PET-Health Interprofessionality and actions in times of pandemic: teachers' perspectivesAbstracts
The Program ‘Education through Work for Health’ (PET-Health) is a nudging policy that provides learning through problematizing experiences in health workplaces, with a focus on interprofessionality. The aim was to report the experience of PET-Health Interprofessionality during the Covid-19 pandemic, from the teachers' perspective. The development of PET-Health with students, tutors, teams from the health system and users demanded, (re) discovering possibilities of information and communication technologies, learning to produce “new presences”, without giving up the collective, participatory action, composed by different knowledge. There was learning of development of skills such as qualified listening for conflict resolution, interprofessional communication and collaborative leadership. This PET-Health proved to be a triggering event towards health education, connecting university, health network and community, and contributed to the development of collaborative skills and constituted a welcoming space for the situations experienced.
Keywords Interprofessional education in health; PET-health interprofessionality; Collaborative practice; Team work; User embracement
O Programa de Educação pelo Trabalho para Saúde (PET-Saúde) é uma política indutora que fomenta o aprendizado por vivências problematizadoras nos locais de trabalho em saúde com foco na interprofissionalidade. O objetivo do presente trabalho foi relatar a experiência do PET-Saúde Interprofissionalidade durante a pandemia de Covid-19, na perspectiva docente. Desenvolver o PET-Saúde com estudantes, preceptores, equipes dos serviços e usuários demandou (re)descobrir possibilidades das tecnologias de informação e comunicação e o aprendizado da produção de “novas presenças” sem desistir da ação coletiva, participativa e composta pelos diferentes saberes. Apreendeu-se o desenvolvimento de competências como escuta qualificada para resolução de conflitos, comunicação interprofissional e liderança colaborativa. Este PET-Saúde mostrou-se um disparador na formação em saúde, conectando universidade, rede de saúde e comunidade; e contribuindo para o desenvolvimento de competências colaborativas e um espaço de acolhimento para as situações vivenciadas.
Palavras-chave Educação interprofissional em saúde; PET-Saúde Interprofissionalidade; Práticas colaborativas; Trabalho em equipe; Acolhimento
El Programa de Educación por el Trabajo para Salud (PET-Saúde) es una política inductora que fomenta el aprendizaje por vivencias problematizadoras en los locales de trabajo en salud con enfoque en la Interprofesionalidad. El objetivo fue relatar la experiencia del PET-Saúde Interprofesionalidad durante la pandemia de Covid-19, desde la perspectiva docente. Desarrollar el PET-Saúde con estudiantes, preceptores, equipos de los servicios y usuarios demandó (re)descubrir posibilidades de las tecnologías de información y comunicación, aprendiendo a producir “nuevas presencias”, sin desistir de la acción colectiva, participativa, compuesta por los diferentes saberes. Se aprendió a desarrollar competencias tales como escuchar de forma calificada para la resolución de conflictos, la comunicación interprofesional y el liderazgo colaborativo. Este PET-Saúde se mostró un gatillo en la formación en salud, conectando universidad, red de salud y comunidad, contribuyendo al desarrollo de competencias colaborativas y un espacio de acogida para las situaciones vividas.
Palabras clave Educación interprofesional en salud; PET-saúde interprofesionalidad; Prácticas colaborativas; Trabajo en equipo; Acogida
Introduction
The Program ‘Education through Work for Health’ (PET-Health) is a nudging public policy proposed by the Ministries of Health (MoH) and Education, which advocates in favor of networks of dialogue between students, teachers and service professionals, expanding learning through problematizing present experiences in health workplaces1. This strategy contributes to the teaching-service integration in the education of students committed to the Brazilian National Health System (SUS) and favors the permanent education of the Network professionals, focusing on Interprofessional Education in Health (IPE) and on collaborative practices2.
In order to meet the Pan-American Health Organization’s (PAHO) call with the World Health Organization (WHO) to implement and strengthen the IPE in the Americas region, the MoH launched the PET-Health/Interprofessionality call, resulting in the participation of the Unifesp Baixada Santista campus, in partnership with the Lusíadas University Center (Unilus). The Pedagogical Project of the Health and Society Institute-Unifesp (ISS-Unifesp) assumes the IPE as one of the guiding principles of education in health, investing in an interdisciplinary and interprofessional curricular proposal. In the formative path of students, the insertion of the ISS-Unifesp in various policies inducing the reorientation of education in health, has strengthened the curricular improvement of undergraduate courses, as well as contributed to consolidate and give sustainability to the relations of the campus with health services in municipalities belonging to the Regional Health Department of Baixada Santista (DRS-IV)3. The general objectives of the PET-Health/Interprofessionality Project have always been in line with the principles of the proposed actions.
The IPE is based on the education of professionals prepared to work in an interprofessional team, emphasizing the comprehensiveness of care, from the perspective of an expanded conception of health4. It is structured in a formative proposal characterized when professionals and/or students from two or more professions learn together, about others, with others and among themselves, which enables a better understanding of the specific roles of each professional/student and strengthens the development of interprofessional collaboration in teamwork5,6.
Interprofessional collaboration, by understanding sharing, partnership, interdependence, and power relations7, it is characterized as intentional work organized in an interprofessional manner, to develop care practices committed to health8. An interweaving of specific, common and collaborative competencies is recognized in the concrete experience of the IPE, understanding competence as:
[…] the ability to articulate and mobilize knowledge, skills, and attitudes, putting them into action to solve problems and face situations of unpredictability in a given concrete work situation and in a given cultural context9. (p. 13)
The specific competences cover a mosaic of representations, historically constructed practices and legislation inscribed at different social moments, creating ways of doing and being in a given profession, characterizing professional identity processes. The common competences are embedded within the specific competences, extending and complexifying key professional identities and structural basis for the implementation of humanized care from the perspective of integrality.
The collaborative competencies that enhance and anchor interprofessional teamwork are another founding axis10. The Canadian Interprofessional Health Collaborative (CIHC), presented in 2010 six domains of competencies for Interprofessional Collaborative Practice (ICP): patient, family and community centered care; interprofessional communication; role clarification; team functioning; conflict resolution and collaborative leadership11.
The year 2019 was a powerful and fruitful first year regarding the objectives proposed and achieved in the PET-Health Interprofessionality for the Project ISS-Unifesp, Unilus and Municipal Health Secretariats (SMS) Guarujá, Itanhaém, Santos, São Vicente in regards to the development of competencies. It was especially relevant because it developed intersectoral actions for health promotion, disease prevention and rehabilitation, and now a second year is projected to be even more transformative, propositional and collective.
Hence, the Covid-19 pandemic triggers displacements through new experiences, solidarity configurations and re-composition of care relations, dedication of front-line professionals (the SUS -from Primary Care to the ICU- resists, persists, insists), and the challenging place of our universities in facing the pandemic.
In PET-Health Interprofessionality, with the suspension of classroom activities and mindful of the deliberations of the Health Secretariats, which also suspended all activities in their services in partnership with the universities, the challenge was assumed in order to continue the goals set out in the project from the reinvention of education, intervention, and knowledge production practices.
This article, in the framework of what was experienced, aims to report the experience of the PET-Health Interprofessionality ISS/ Unifesp/ Unilus/ SMS-Guarujá, Itanhaém, Santos, São Vicente, from activities carried out during the Covid-19 pandemic, using the teachers’ perspectives.
The PET-Health Interprofessionality: ISS-Unifesp/Unilus/SMS-Guarujá, Itanhaém, Santos, São Vicente
The PET-Health Interprofessionality was composed of four undergraduate courses at ISS-Unifesp, Physical Education, Physiotherapy, Social Work, and Occupational Therapy, and the Medicine course at Unilus.
The project involved four health departments in the Baixada Santista (Guarujá, Itanhaém, Santos, and São Vicente) and was composed of a coordinator, five groups with thirty students from the five courses, ten teachers/tutors, and twenty preceptors inserted in the SUS. The groups were composed of 12 participants, two tutors/teachers, six students, and four preceptors. It is important to highlight that tutors, preceptors and students were from the different areas covered by the courses, besides having professionals from other areas, such as dentistry, biomedicine, nursing, psychology, and biological sciences. Effectively, an interprofessional context, evidenced by the intentionally organized situations of interprofessional learning, by the Pedagogical Project, which from the assumption of the IPE as a guiding principle, undertakes a health education that invests in education for teamwork from the users’ needs12.
The dynamics of the activities, including work in the PET-Health Interprofessionality insertion field (health services/places) and weekly meetings focused on the tutorial groups, sought to translate the fundamental intentionality of configuring, sustaining, and developing group compositions and interprofessional teaching, research, and extension interventions. From the authors’ perspective, there is an encounter that reflects the intentional desire to build PET-Health Interprofessionality, from its conception, through its implementation in permanent movements of self and hetero-evaluation: this encounter was called InterPET.
The InterPET were designed as an aggregating and uniting space: all 61 members participated in moments of interprofessional learning about what they lived and dialogued about the assumptions of the IPE, building interlocutions with other researchers, guaranteeing a rich opportunity for the exchange of experiences among the groups.
A guiding factor to achieve the objectives and develop the actions was the welcome and follow-up from the advisors appointed by PAHO, provided throughout the course of the PET-Health Interprofessionality. By being open to dialogue, listening attentively to the questions and to the recreation proposals, as well as with critical and supportive interlocution, the advisors represented an important partnership in the reorganization of the activities, being fundamental in the incorporation of digital information and communication technologies (ICT) in an intentional way, collectively planned, implemented by the groups, and evaluated from the perspective of the development of collaborative competencies.
The mediation of the project coordinator with the advisors in the communication with the groups in the tutors and InterPET meetings favored, not only the exchange of experiences, network communication, and empowerment of groups and people, but also the validation of the process of renegotiating the actions with the services and managers of universities and municipalities, contributing with the continuity of the program during the pandemic.
PET-Health Interprofessionality in March 2020: what now?
The beginning of the reorganization process of the PET-Health Interprofessionality activities, as in all sectors, was marked by insecurities and anguish, especially regarding the teaching-service-community integration.
In this way, adjustments were necessary for the continuity of another year of the outlined objectives and proposed activities. A first aspect to consider was that the preceptors involved were allocated to the health services in which they were assigned to face the pandemic, which meant that in many meetings the group’s approach was to welcome them, sometimes devastated by their daily experiences. This scenario was saddening and it did not allow to continue the planned actions in face of this reality.
Another relevant point was the students’ reaction of insecurity and uncertainty when confronting this scenario. The moment called for welcoming and listening, since we knew that the teaching-service-community integration was compromised by the lack of physical presence. However, despite the difficulties and the immediate imposition of social distancing, we overcame the obstacles to continue the activities of PET-Health Interprofessionality.
At the beginning of the pandemic crisis, the groups prioritized the welcoming of all members. The pandemic challenged us, and the sufferings were present in different ways, strengthening the bond by the welcoming provided by the encounters, favoring communication and team functioning. Several members expressed their fears and anxieties, seeking support and hope among the partners.
The activities developed by the teams started to be possible, for the most part, by ICT. These are tools that assist in the educational process and can be considered a trigger resource for the learning process13. However, there was no time for education, ensuring digital inclusion, and democratizing access to high-speed connections.
In this health, political, educational and social emergency brought on by the pandemic, despite the important contributions of ICT (clear and efficient communication, extended care coordination in the context of clinical practice and relevant outcomes in the care of users with chronic conditions), resistance and lack of investment by health managers of the municipalities involved were present, compromising the quality of care and educational practices. In this regard, the partnership with universities and the support from teachers and students required dedication to continue the actions, engaging in the construction of inventive learning.
Unifesp made available to its members the “G-Suite for Education” applications (Google Meet, Drive, Classroom, and other tools) and thus it was possible to continue the tutorial group meetings and part of the actions. Google Meet was the most used platform for communication between members of PET-Health Interprofessionality, and the rest of the people involved in the actions. Google Drive was used as a space to share documents, photos and also for shared production of presentations, materials for dissemination in social networks, abstracts for conferences, book chapters, articles, reports and others. However, not all members were familiar with the resources and needed to look for help in improving their use.
Whatsapp, which was already used both as inter and intra-group communication strategy, was also widely explored as a fast and efficient means of communication for the organization of activities and space for exchanges with users and services.
Regarding teacher education, we highlight that PAHO together with the MoH offered a group of professionals involved in PET-Health Interprofessionality the “Refresher Course in Teacher Development for Interprofessional Health Education”. During the course, the activities developed involved the other members of PET-Health Interprofessionality: podcasts, mandalas covering the components of collaborative practice, questionnaires (through Google Forms) about professional identity, and videos, which contributed to the approach with different ICT. The professionals who attended the course were encouraged to share their readings, reflections, and activities with the PET-Health Interprofessionality components through a perspective of amplificating networks and resonance production.
Interprofessional collaboration and learning in PET-Health Interprofessionality: times of reinvention and resistance
Through uncertainties and mistakes, we faced the challenge of “playing around” with the technologies and experimenting (in Bondia’s14 sense of experience, as something we mean) the emergency remote activities: this crossing, as it was going to be revealed later, would lead to new destinations.
Social networks were powerful tools to maintain contact and bond with users, but additionally, they also allowed us to provide the population with correct information from reliable sources. Specific pedagogical materials were built for the dissemination on social networks, which was certainly key for the students’ learning and maturation, once they planned and built these materials with the support of tutors and preceptors. The partnership between the preceptors was crucial for the development of the posts and actions, as they were in direct contact with the network users and could recognize the necessary and/or requested demands.
Permanent Education in Health aims to propose organic relationships between teaching (pedagogical concept) and health care15. The project was woven and built between tutors, preceptors and students, in meetings with other team members from the health services, as this link with the territory was maintained by the preceptors as well as by extended WhatsApp groups, shared social networks, and the presence of students and tutors in the health services/sites for planned actions and/or events on pre-established dates.
The PET-Health Interprofessionality setting allowed the interlocution between teachers, students and network professionals, which provided an environment with reflections on interprofissionality and health in education and daily practice in SUS, articulating theory and practice, as well as teaching and learning16. To illustrate one of these actions, we briefly describe below the experience about developing a educational program for newly hired community health workers, in which those available attended monthly scheduled meetings. To this goal, the activities were planned in extended meetings through Google Meet, including representatives of the Family Health team. The tutors organized the meetings and shared knowledge; the students participated in the production of videos, educational materials, among others; preceptors prepared the pedagogical material and developed the educational proposal (favoring active participation and discussions based on case studies experienced in the daily practice) with the community agents, setting up moments of great learning and sharing.
The group meetings, held through Google Meet, were important moments to agree on the demands, to stimulate qualified listening, solve difficulties and challenges, in addition to being a welcoming space. Each group was organized according to the reality of the participants, recognizing this space as unique for the development of interprofessional collaboration.
Since interprofessional collaboration is not learned by mere chance or voluntaristic moves, Table 1 depicts several strategies carried out during the Covid-19 pandemic and its nexus, that highlight the intentionality of developing the specific, common, and collaborative competencies for student health education from the faculty perspective.
Strategies developed during the Covid-19 pandemic in the context of PET-Health Interprofessionality.
Despite the difficulties, it is possible to underline the intentionality of developing the network of guiding competencies of interprofessional collaboration using ICT in the context of the Covid-19 pandemic from a diversity of actions. In all the actions, we tried to develop a care centered on the patient and the family, valuing listening and the expression of the needs of all the parties when planning and carrying out the actions, in order to promote integral care.
According to Agreli et al.17 the three pillars of patient-centered care (PCC) are linked to the expanded perspective of health care (where one finds the holistic, integral approach and orientations based on the participants’ needs), patient participation in care (predominance of the concepts of autonomy, self-care, and patient participation), and, finally, humanization (deep interactions between the team’s professionals and users, relationships that are surrounded by respect, empathy, listening, affection, sensitivity, bonding, and dialogue). This perspective is concurrent with the guidelines published by the WHO in 2016 for PCC in health services18.
The intentionality of developing PCC was evidenced when the users’ demands (via social networks) and also the perception of the Network professionals were considered and the actions were jointly agreed upon. A Whatsapp group, for example, with groups of specific users and health team allowed keeping the previously established bond. The preceptors’ interlocution with users was also a key element to guarantee the PCC in the care process.
Interprofessional communication19 was present in all the work strategies defined for the pandemic period, since at least two actors from different professions, be they preceptors, tutors, students, or health team professionals were together.
However, we identified some obstacles, because it was not always possible to include the totality of the communication, since we depended exclusively on digital tools and, sometimes, non-verbal communication was not present. One fact that shows this difficulty is the “closing” of the cameras and microphones of the electronic devices. Disabling microphones during virtual meetings is necessary, as it organizes and respects the speech of the other team members and minimizes problems related to the low quality of the internet connection. However, the deactivation of the cameras reveals itself as an issue to be problematized, because on the one hand it seems to reflect a lack of access to quality internet, favoring that there is no damage/interference, and on the other hand it shows the vulnerabilities, discomforts, and fears in face of very new ways of learning with the mediations of the screens.
Stimulating efficient, interactive, and collaborative communication among all group members was a challenge for the tutors, whose role was to lead the group meetings. In collaborative leadership, everyone involved supports the choice of leader and takes shared responsibility for the processes chosen to achieve results11.
The tutor did not always take the lead in the meetings, but played an important role in organizing the work, especially during the transition to virtual activities, since new communication and work strategies had to be defined and the preceptors remained at their workplaces to face the pandemic. However, since there were already bonds among the peers and an agreed upon way of working, it facilitated taking the leadership to carry out the actions from the decisions taken together.
As presented in Table 1, collaborative leadership was present in different activities, such as the production of materials for the social networks, shared production of texts, and the organization and holding of virtual meetings/events.
One of the discussions present since the beginning of PET-Health Interprofessionality, especially with the students, was about the role and limits of each professional area. Sometimes the tutors were asked about the role of each preceptor in certain activities. The triggering issue was always curiosity about interpersonal relationships, the functioning of the Network, and what health management is. The most common questions were: “But... what is my role as a physical therapist in the waiting room?”, or “How can I, as a social worker, contribute to a health promotion group or to the production of a life narrative?”, or “What is this management so often discussed in the meetings with the preceptors?”, among many others. Besides these questions, we observed another obstacle: the social representations still present in health education.
As a result of integral practice in the exercise of common and specific skills of health professionals. Notwithstanding the influence of the institutional design of the health system and its policies in the attempt to achieve comprehensive care, universities and their teachers still suffer from teaching-learning practices that follow the classic Flexnerian prescription (fragmented, specialized, biologizing, and focused on the liberal model)20. (p. 1181)
These issues were intensely discussed in group meetings, with the active participation of the preceptors and, in this context, the course meetings were fundamental to define the role of each professional area. These meetings (course) took place monthly and were composed of the tutors and their respective students from the professional education area. The students brought their experiences, questions and concerns, and the tutors, through a dialogue that articulates listening, problematizing questions and collective construction, favored reflection on the professional roles in the configuration of health care. The professional identity, thus, was being interwoven with the awareness related to identity processes in which professional and interprofessional voices provoke reverberations in the daily lives of health teams8.
Certainly, these learning moments were important for the development of PET-Health Interprofessionality, especially during the pandemic. As the groups knew the limits and attributions of each profession and each member recognized themselves within the team, it was possible to develop actions in this period, building convergences and dealing with divergences and/or conflicts in a dialogical way, with the perspective of not paralyzing the care and educational practices.
From the perspective presented here, it is recognized that the experience of ISS-Unifesp students that are allocated to classes with students from different areas of education since the beginning of their studies, allows joint learning and resulted in an anchor for the experience of interprofessional work. This process causes students to change their attitudes, knowledge, and skills. When added to interprofessional socialization, uniprofessional identities are expanded to a professional and interprofessional identity. Without both, the health care process becomes fragmented21.
Group meetings were very present strategies during the pandemic period. These discussions were sometimes surrounded by conflicts that needed to be resolved for the team to function well. Interprofessional collaboration generates disagreements and they need to be faced in a constructive way as they emerge. The events that lead to differences of opinion can originate from positive or negative sources; when the positive dimension prevails, it provides edifying verbal or nonverbal communications22. On the other hand, when team members do not have the expertise in conflict resolution, the performance of the whole presents negative results for care23.
It was perceived that the process fostered highly important collaborative competencies including: qualified listening for conflict resolution, interprofessional communication, and collaborative leadership. These competencies were evidenced in the experiences and were crucial for the development of interprofessional collaboration, enabling the construction of the bond within the health groups and teams. Even in the context of the pandemic, this bond was intensified and made it possible to reflect together on how to solve a diversity of problems.
Concluding remarks
Despite all the “crises” imposed by the pandemic of Covid-19, it is possible to affirm movements and moments of re-signification of practices to give continuity to interprofessional education in the context of PET-Health Interprofessionality.
At the end, the reports of both students and preceptors, and of tutors/teachers show us not only the challenges and limits of ICT for the development of common, specific, and collaborative competencies, but also its power, since it was able to connect several points of the health network.
PET-Health Interprofessionality was the seed that germinated and produced fruits in the university and health networks for interprofessional collaboration. The bonds established allowed the collaborative spirit to emerge, mainly because it brought the interprofessional identity, the mutual identification among professions, and provided the essence of teamwork. This PET-Health Interprofessionality allowed the participants to be ‘contaminated’ with the concepts, foundations, assumptions, and the essence of the IPE. Even facing social distance, it was possible, through ICT, to produce new presences, expand actions, reach new components, and share knowledge.
The previous link between the members of the groups and their link with the service contributed to think about the continuity of the work in the remote emergency model. The joint work with the preceptors brought the students closer to the SUS practice scenario, with its potentials, vulnerabilities, and challenges. Learning together with the preceptors, representatives of professionals who resist and dream of a humanized service, centered on people, families, and the community, is an inspiration for the students to orient their professional careers towards a comprehensive approach to healthcare.
Finally, the health secretariats, represented by their teaching and internship center managers, expressed their interest for new partnerships and the continuity of the work, once they have experienced the interprofessional practice. Moreover, they recognize how much the university can be a partner in fostering new attitudes, values, and knowledge. So much learning and new challenges! Experiences that invite collective resignification, collective construction/configuration of solidarity mosaics/arrangements that leave no one behind: and here we are particularly interested in being attentive to those who are most vulnerable (social, emotional and pedagogical conditions). Those are experiences that flourish from the integration of teaching-service-community, having SUS as the organizer of education and the locus of emancipatory, resolute and equitable health care practices.
Acknowledgments
To all colleagues who made up the PET-Health Interprofessionality Project Health and Society Institute - Campus Baixada Santista - Unifesp, Lusíada University Center - Unilus, Guarujá Health Department, Itanhaém Health Department, Santos Health Department, São Vicente Health Department.
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Chriguer RS, Aveiro MC, Batista SHSS, Garbus RBSC. PET-Health Interprofessionality and actions in times of pandemic: teachers'perspectives. Interface (Botucatu). 2021; 25 (Supl. 1): e210153 https://doi.org/10.1590/interface.210153
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Publication Dates
-
Publication in this collection
03 Dec 2021 -
Date of issue
2021
History
-
Received
11 Mar 2021 -
Accepted
11 Aug 2021
