ENSSAY / ENSAYO / ENSAIO

Permanent education in health. An instrument to enhance interpersonal relations in nursing work

La educación permanente en salud. Instrumento potenciador de las relaciones interpersonales del trabajo en enfermería

Educação permanente em saúde. Instrumento potencializador das relações interpessoais no trabalho da enfermagem

Juliane Portella Ribeiro¹; Laurelize Pereira Rocha²

¹RN, Psychologist, Ph.D Candidate, Universidade Federal do Rio Grande -FURG/RS-, Brazil. ju_ribeiro1985@hotmail.com.

²RN, M.Sc. Candidate, FURG/RS, Brazil. laurinharoch@hotmail.com.

Receipt date: February 10^th 2012. Approval date: May 15^th 2012.

Subventions: none.

Conflicts of interest: none.

How to cite this article: Ribeiro JP, Rocha LP. Permanent education in health. An instrument to enhance interpersonal relations in nursing work. Invest Educ Enferm. 2012;30(3): 412-417

ABSTRACT

This is a reflexive study about the need to adopt Permanent Education in Health, as an instrument capable of transforming interpersonal relations in nursing work, as it values and respect collective construction with a view to the qualification of care. Privileging specialization programs only, with a focus on work techniques, on educative processes, as a training strategy for health services, ends up reinforcing the fragmentation of care, teams and the work process. In conclusion, Permanent Education in Health serves not only as teaching and learning practice to update and transform practices, but also influences team relations, transforming joint action processes and, at the same time, implying each subject-worker involved in health practices.

Key words: Nursing; Education; Health education.

RESUMEN

Se trata de un estudio reflexivo sobre la necesidad de adoptar la Educación Permanente en Salud, como un instrumento capaz de transformar las relaciones interpersonales en el trabajo de la enfermería, ya que valora y respeta la construcción colectiva para la calificación de la atención. Privilegiar sólo la especialización con direccionalidad en la técnica del trabajo en los procesos educativos, como estrategia de capacitación para los servicios de salud, acaba por reforzar la fragmentación del cuidado, de los equipos y del proceso de trabajo. Se concluye que la Educación Permanente en Salud, además de servir como práctica de enseñanza y aprendizaje para la actualización y transformación de las prácticas, actúa en las relaciones del equipo, transformando los procesos de acción conjunta y, al mismo tiempo, implicando cada sujeto-trabajador involucrado en las prácticas de salud.

Palabras clave: Enfermería; Educación; Educación en salud

RESUMO

Se trata de um estudo reflexivo sobre a necessidade de adotar a Educação Permanente em Saúde, como um instrumento capaz de transformar as relações interpessoais no trabalho da enfermaria, já que, valoriza e respeita a construção coletiva, para a qualificação do atendimento. Privilegiar só a especialização com direção na técnica do trabalho, nos processos educativos, como estratégia de capacitação para os serviços de saúde, acaba por reforçar a fragmentação do cuidado, das equipes e do processo de trabalho. Conclui-se que a Educação Permanente em Saúde, além de servir como prática de ensino e aprendizagem para a atualização e transformação das práticas, atua nas relações da equipe, transformando os processos de ação conjunta e, ao mesmo tempo, implicando cada sujeito-trabalhador envolvido nas práticas de saúde.

Palavras chaves: Enfermagem; Educação; Educação em saúde.

INTRODUCTION

We are constantly subject to the action of the social context that changes and permanently continues its history. In line with our historical construction, we can understand our constitution as professionals and perceive the influence of different forms of thinking and practicing life in society.

In the Industrial Revolution, the Taylorist and Fordist philosophies drove the trend towards individual work, centered on specialization. Productivity-focused concerns segmented operations, enhancing the technical division of work through the decomposition of workstations, simplifying tasks and the gestures needed to accomplish them, furthering and strengthening the hierarchization of power and control over the workers. This organization provoked the expropriation of workers' knowledge of the entire work process, depriving them from intervening in important and human issues related to this same process, without any concerns with workers' needs and interests.¹

In the 1980's, however, globalization brings about a transformation in the business world, demanding adaptation to new production and trading processes. To enhance production and competitiveness, the establishment and sustainment of permanent education and job recycling programs are fundamental. Under the influence of the Toyota philosophy, workers' knowledge and experience starts to be valued and used, involving them in the identification of problems, participation in decision making about changes that enhance production and production and service quality, and also encouraging teamwork.¹

Despite these transformations, it is highlighted that the characteristics of the Taylorist and Fordist philosophies did not disappear, hampering interpersonal relations and professionals' engagement in teamwork, in a climate of openness, honesty, confidence and cooperation, independently of their academic background.² These philosophies result from sociopolitical and economic organization, and therefore reproduce the dominant ideology and human beings' commitment to their reality.

Nursing, in turn, is a profession that does not exist without collective cooperation, without teamwork. As the profession works to deliver health care and assist human beings, however, constant improvements and technological training are fundamental. But, are knowledge additions or updates sufficient to transform interpersonal relations in nursing work? Privileging specialization programs only, with a focus on work techniques, on educative processes, as a training strategy for health services, ends up reinforcing the fragmentation of care, teams and the work process. Therefore, the transformation should center on the profile change from exclusively technical, mechanic, rigid workers without autonomy, to creative, flexible, critical, communicative and knowledgeable workers, who are aware that they are constantly learning, who are able to communicate and establish relations and who reflect on their actions, thus advancing in interpersonal relationships and in the quality of the service they deliver.³

In view of this demand, this study reflects on the need to adopt Permanent Health Education as an instrument capable of transforming interpersonal relations in nursing work, as it values and respects collective construction with a view to the qualification of care. Education aims to raise individuals' awareness about the need for (re)construction since, as a member of a team that consists of subjects with distinct particularities, they need each other to deliver efficient and high-quality care. Reconstruction is based on unlearning precast concepts from a system in force and opening up for new knowledge, new learning. Construction is the search to ''learn how to learn'', which involves recognizing one's acts, colleagues' ideas, the profession's and the institution's mission in order to adapt to changes and intervene, using knowledge for the group's growth as, when one learns, one is acting at the same time.³

The historical construction of workers

In the beginning, man lived in contact with other man as a way to guarantee his survival and species. Initially, groups originated not only as a form of defense against natural danger, but to equip the mastery and power over rival groups. As these primitive groups became more established, however, they lost their initial characteristics of solidarity, loyalty and mutual protection, turning into instruments of domination and tyranny over these same groups.⁴ Modern industrial society, marked by technology, has demanded more specialized employees in the work environment to keep the system working. As technology advances, specialization also tends to increase and, thus, work in fractioned in small parts, making subjects work individually and attempt to develop skills in order to be valued for the knowledge they possess, which has stimulated competition and distancing from teamwork.⁵

Any change in production relations was aimed at releasing man, making them free to sell their workforce. Today, man's action starts to belong to society, to be regulated by the supply and demand laws, making him respond to their requirements to continue in the job market and thus guarantee his survival.⁶ Even in nursing, in which professionals supposedly gain knowledge on the work process in their academic education, and should use it in their practical life to support planned and high-quality care delivery, focusing on the transformation of care, it is difficult to be able to overcome the daily reality the capitalist system imposes, turning them into mere piece workers.⁷

Thus, individualism, rivalry and competition among men appear as an unquestionable truth, demonstrating the need to expose the construction of the individualist man and its implications for teamwork to the nursing work process. In that sense, education turns into a necessary instrument to show group members that, despite individual diversity and similarities, they share a common and interdependent goal, which in nursing work is care delivery to human beings.⁸ Teamwork is such a clear idea in the context of nursing work that it becomes imperative not to consider it differently. The authors, however, motivated to stimulate the readers' reflections, present theoretical reference frameworks to consider the current form of the nursing work process and the need to develop technological resources to put in practice work that are determined by the notion of learning how to learn.

In recent years, in nursing and other health professions, actions to achieve humanized care practice have been highlighted in the work process, especially through the National Humanization Policy. To develop humanizing actions in health care, however, humanization needs to be the institution's philosophy, so as to underline the subjective aspect present in any human action, in any health practice.^7,9 When humanization is the institution's philosophy, it becomes fundamental to encourage the team, valuing professionals as biopsychosocial beings as, the more respected, valued and motivated they feel as persons and professionals, the healthier the interpersonal relations they can establish with patients, relatives and the multiprofessional team.^7,9

Therefore, nursing management needs to be in accordance with current perspectives, so as to include humanization into management models. Nursing teamwork, however, is lacking models that permit the construction of collective spaces to reflect on and assess the meaning of daily actions. Departing from common knowledge, it is known that isolated actions make it harder to reach goals. Nevertheless, society strongly encourages competitiveness and individual talent, making any changes in the way people relate improbable. The change from individualism to other teamwork organization forms, in which people cooperate and horizontal relationships exist, demands a change from individual (personal) to teamwork interests in the organization of practices.

In this intent, it is not sufficient to acknowledge that the organization form is not effective or that individuals' way of thinking and acting is inappropriate. Instead, one needs to move beyond, break with current routines and put in practice new strategies. For this change to take place in practice, people and organizations need to experience discomfort in daily work, that is, they need to perceive that the current form of doing or thinking is insufficient or unsatisfactory to cope with the challenges.¹⁰ Acknowledging that professionals and institutions' adjustments and fresh readings can bring about a renewal in strategies and models in coherence with the context.

This process causes the intersection between education and work, which comes with great potential for the construction of knowledge and practices that, in confrontation with reality, adapt themselves to permit the overcoming of health services' traditional practice model. Permanent education gains these characteristics and evidences that renewal can be conquered through problemization in each team's work, in which the dialogue between current practices and conceptions designs new agreements for contact and practice in health services.^11,12

The teaching-learning process Permanent Education produces is based on the constitution of knowledge through the routines, attitudes and daily activities professionals practices in the work environment. When reflecting on their practice, they exercise their ability to transform reality critically and autonomously. Based on the premises of significant learning, this encourages professionals' exercise and development of enterprises and the creation of new strategies in health practice.¹³ This is mainly about investing in health care transformation and qualification, through the organization of actions and services, educative processes, health practices and pedagogical practices. This demands interactions among the stakeholders involved in health production, including service workers and users, the health system and teaching institutions, highlighting workers' education and development.¹⁴

In this context, the health professions can expand their knowledge and skills, resulting in improvements in the work process, in professionals' quality of life and in health education transformations. It is a process of becoming, marked by constant reflections and revisions in coping with daily challenges in professional practice.

Permanent Education is an essential teaching-learning practice for nursing, as it acts in the transformation of the work process, encouraging the quality of client care delivery at health services.¹³ The valuation of the work process is emphasized as a learning focus, through which gaps in knowledge and attitudes are identified, which are manifested through difficulties in the work routine.¹⁵

These difficulties may have different organizational, technical or human origins. Some demand exclusively technical-scientific actions, while others involve interpersonal relations and principles. In addition, apparently technical difficulties may reflect latent conflicts with regard to the different thoughts and professional activity forms.¹⁵

Each professional has his/her particularities and established conceptions about the work process, about his/her role in health institutions, the organizational system, and that is how (s)he fits into the team.¹² The team consists of subjects with different forms of thinking and acting, one of the causes of interpersonal conflicts in groups. Thus, Permanent Health Education offers space for reflection and discussion, allowing professionals to acknowledge differences and jointly seek actions to achieve the desired transformations.¹⁵ Besides serving as teaching-learning practice to update and transform practices, Permanent Health Education acts in team relations, transforming joint activity processes and, at the same time, implying each subject-worker involved in health practices. In this sense, it is the team that should identify existing problems in health services and organizations, discussing and articulating about possible solutions, with a view to achieving more satisfactory results at work.

Workers cannot be mere spectators in recycling and training programs in health. Instead, they should act as participants, showing shortages, questioning and proposing ideas to solve the difficulties found. Thus, Permanent Health Education appears as an instrument that is capable of enhancing interpersonal relations in nursing work, transforming the work process into a more humanized practice, furthering organized environments that are in conditions to respond to workers and care clients' needs.¹⁶

Final considerations

Permanent Education in Nursing and Health work supports the educative process through the construction and reconstruction of knowledge based on professionals' daily experiences. Through problemization, they are encouraged to reflect, act and again question health practices. Thus, professional health education needs broader competences, with a view to inculcating professionals with the need to reflect on the work process, on their individual and collective attitudes, granting them support to significantly intervene in their practices. It is only when discussion is stimulated at the base that the educative value of work itself can be acknowledged, and of workers as participatory actors responsible for the construction of changes in health practices.

More commonly, however, Permanent Education in health and nursing is linked with technical-scientific knowledge, related to values that seek to fragment actions and individual specialized work, misrepresenting care humanization to clients and workers themselves. The current context is calling for adjustments and fresh reading by professionals and work and teaching institutions, so that Permanent Health Education does not turn into a mere slogan, simply renewing the processes related to ''banking'' education'',¹⁷ which underestimates the subjective dimension.

REFERENCES

1. Brasil. Conselho Nacional de Secretários de Saúde. SUS: avanços e desafios. Conselho Nacional de Secretários de Saúde. Brasília: CONASS, 2006 [Internet] . [cited 2012 February 21] . Available from: http://www.conass.org.br/arquivos/file/susavancosedesafios.pdf        [ Links ]

2. Costa EP. Técnicas de dinâmica: facilitando o trabalho com grupos. Rio de Janeiro: WAK; 2002.         [ Links ]

3. Zabalza MA. Estruturas organizacionais das instituições universitárias. In: Zabalza MA. O ensino universitário: seu cenário e seus protagonistas. Porto Alegre: Artmed; 2004. p. 67-104.         [ Links ]

4. Osorio LC. Psicologia grupal: uma nova disciplina para o advento de uma era. Porto Alegre: Artmed; 2003.         [ Links ]

5. Davis K, Newstrom JW. Comportamento humano no trabalho: Uma abordagem psicológica. São Paulo: Pioneira Thomson Learning; 2002.         [ Links ]

6. Lane STM, Codo W, Andery AA, Neto AN, Ciampa AC, Carone I, et al. Psicologia social: o homem em movimento. 10. ed. São Paulo: Brasiliense; 2006.         [ Links ]

7. Oliveira BR, Lopes TA, Vieira CS, Collet N. O processo de trabalho da equipe de enfermagem na UTI neonatal e o cuidar humanizado. Texto Contexto Enferm. 2006; 15 (n. esp):105-13.         [ Links ]

8. Delors J. Educação: um tesouro a descobrir. Relatório para a UNESCO da Comissão Internacional sobre Educação para o Século XXI. Destaques. Brasília: MEC/UNESCO; julho de 2010 [Internet] . [cited 2012 February 20] . Available from: http://unesdoc.unesco.org/images/0010/001095/109590por.pdf        [ Links ]

9. Brasil. Ministério da Saúde. Secretaria-Executiva. Núcleo Técnico da Política Nacional de Humanização. HumanizaSUS: Política Nacional de Humanização: a humanização como eixo norteador das práticas de atenção e gestão em todas as instâncias do SUS / Ministério da Saúde, Secretaria Executiva, Núcleo Técnico da Política Nacional de Humanização. – Brasília: Ministério da Saúde; 2004.         [ Links ]

10. Ceccim RB. Educação Permanente em Saúde: desafio ambicioso e necessário. Interface - Comunic, Saúde, Educ.2005; 16(9):161-77.         [ Links ]

11. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação na Saúde. Política de educação e desenvolvimento para o SUS: caminhos para a educação permanente em saúde: pólos de educação permanente em saúde / Ministério da Saúde, Secretaria de Gestão do Trabalho e da Educação na Saúde, Departamento de Gestão da Educação na Saúde.– Brasília: Ministério da Saúde; 2004.         [ Links ]

12. Ceccim RB, Ferla AA. Educação Permanente em Saúde. In: Bahia. Secretaria da Saúde. Superintendência de Recursos Humanos da Saúde. Escola Estadual de Saúde Pública. Estágio de vivência no SUS: o cotidiano do SUS enquanto princípio educativo, coletânea de textos / Secretaria da Saúde. Superintendência de Recursos Humanos da Saúde. Escola Estadual de Saúde Pública. - Salvador: SESAB; 2009. p.70-5.         [ Links ]

13. Pease APF, Moarais MEP, Crivellaro JLG. Educação permanente em saúde. [Internet] . [cited 2010 Novembre 11] . Available from: http://www.uniandrade.edu.br/links/menu3/publicacoes/revista_enfermagem/artigo042.pdf        [ Links ]

14. Brasil. Ministério da Saúde. Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação em Saúde. Política Nacional de Educação Permanente em Saúde / Ministério da Saúde, Secretaria de Gestão do Trabalho e da Educação na Saúde, Departamento de Gestão da Educação em Saúde. – Brasília: Ministério da Saúde; 2009.         [ Links ]

15. Batista KBC, Gonçalves OSJ. Formação dos Profissionais de Saúde para o SUS: significado e cuidado. Saúde Soc. 2011; 20(4):884-99.         [ Links ]

16. Smaha IN, Carloto CM. Educação permanente: da pedagogia para a saúde. [Internet] . [Cited 2010 Novembre 16] . Available from: http://www.estudosdotrabalho.org/anais-vii-7-seminario-trabalho-ret-2010/india_nara_smaha_cassia_maria_carloto_educacao_permanente_da_pedagogia_para_a_saude.pdf        [ Links ]

17. Freire, P. Pedagogia da autonomia: saberes necessários à prática educativa. 37^a. ed. São Paulo: Paz e Terra; 2008.         [ Links ]