This study was performed taking the above mentioned aspects into consideration and believing in the relevance of education at work, specifically for health care professionals with the public health care network.

OBJECTIVE

To identify, characterize, and analyze the educational activities developed with health care professionals in hospitals, under the light of the concepts of integrality, team work, and continuing education.

METHOD

This study was performed with three public hospitals located in the same region in the city of São Paulo. The region had about 400,000 inhabitants, and 22 public health care services available in the area: 14 primary health care centers (PHC), four specialized centers (SC), three hospitals, and one emergency care center.

These institutions are characterized as general hospitals, but with different profiles. In this study, they will be identified by letters, as follows: A is a university hospital with 258 beds, 1,837 employees, 1088 health care professionals, 183 nurses and 478 nursing aides and technicians. B is a state teaching hospital with 120 beds, 972 employees, 637 health care professionals, 58 nurses and 262 nursing aides: and C is a municipal hospital with 81 beds, 354 employees, 301 health care professionals, 36 nurses and 154 nursing aides.

Data collection was performed from April to November 2006, regarding the data of year 2005. Because in that region there were no systematized records of the education activities of health workers before 2006, directed interviews were performed with key-informants, representing each professional category, who were appointed by the service managers, as they were familiar with the work dynamic and the educational processes that took place in that period. Each participant was asked to report the educational activities performed with health workers at the respective hospital, considering the following variables: name of educational activity, theme, addressed content, target public, teaching strategy, place where the activity was developed, who established the need, the evaluation of the activity. Interviews were performed with 53 key-informants, 16 from hospital A, 20 from hospital B, and 17 form hospital C. The interviews were recorded and transcribed, and the information was stored in operational categories.

Analysis categories were created for each of referred variables, and the Theme category was created based on the information of the variables name, theme, and content addressed in the educational activity, which were: Aide: technical and health recovery; Aide: health promotion and/or prevention; Aide: health recovery and promotion and/or prevention; Administrative and worker's health promotion ; Interaction and interpersonal relationship; Themes outside the institution: symposium, congress and alike, Themes in the institution: meetings, knowledge exchange, and others. The other variables were categorized as follows: Target public: nurses, nursing aides and technicians, nursing workers and physicians, all service workers, work teams, community; Teaching strategies: traditional, participative and mixed; Location were the activity was performed: internal (at the service), outside (out of the service), external/community (outside the service, in the community); Who established the need: internal (at the service), external (outside the service).

The analysis was performed under the light of the concepts of health integrality, team work, and continuing education. Descriptive statistics with central tendencies measurement was also used.

The study was approved by the Research Ethics Committees at the School of Nursing at USP (register number 423/2006/CEP-EEUSP) and by the Municipal Health Department (register number 034/2005 CAAE:0020.0.162.000-05), as well as by the directors of the studied service centers and all the study subjects were consulted and signed the Free and Informed Consent Form.

RESULTS

Regarding the health care professionals' characteristics, it was found that women prevailed among the three hospitals. In Hospital A, the mean age was 41 years (sd±10.8), time working at the service was in average 12 years (sd± 10), 52.8% had complete higher level education and 47.2% had complete secondary level. In hospital B the mean age was 42.1 years (sd±10.4), an average 9.1 years (sd±14.5) working at the service, 51% with higher level education, and 49% with secondary level. In Hospital C the professionals' mean age was 43.2 years (sd±10.4) and mean time working there was 10 years (sd±16.7), 45.2% with higher level education, and 54.8% secondary level education.

The professionals working at the studied hospitals were in average the same age and with the same time working at the service. As for the educational level, higher level education predominated in Hospitals A and B while secondary level predominated in Hospital C.

There were 629 educational activities at the three health facilities, 363 (57.7%) of which were developed at Hospital A, 163 (25.9%) at B and 103 (16.4%) at C. Considering the number of health professionals, there was a relation of 0.33 in Hospital A; 0.25 in B and 0.34 in C.

The findings on Table 1 show that the educational activity theme predominating in the three hospitals was aide, with emphasis on the dimension technical and health recovery, with 38.5% in A, 35.6% in B and 25.2% in C. The following categories were Administrative and Workers' health promotion, corresponding to 28.6% in A, 26.4% in B and 19.4% in C.

Table 2 shows that the highest percentages relating to the target public - multiprofessional team, corresponded to 26.2%, 28.8% and 23.3% in hospitals A, B and C, respectively.

In the activities directed to professional with higher level education, in Hospital A and B, the predominant category was nurse (26.2% and 4.9%), while in Hospital C the highest percentage was for the category physician (9.7%). In secondary level, the highest percentages concerned the categories nursing technician and aide, with 2.2% in A, 0.6% in B and 8.7% in C. It should be noted that the nursing team was present in educational activities at the ration of 11.8% in A, 9.8% in B and 11.6% in C.

Regarding who established the need, it was found that 50.4% originated inside the hospital; that is, team and specific sectors, superiors, as well as individuals initiatives by the professionals.

The activities were usually performed at the institution 54.5% in A and 38.8% in C. Hospital B presented the same frequency - 33.3% of activities performed inside and outside. For this variable, a total 19.6% referred to uninformed data for the three hospitals.

In terms of the teaching strategies, traditional strategies predominated with 33.1% in A, 32.5% in B and 28.2% in C, such as expositive classes and lectures.

Of the analyzed educational activities, it was observed that evaluations were performed in only 16.5% of activities in Hospital A, 17.8% in B and 29.1% in C. There was no evaluation for 38.8% of the activities in Hospital A and 17.8% in B. It should be noted that the number of activities that the interviewees did not know how to give information about their evaluations was 44.6% in A, 64.4% in B and 70.9% in C. Among the evaluated activities, the techniques reported as most frequent were performance evaluation and written evaluation.

DISCUSSION

The results revealed a profile of educational actions distant from the concept of integrality, because at the three hospitals the predominant activities concerned the aide theme focused on technique and health recovery. The categories referring to educational activities directed to promotion and/or prevention and to recovery and promotion and/or prevention, represented 4.9%.

Hence, it draws attention there is fragility in the comprehensive health approach in the educational processes of professionals that perform them and take responsibility for the service and care delivered to users, considering that the literature, by acknowledging the polysemic character of integrality, points at the integration of health promotion, prevention and recovery as one of its strongest directions.

The scarce debate about comprehensive care, is also expressed by the low investment made in themes related to social interaction and interpersonal relationship, that appears to be reducing in hospitals A, B and C. A second meaning attributed to integrality refers to the broad and contextualized understanding of the users' health needs, which requires listing and dialogue from health care professionals, that is, the challenge of continuing learning to deal with users in a way that builds trust, compromise and genuine interest, beyond the domain of knowledge and interventions particular to each singular care need.

A recent analysis of hospital care tendencies emphasizes fractioning care as a component that reflects corporativism and the privilege given to hospitals in social health policies, which reiterate the intervention and medical model, ignoring the need to integrate health promotion and prevention to actions of health recovery⁽¹⁰⁾.

Results about the target public of educational activities reiterate the fragile presence of correlated concepts of integrality and team work in the studies hospitals, because there is an expressive presence of actions directed to the specific professional areas and, among them, those directed to professionals with higher level education in detriment to those with secondary education.

On one hand, 26.8% of the activities have specific areas as their target public, such as dentists, nurses, pharmacists, physicians, physiotherapists, and speech therapists. On the other hand, 26.4% of the actions are aimed at groups formed by professionals of different areas. This could be an argument in favor of team work integration, if the was not such an unequal investment in the continuing education of professionals with secondary level education, considering that together, pharmacy, laboratory and nursing add up to 11.6% of the educational activities. In this sense, special attention is also drawn to the discrepancy in the amount of educational activities directed to nurses and nursing aides and technicians, because they are responsible for most of the direct user care practice, and thus need to acquire nursing knowledge, as do nurses.

Among the university professionals, there are high percentages of actions directed to nurses and pharmacists, which is understood as the expression of training policies and the development of the respective areas in hospital A.

The predominance of educational activities of internal origin at the three hospitals, as well as the activities performed inside the hospital at hospitals A and C, on one hand assign the direction of the CEH public policy, which assumes that educational activities for professionals should be based on the users' health needs and on everyday practice. Literature, with a critical focus on this theme, stresses gaining conscience that people educate themselves based on the situation surrounding them and by interacting with others⁽¹¹⁾. A WHO report⁽⁴⁾ corroborates this concept stating that stand-alone courses, conducted outside the work environment have a poor history as modifiers of the workers' current practice. Against this interpretation of the results is the understanding that the emphasis on the internal demand is also related to the practice of identifying needs by means of hospital infection committees, questionnaires and professional performance evaluations⁽¹²⁾ and to the reproduction of the biomedical care model aimed at the primacy of hospital care, that is, at inside the hospital itself.

In this sense, it is recommended that public hospitals should participate in the integration committees (CIES), collaborating with their expertise in health recovery actions and taking advantage of the other hospitals' accumulated experience of knowledge and practices from the perspective of integrality, team work, and CEH.

In addition to the integration movement, shown as necessary in the results section, there should be discussions about teaching strategies, considering the fact that traditional strategies predominance, especially expositive classes, panels and similar others. Participative strategies encourage professionals to develop, based on their references and work context, new knowledge pertinent to apprehension, and care to a broader sphere of users' needs and service with an efficient and efficacious practice.

The evaluation of training program results are the least developed aspects in the education proposals and, though its importance is acknowledged, its effective practice and allocation of resources have second-place priority. The primary function of the referred evaluation is the search to improve practice; it works as a mechanism to integrate and offer continuity to the critical trajectory of projects, reducing distances between sources of funding⁽¹³⁾. Furthermore, it is essential to understand the variables that effectively affect the result of in-service training, so those responsible can intervene in the process, improving its effectiveness⁽¹⁴⁾.

FINAL CONSIDERATIONS

The study revealed that, in the studied hospitals, there was a predominance of educational activities directed at performing techniques and recovering health, aimed at specific areas, mainly professionals with higher education, using traditional teaching strategies and scarce evaluations experiences. Hence it was evidenced there is an educational practice for health care professionals, which reiterated the clinical model of individual health care and the fragmentation of actions, which is distant from the concepts and propositions of the public health policy towards integrality, with inter-professional, inter-disciplinary and inter-sector team work.

Acknowledging that the referred comprehensive approach is under development in the country, it is recommended that this perspective be used as a shared normative landscape for the integration of hospitals in the health care network, the combination of the knowledge from the several professional areas and, especially, the dialogue between professionals - users and population - service.

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Correspondência:

Daisy Maria Rizatto Tronchin

Av. Dr. Enéas de Carvalho Aguiar, 419 - Cerqueira César

CEP 05403-000 - São Paulo, SP, Brasil

Publication Dates

• Publication in this collection
  07 Apr 2010
• Date of issue
  Dec 2009

History

• Accepted
  01 Dec 2009
• Received
  15 Sept 2009