ORIGINAL ARTICLES
Continuing education and quality in a public hospital: a descriptive study
Roseluci Santos de Salles1, Marcos Paulo Fonseca Corvino1, Monica Villela Gouvea1
1Fluminense Federal University
ABSTRACT
Aim: to analyze educational activities developed with health professionals in the light of the concepts of quality and continuing health education (CHE).
Methods: this is a descriptive study using a qualitative approach. The survey was conducted through interviews with fifteen key informants who are representatives of different professional groups in a public hospital, located in the municipality of Rio de Janeiro. Data were collected in September and October 2013 and were analyzed according to Bardin's procedures.
Results: the institution, guided by the logic of hospital accreditation, develops normative educational activities, mostly focused on health recovery for specific areas, revealing a distancing of the educational logic advocated by CHE.
Conclusion: A greater investment in CHE in the institution is an important tool for the necessary improvement of the role of health professionals.
Descriptors: Education, Continuing; Quality of Health Care; Hospital Care.
INTRODUCTION
This paper studied the Continuing Health Education (CHE) in a public hospital that specializes in technical assistance, traumatology and orthopedics. This is an institute which has been certified by the Brazilian Consortium for Accreditation/Joint Commission International (JCI) since 2006, and which has been promoting the culture of quality among its workers.
The JCI Standards Manual for Hospitals(1) points out that the hospital accreditation was developed to create a safety and quality culture in institutions that are committed to improving patient care. The program aims at stimulating a continuous and sustained improvement in health institutions. The standards, validated through scientific studies, are arranged around functions and are widely used around the world. The evaluation process collects information on compliance with the standards throughout the institution and the accreditation decision is based on the global level of compliance observed.
In turn, the CHE proposal gained strength in the 1980s, from initiatives by the Pan American Health Organization(2), although continuing education has been under discussion in Brazil since the 1960s. The Ministry of Health (MoH), which was created in 2003 by the Secretary of Labor Management and Health Education, aimed at reordering the training and qualification of health workers, which facilitated the development of a national policy for CHE(3).
The Continuing Health Education National Policy (PNEPS) recommends multi-sectoral joint management, health care, social control and training institutions, through education based on the daily work process. The PNEPS aims to provide a teaching-learning network of professional activities in the Unified Health System (UHS) for the training and development of employees, based on the health needs of the users/population(3).
The study institution has its own CHE sector where the leading researcher of this study has been operating for 12 years, plus a Quality Advisory Team seeking to ensure compliance with the quality standards established for the accredited institution.
Given these considerations and believing in the importance of education for workers as the day-to-day problem solvers we carried out this study with the aim of studying the educational strategies developed with health professionals in a public hospital in the light of quality concepts and permanent health education.
METHOD
This is an exploratory and descriptive study using a qualitative approach. The scenario of the research is a specialized UHS hospital, located in the municipality of Rio de Janeiro that aims to promote actions such as being an institute of reference in care, teaching, research, prevention and coordination of public policies in its specific area.
Data were collected in semi-structured interviews with 15 subjects. These individuals are considered key informants because they have been institutionally affiliated for at least two years, have already been responsible for conducting managerial and educational processes in the institution, and have participated in at least 75% of the meetings promoted by the Quality Advisory Team. The Quality Advisory Team is responsible for ensuring compliance with the established standards for the accredited institution. The study was approved by the Ethics Committee in Research of the Hospital Antônio Pedro, Fluminense Federal University - FFU (Opinion 210,601 - 03/08/2013) and of the hospital studied (Opinion 232,286 - 03/27/2013) under the CAAE 10004012.3. 0000.5243. All participants in the study were consulted and signed the free and informed consent.
The research group consisted of five nurses, three pharmacists, three physicians, two physiotherapists, a nutritionist and a business administrator/systems analyst. Data collection occurred between September and October 2013. Each participant was supposed to reflect on the education strategies with which they have been involved. Interviews were recorded, transcribed and the information was systematized. The empirical data analysis process was carried out according to thematic analysis(4,5), in the light of quality concepts(1) and CHE(3).
RESULTS
The health professionals involved in the study are part of a group who know the institutional processes, although only three of them have three years of operation, while the others have been working between six and twenty seven years in the institution. All respondents participated in discussions planned by the Quality Advisory Team and three of the participants permanently integrate workgroups in this advisory group, in addition to performing their routine duties.
The interviews allowed us to understand that the vast majority of the educational activities developed in the institution have been aimed at the recovery of health in specific areas. These data show the consolidation of the clinical model of individual assistance and the fragmentation of actions. When asked to reflect on these educational activities, professionals recognize that it would be necessary to think about integrating strategies of knowledge which are capable of promoting the integration of work processes in hospital care.
However, all participants considered that appropriate educational strategies could potentiate the work process. Among these strategies, they recognized the effectiveness of group discussions and dynamics. In this regard, they cited as fundamental the investment in the training of new workers and the ongoing training related to the assessment of results and application in daily life.
Respondents also referred to the importance of promoting activities that will facilitate communication and the contribution of the various professionals, emphasizing the importance of involving managers in this discussion.
The respondents felt that the institutional search for quality leads professionals to correct bad practices, change procedures and implement actions towards continuous improvement of care. In this sense, they emphasize the importance of the accreditation process whose methodology guides actions for patient safety.
On the other hand, when asked about the main challenges for the implementation of educational strategies in the daily service, participants mainly identified workers’ resistance to interact with other professionals. It was cited also as a cultural issue, the attitude of certain professionals in hospital environments that overestimate their knowledge and practices to the detriment of the knowledge of other workers involved in the care of hospitalized patients.
The results were systematically seeking to relate the educational activities developed with health professionals in the institution in the light of the concepts of quality and CHE. Thus, in this study we have adopted the health work process as a nuclear theoretical framework(6) according to Peduzzi and Schaiber and specific concepts that are consonant with the category work that allow the composition of a relevant theoretical framework for the object of the study: quality and continuing health education.
DISCUSSION
In order to discuss educational activities in the hospital, it is necessary to continue the work process in such places. Work has been used as an important analytical and interpretive category in investigations in terms of human resources for health both in the macro-social perspective, which includes the labor market dynamics and the labor force, as the micro-social perspective that includes the everyday work processes(7).
Hospitals are complex systems involving many workers who, not only are able to provide assistance, but may also be in other areas such as administration, hygiene, maintenance and others. This work is generally run in a fragmented manner and it promotes a gap between the actions taken by professionals and leads to the compartmentalization of the person being cared for(8).
In this sense, the qualitative analysis of the educational activities developed in the study institution points out the predominance of activities aimed at the recovery of health in specific areas, revealing a gap in the comprehensive logic and in the teamwork.
Such actions reinforce the clinical model of individual assistance, with fragmentation of actions. The centered procedure/professional technicist logic prevails in this hospital practice. In this scenario, the performance of work often becomes an obligation, in which the active and responsible participation is replaced by a mechanical action(9).
The traditional hospital institutional model alienates professionals and transforms the everyday work by depriving them of satisfaction or personal or collective development. In this context, while the concept of quality, guided by the logic of accreditation, seeks to minimize or reduce risk to zero in a normative and prescriptive manner, the CHE arises as a possibility to rescue the role of health professionals.
In this context, the CHE is an important tool for transforming working conditions in a hospital, since the PNEPS was created with the prospect of expanding the autonomy of subjects and encouraging the construction of a critical and reflective consciousness. The strategy considers the problems of practice as an object of reflection and change.
Note that, although there is greater adherence to the logic of CHE in the basic health network, PNEPS orientates its application to all levels of the system, including hospitals(3). However, when there are CHE sectors in hospitals, these sectors are usually dedicated to the offer, often prescriptive, of training and courses aimed mainly at technical level workers. These trainings rarely involve higher education professionals when new equipment or new technology is acquired(10).
We may note that this concept approaches the logic of continuing education or in-service training and moves away from the precepts of PNEPS. The CHE goes further to meet the ideological proposal of UHS when it commits to supporting the changing process of the care and pedagogical model and is not limited to vocational training as a didactic-pedagogic option, but as a political-pedagogical strategy, which considers the work process as the center of a political and educational process(11).
In the context of the research, the testimony of key informants relates the question 'quality' to the level of worker qualification. In this sense, the authors point out that, with respect to changes in the work arising from the educational activities of workers, one can distinguish the transformation of practices and behaviors. The first concerns the work as social action; that is, the way users' care needs are perceived and the answers offered by workers and service; and the second refers to individual changes in the attitudes of workers(10).
Thus, one cannot expect the employees to make a mechanical and direct implementation of capabilities or training for the work situation. One must consider that the results and the impact of the educational process in the quality of services to include a number of aspects concerning, among other things, the characteristics of the work process, working conditions and organizational structure.
On the other hand, the study hospital is an accredited health institution. The accredited institution can be understood in two dimensions. The first, as an educational process that may lead health professionals to acquire the culture of quality; and the second, as a process of evaluation and certification of service quality by analyzing and certifying the level of performance achieved by the institution according to predefined standards(1).
In an accreditation program, professionals are encouraged to participate in the process of mobilization and creation of objective goals, aiming to ensure better quality of care. A 2012 study, conducted with professionals in an accredited hospital, pointed out positive and negative aspects that have direct influences the daily work of professionals.
The study showed that accreditation provides pride and satisfaction for professionals and gives a sense of responsibility for earning the title and the appreciation of the hospital. It has also revealed the issue concerning the representation of security for health professionals, and the possibility of personal growth and the appreciation of the curriculum with learning. On the other hand, the professionals said they were in a scenario of permanent pressure, stress, lack of appreciation and lack of recognition(12).
In this sense, the respondents observed that some professionals are reluctant to participate in educational actions or activities focused on quality because they already consider themselves experts in proper patient care. On the other hand, other professionals have expectations that such activities may specifically meet the difficulties experienced in the workplace or the needs of patients, which often go beyond biomedical or technical issues.
In this regard, we have observed that the challenge before us in the hospital, both for CHE and for the pursuit of quality through an accreditation program is the promotion of participation, articulation and involvement of all subjects, whether they are managers, health services trainers, workers or service users.
The study allowed us to perceive that the institution needs to invest in more horizontal relationships, in addition to the investment in quality standards that it currently performs, aiming at intensifying the relationship skills of workers, developing people and groups(13). The conflicts, difficulties and explicit actions from the reflection on this experience are essential for the production of collective knowledge.
In this context, the CHE processes require the services and sectors involved with the updating of health institution workers to adopt a problem solving and pedagogical concept. This would stimulate reflection in terms of practice and knowledge building to be developed for others. This is an educational process focused on the commitment to change through the search for the improvement of health care quality.
CONCLUSION
Adjusting work processes to the expected patterns, comprising the purposes that underlie them, developing continuous improvements in their daily practices as well as making use of institutional benefits that the accreditation process allows, means a better use of such a process as an effective tool for the evaluation and management of quality for a team.
The group of professionals from different backgrounds involved in the survey said they are part of a promising educational environment where it exceeds the logic of mere compliance with mandatory training schedules. Reflection on the educational processes experienced at work motivated a reflection on the role of workers as individuals and as subjects for transformation.
In the interviews, it was observed that there was a desire for the constructive learning proposed by the CHE. In the workers' everyday life this profile is in harmony with the development of the proposed quality culture. Despite the normative and evaluative aspect, the standards set in the accreditation process can be added and the problems discussed through the CHE concept, reinforcing the pillars to be considered in achieving the targets proposed.
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Received: 10/23/2013
Revised: 05/25/2015
Approved: 06/24/2015