Permanent education: a tool to think and act in nursing work

Abstracts

Esta pesquisa torna-se importante na medida em que contribui para a reflexão sobre ações educativas dirigidas aos trabalhadores de enfermagem, com enfoque na finalidade, nos instrumentos e nos sujeitos responsáveis pelo cuidado. Teve como objetivo geral analisar os efeitos das ações de educação permanente na qualidade de assistência de enfermagem, em um hospital privado, de grande porte, no município de Belo Horizonte, MG. Optou-se por um estudo qualitativo na corrente filosófica da dialética, tendo como sujeitos 02 enfermeiros, 17 auxiliares e técnicos de enfermagem do 8º e 9º andares e a gerente de enfermagem. Os resultados revelaram que as ações educativas não estão articuladas ao processo de trabalho e que existe a necessidade de aprimoramento gerencial dos enfermeiros, possibilitando a realização da pedagogia de problematização. Conclui-se que deveria ser revista a inserção dos profissionais da enfermagem no contexto do processo de trabalho, articulada com a capacitação baseada na estratégia da educação permanente.

educação em enfermagem; capacitação; educação continuada em enfermagem

La importancia de esta investigación es que contribuye a la reflexión sobre acciones educativas dirigidas a trabajadores de enfermería, con énfasis en la finalidad del cuidado, los instrumentos utilizados para la realización del cuidado y los sujetos/trabajadores de enfermería responsables por el cuidado. El objetivo de la investigación fue analizar los efectos de las acciones de educación permanente en la calidad de la atención de enfermería, en un hospital privado de grande porte, en Belo Horizonte - Brasil. El estudio utilizó la aproximación cualitativa, orientada por la corriente filosófica de la dialéctica. Los sujetos de la investigación fueron 02 enfermeros, 17 auxiliares y técnicos de enfermería del 8º y 9º piso y la jefe de los servicios de enfermería. Los resultados revelaron que las acciones educativas no están articuladas al proceso de trabajo de enfermería, apuntando la necesidad de mejorar la función gerencial de las enfermeras para que ellas asuman las acciones educativas en las unidades asistenciales, utilizándose de la concepción pedagógica de la problematización. El análisis permite concluir que es necesario revisar el papel de los profesionales de enfermería en el contexto del proceso de trabajo, además de la capacitación basada en la estrategia de educación permanente.

educación en enfermería; capacitación; educación continua en enfermería

ORIGINAL ARTICLE

Permanent education: a tool to think and act in nursing work¹

Carlos Alberto Caciquinho Ricaldoni^I; Roseni Rosangêla de Sena^II

^IRN, M.Sc., Specialist in Occupational Health Nursing, Specialist in Hospital Administration, Member of the Research and Study Group on Nursing Practice and Teaching - NUPEPE EEUFMG, Mater Dei Hospital; e-mail: [e-mail]

^IIRN, Ph.D., Adjunct Professor, Minas Gerais University School of Nursing - retired, Coordinator of NUPEPE/EEUFMG, Consultant of the Kellogg Foundation; e-mail: [e-mail]

ABSTRACT

This research is important to the extent that it contributes to reflections on educational actions directed at nursing workers, focusing on the purpose, instruments and subjects responsible for care. The general aim was to analyze the effects of permanent education actions on nursing care quality at a large private hospital in Belo Horizonte, Minas Gerais, Brazil. We carried out a qualitative study in the framework of dialectics. Data were collected from two nurses and seventeen nursing auxiliaries and technicians who worked on the eighth and ninth floor and from the nurse manager. The results showed that education is not articulated with the work process and that professionals need management improvement, permitting teaching through problem-raising. The role of nursing professionals needs to be reviewed in the context of the work process, together with training based on the permanent education strategy.

Descriptors: education, nursing; training; education, nursing, continuing

INTRODUCTION

Education has been considered an instrument for changes and transformations in society. Social and educational transformations affect production modes, different knowledge areas and the production of goods and services.

In education and health, the accumulation of knowledge, translated in work process technologies and quality indicators, has influenced the organization of work, requiring workers to acquire new skills dynamically.

Technological development is associated with the populations' growing health demands and needs, in qualitative and quantitative terms, and requires the incorporation of permanent education processes, associated with a program for the development of people in a concrete living and work reality^(1-2).

Thus, education is seen as a strategy for the individual to have better training and greater possibilities to construct him/herself in the labor world, as a subject that constructs and deconstructs, in a dynamic and complex movement that is mediated by political, cultural and ethical values.

Workers' education is an essential factor for the development of a society in constant transformation. In the labor world, the possibility of permanent education should thoroughly consider the incorporation of new technologies, and social pressure itself should give rise to processes that guarantee citizenship. The emerging needs for social and educational changes are not restricted to adults' aspirations in a world of transformations. They orient themselves as a demand posed by the social organizations themselves, which require the incorporation of the permanent education process associated with development programs⁽¹⁾. It should be acknowledged that "today, many educators, perplexed by the rapid changes in society, technology and the economy, inquire about the future of their profession, and some are afraid of losing it without knowing what to do"⁽³⁾. The educational system hegemonically continues as a subordinate training system for subordinate people, detached from learning how to learn and knowing how to think. Thus, the aspired quality does not appear⁽⁴⁾.

In this study, the permanent education concept is adopted as a continuum of work-learning actions that occurs in a space of health work/production/education, which departs from an existing situations (generally a problem situation), and is directed at overcoming it, at changing it, at transforming it into a different and desired situation⁽²⁾.

Although the hospital scenario under study has offered in-service training for many years, aimed at training nursing workers for high-quality care, it has not achieved an actual articulation between training actions and management and care processes. Until the start of this study, in 2004, despite effort, no methodology had been constructed and used in coherence with permanent in-service education processes. This makes it necessary to identify mechanisms and instruments that articulate training activities in daily nursing work, that is, activities inserted in the work process of the nursing team.

This study contributes to reflections on educative actions destined at nursing workers in the study hospital, focusing on the purpose, instruments and subjects responsible for nursing care. The study results are expected to contribute for nursing workers to reflect on their praxis, considering integrality and the possibilities of exercising care without fragmenting it into tasks and/or procedures. Moreover, it can contribute to the definition of new in-service training modalities, mechanisms and instruments, in articulation with hospital management and care sectors.

THE STUDY OBJECT AND METHOD

When analyzing the concepts and methods of Permanent Health Education processes, it should be taken into account that, for service, work, care, education and quality (as a reflex of enjoying citizenship in health), the goal and reason of being is to contribute to attend to the population's individual and collective health needs and demands, as a process of reflection and growth of the institution, in a constant cycle of changes and transformations⁽²⁾.

In this process of multiple determinations and relations, the fundamental role of service institutions stands out, with a view to the permanent development of professional skills, thus contributing to social well-being. In one understanding of the relation between education and work, "traditional education and new education share the conception of education as an individual development process. However, the original trait of education in this century is the dislocation of foci from the individual to the social, to the political and to the ideological/ethical. Institutional pedagogy is one example. Another witness is socialist countries' education experience of more than half a century. In the XX^th century, education became permanent and social. (...) However, some ideas are spread across the globe, such as the idea that there is no age to get education, that education extends itself across life and that it is not neutral"⁽³⁾.

The challenge of permanent education is to stimulate the development of professionals' conscience about its context, by making them responsible in their permanent training program. Therefore, there is a need to reconsider the methods used in health services for permanent education to be, for everybody, a systemized and participatory process, in which thinking and acting are fundamental inputs for learning and working. Independently of the perspective contemporary education adopts, a future-oriented education will center on critical, reflexive and transformative education, overcoming the limits imposed by the state and the market and, hence, an education that is much more directed at social transformation than at cultural transmission⁽³⁾. Therefore, the authors believe that the pedagogy of praxis, as a transformative pedagogy, in its different manifestations, can offer a more effective reference framework than pedagogies centering on cultural transmission.

This study aims to analyze the effects of permanent education actions on nursing care quality at a large private hospital in Belo Horizonte. In addressing the study object - permanent education as a tool for nursing care quality - a qualitative study was chosen, accepting the definition of qualitative research as "capable of incorporating the issues of meaning and intentionality as inherent to acts, relations and social structures, the latter being considered as significant human constructions, in their arrival as well as transformation"⁽⁵⁾.

Considering the social relations and transformation processes that exist in daily reality, which involves nursing professionals' praxis, this study was based on dialectics as a theoretical-philosophical reference framework.

The formation of the analytic categories was sustained by the researcher's experience in nursing professional training and by a bibliographic review on permanent education, defined as:

- nursing work process - this process is marked by the technical division of work, integrating workers with different education levels: nursing auxiliaries, nursing technicians and nurses. Professional training integrates thinking and acting, with a view to guaranteeing nursing care quality and workers' satisfaction about their work and its purpose;

- permanent education - is an educative process that occurs in the space of thinking and doing at work. Its challenge is to stimulate professional development, in a context of responsibilities and needs for updated knowledge, as permanent education is a process of reflection and growth, with cycles of change and transformation, considering service, work, care, education and care quality;

- process of articulation between theory and practice - theory and practice interact and complete one another, as theory needs practice to be real and practice needs theory to continue being innovative. It is through this articulated interaction that the subject is transformed, making him/her learn and interact with the world.

The study institution is a large hospital with 334 beds, divided in two interconnected blocks, totaling 25 floors and four external units, i.e. one site for highly complex care, with two Surgical Centers and one Obstetric Centre, Emergency Unit with urgency care (Medical Clinic, Pediatrics, Cardiology, Otolaryngology, Plastic Surgery, General Surgery, Orthopedics, Neurology, Geriatrics, Ophthalmology and Gynecology. Other services include Hospitalization Units, Nursery, PICU (Pediatric Intensive Care Unit), ITC (Intensive Treatment Center), different diagnosis sectors and an EHICS (Epidemiology and Hospital Infection Control Service). The hospital was inaugurated on June 1^st 1980. In 1996, its expansion started with the construction of a new 18-floor building, covering 26 thousand square meters of constructed area and tripling the hospital's care capacity.

The hospital aims for better care quality, user and worker satisfaction. As a result of these efforts, in February 2004, it was assessed by the National Accreditation Organization (NAO) and was accredited as level three, characterized as of excellent level. In view of this title, the hospital started to be considered as one of the best hospitals in Brazil, considering the fact that, until 2004, only two of the 33 hospital institutions that had gone through this process all over the country had been included in this category. This accreditation requires maintaining a permanent education process, covering technological advances and care alternatives and modalities.

The research subjects were defined as nurses, nursing auxiliaries and nursing technicians who work at the study hospital, on the 8th and 9th floor of block 2 and have participated in the institution's training programs. The nurse manager was also included, totaling 23 invited professionals, 17 of whom participated.

The inclusion of these two sectors was defined together with the nurse manager, based on the following inclusion criteria: units with recently constituted teams, including nurses who involve the team in the training program, and which are included in the institutional policy's priority setting. The realization of this study was guided by Resolution 196/96, by the Ministry of Health, complying with criteria for the realization of research involving human beings. Authorization was obtained from the hospital board and approval from the UFMG ethics committee. All subjects signed the free and informed consent term.

The following guiding questions were asked, in order of presentation: describe your work, in your sector. What is your work like, in your sector? How have you received or are you receiving training for this work?

To achieve the study objectives, instruments were chosen in coherence with the research method and object. Thus, data were collected through focus groups and individual interviews with key informants. The focus group was defined as the collective interview technique, allowing from group reflections and interactions about a guiding question proposed by the researcher⁽⁶⁾. The focus group sessions were audio and video-recorded by the researcher, and later fully transcribed by a scientific initiation student from NUPEPE (Research and Study Group on Nursing Teaching and Practice at Minas Gerais Federal University) and revised by the researcher. Data were collected on September 14^th-19^th 2004.

The systemized theoretical framework of discourse analysis was considered for qualitative data treatment, which allowed an understanding of the phenomena, where "language contains a view of the world, which determines our way of perceiving and conceiving reality and imposes this vision. Language is like a mould that orders chaos, determining what a thing is, what knowledge is, etc. It creates an ordered image of the world."⁽⁷⁾ The narrative texts, resulting from the focus groups and interview transcriptions, were interpreted on the basis of the discourse segmentation, which allowed the author to perceive the existing mutual relations in each reading, permitting the construction of empirical categories (work process and permanent education), discussed below.

PERMANENT EDUCATION: AN EDUCATIVE AND TRANSFORMATIVE ACTION

The care relation is an interdependence based on nursing professionals' daily work, "according to which the care action is interdependent and is constructed in the daily reality of nursing activities, in its objective dimension, in the subjectivity of caregivers and care receivers. Through the mediation of space-time interactions, we start to think about this construction in its individual and collective dimensions"⁽⁸⁾.

Primary data analysis revealed that care lies closer to nursing auxiliaries and technicians than to nurses. Nurses are more concerned about administrative issues, provoking distancing from care. Within the administrative area, nurses are concerned about patient files and material and medication control. This concern is related with the origins of nurses' insertion in hospital institutions, aimed at reducing costs. When nursing started, women were linked up with the image of a charitable spirit and with the role of administering the household without questioning, that is, the emergence of this profession was associated with a controlling function, in a household economy perspective⁽⁹⁾.

More recently, in institutions, cost control is considered with the "idea of the need for rigid cost control, as if it were inevitable to survive in an environment of competition among service providers, for funding and for the clients, advocating that only those who work economically and satisfy the client will continue"⁽¹⁰⁾.

Professionals expressed their concern about the study institution's demands in terms of material control, cost control and registers. They perceive that control requirements have put the systemization of nursing care on a secondary level. Nursing care should not be restricted to visits in order to survey complaints and carry out procedures, but should implant mechanisms to make sure that the nurses guarantee care integrality and quality at the unit.

Actions to control and supervise the work of nursing auxiliaries and technicians are highly directed at the maintenance of a micro hospital world, restricted to nurses who, in a way, are made responsible for its functioning, in administrative terms, in controls and registers, as well as in care, directed at satisfying patients, users and other workers.

The interviewed nurses' statements reveal that nurses analyze their work as more directed towards administrative actions and demonstrate frustration because they cannot be more present in care actions. It should be asked whether this is not a way for nurses to maintain the hegemonic "modus operandi", without establishing strategies to overcome it and construct a new care practice. Perhaps because of insufficient training to perform care actions or great pressure, nurses control the work process in a little systemized way, generating fragmentation in the organization of the process.

Permanent professional education should be a part of workers' thinking and acting, with a view to benefiting their personal and professional growth and contributing to the organization of the work process, through steps that can problematize reality and produce changes.

Data analysis shows that nurses, nursing auxiliaries and technicians see their work as an important factor, but emphasize that it is a hard job, perhaps because they live with suffering, or also because the subjectivity-centered interaction between patients/users and nursing staff gives rise to bonding, responsibilization, confidence, friendship, complicity and, often, conflicts.

According to the interviewed nursing auxiliaries and technicians, the organization of the sector, including material availability, is fundamental for care delivery and quality. When materials are not available, care quality is affected.

The analysis of the interviewees' data and observations reveal that work organization is a systemic process, leading to support and collaborative relations, producing the articulation of nursing work with that of other sectors that provide inputs for care quality, such as: pharmacy, SMC (Sterilized Material Central), warehouse, nutrition and laundry. The work process in hospitalization units needs to be reorganized with a focus on user-centered care.

The interviewed nursing auxiliaries and technicians see nurses as references to solve doubts or answer questions about procedures and difficulties to incorporate new technologies. Another descriptive way is learning is through support from other colleagues. They described that, in this case, there is a possibility of learning "the wrong way", receiving inappropriate or insufficient orientations from another colleague. Learning constructed on the basis of relations between work colleagues may lead to the non-standardized realization of techniques. Standardized procedures are aimed at patient safety. Nurses are questioned when a nursing auxiliary or technician is realizing procedures differently from other colleagues.

According to the interviewees, when professionals are followed while they perform activities, this offers the opportunity to apply the problematization pedagogy, allowing for critical reflections about the care act, and not only about the technique that is to be applied. At this moment, questions can be asked about the reason for doing something one way or another? Problematization pedagogy can favor learning because it contributes to the continuity of praxis, that is, making it possible to transform reality⁽¹¹⁾.

In the training process, problematization pedagogy stood out as an instrument that allows for permanent and practice-based learning. Therefore, it should be asked whether nurses know and master this pedagogical concept, and whether they have time and are interested in developing it.

Empirical data analysis demonstrates that training in this hospital scenario is disarticulated with the work process of administering and delivering care. This lack of articulation is directly related with the way training activities took place, which did not allow the nursing workers to understand the reason for doing a certain activity and/or procedure in their daily work. However, the authors found that some changes occurred in the "training sector", in response to the team's reflections during the course of this study. A change of name was proposed, from training sector to Permanent Education. This change rests on a conceptual and methodological approach that articulates the training processes, work organization and development, considering daily work and nursing workers' thinking, acting and feeling.

PROVISORY SYNTHESIS: THE START OF A LONG WALK

As a result of permanent education processes, training and permanent education services and sectors need to adopt the pedagogical concept of problematization, aimed at stimulating reflections on practice and knowledge construction.

Permanent education plays a strategic role for the organization of the nursing work process, in articulation with other nursing practices and hospital sectors. It should be based on critical and reflexive concepts and methodology. This process implies acknowledging that routine practices, outside the context of actual problems, probably will not allow for the development of reflexive abilities⁽¹²⁾. Thinking about innovative permanent education proposals supposes the challenge of managing learning experiences of interest to the people involved, permitting links in the process of understanding and knowledge construction; promoting intelligent, creative and profound ways of thinking, in order to favor personal and social development and in-service workers capacity to reflect. These processes should allow workers to learn, in the complex contemporary world, any link, in the context of solidary and democratic learning, which helps professionals and tends to strengthen personal growth and professional transformation processes. Autonomous learning develops the capacity to learn how to learn and awareness about the need for permanent training.

This evidences the need for a nursing training program, with a view to adopting conception-based permanent education that benefits subjects' growth, which is fundamental to determine care quality.

The authors recommend the adoption of critical-reflexive pedagogy, with methodologies that permit the problematization of daily work situations, as well as the construction of interventions that allow for changes, not only inside the institution, but also in the individual's social relation as a subject that delivers care to patients.

Moreover, the need is identified for the institution to invest in nurse management training, considering that nursing auxiliaries and technicians manifested, among other aspects, concern about the nurse's need to commit him/herself to the team's work. Management training should provide nurses with political-management competencies that provide them with a broad and integral view of the institution, as well as more proactive action in their relation with other nursing workers, hospital staff and patients.

The authors propose to use the systemization of nursing care for care planning, execution and assessment. In this context, control could be more effective, allowing nurses to get a view of the whole and put the realization of its object - care - into practice.

This study remains unfinished, considering its goal of expanding reflections on training and the work process at a hospital institution, in view of permanent nursing education as a tool for care quality.

Recebido em: 11.3.2005

Aprovado em: 29.5.2006

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Paper extracted from the Master's Thesis

Publication Dates

• Publication in this collection
  09 Feb 2007
• Date of issue
  Dec 2006

History

• Received
  11 Feb 2005
• Accepted
  29 May 2006