Abstract

This article presents a methodology for professional training in obstetrics nursing (ON) that goes beyond teaching specific competencies and contributes to the change in the model of childbirth care as proposed by Brazilian Unified Health System. This methodology addresses gaps and challenges in the current ON model and it builds on existing initiatives for the inclusion of ON in the teamwork environment. The training-intervention-evaluation method proposes the inclusion of evaluation as part of the training, which is in line with methods for intervention research. A triangulation of strategies, techniques, and instruments is conducted articulated to analytical dimensions of obstetric and neonatal care. This methodology was implemented in multicentric ON courses coordinated by the Federal University of Minas Gerais (UFMG) between 2016 and 2018. A total of 20 ON courses across states, 1,150 professionals (students, faculty, coordinators, preceptors, and supervisors), and 400 health services (internship fields and teaching hospitals) participated in the process. In conclusion, based on the experiences of those participating in this project, the implementation of this methodology produced nurses more qualified and better prepared for practice and for adapting the model of childbirth care.

Key words
Professional Training; Health Education; Nursing; Health work

Training-intervention perspective: focus on obstetric nursing

From 2011 onwards, the Ministry of Health (MOH), through the 'Stork Network' (Rede Cegonha), expanded initiatives of strategic courses in Women's Health Policy, including those of obstetric nursing (ON), encouraging the training of professionals to contribute to the change of model of delivery and birth care¹1 Organização Pan-Americana da Saúde (OPAS). Centro Latino-Americano de Perinatologia, Saúde da Mulher e Reprodutiva. Conjunto de ferramentas para o fortalecimento da parteira nas Américas. Montevidéu: CLAP/SMR; 2014.

2 Comissão Nacional de Incorporação de Tecnologias no SUS (CONITEC). Relatório de Recomendação. Diretriz Nacional de Assistência ao Parto Normal. Brasília: MS; 2016.^-33 Costa AANM, Schirmer J. A atuação dos enfermeiros egressos do curso de especialização em obstetrícia no nordeste do Brasil - da proposta à operacionalização. Esc Anna Nery 2012; 16(2):332-339.. In partnership with the MOH, the UFMG Nursing staff (EEUFMG) has been conductinga series of courses since 2012 and, recently, has aligned pedagogical strategies in the training-intervention framework, in a commitment to expand methodologies towards the challenges pointed out by the MOH. Thus, the specialization and improvement courses that EEUFMG has been coordinating since 2016, on a multicenter basis, were structured with 20 collaborating universities, more than 400 maternity hospitals, including teaching hospitals, expanding training for nurses throughout the country.

The main objectives of the courses have been updated to: contribute to a new model of delivery and birth care, seeking to improve maternal and neonatal health indicators; strengthen the Stork Network and maternity hospitals by transforming their care models and, in these directions, to train nurses for neonatal obstetric care, focusing on teamwork and able to contribute to the services' reorganization.

By converging these objectives as intervention-training, we seek to expand the qualification for interference in the organization and management of work processes, surpassing educational approaches centered on the transmission of knowledge and detached from the knowledge of experience. This challenge is in line with one of the principles of the Unified Health System (SUS) – of teaching-service integration – being the legitimate originator of vocational training. It is worth remembering the current scenario of delivery-birth care in Brazil, with disturbing indicators of morbidity and mortality, caesarean sections, inadequate care practices⁴4 Leal MC, Gama SGN. Nascer no Brasil. Cad Saude Publica 2014; 30(Supl. 1):S5. and difficulties to insert the ON into the interprofessional practice⁵5 Amorim T, Gualda DMR. Coadjuvantes das mudanças no contexto do ensino e da prática da enfermagem obstétrica. Rev Rene 2011; 12(4):833-840.^,66 Pereira ALF, Nicácio MC. Formação e inserção profissional das egressas do curso de residência em enfermagem obstétrica. Rev Enferm UERJ 2014; 22(1):50-56..

The obstetric neonatal model is still medical-hospital-centric, through which crosses a complex web of knowledge, interests and powers influencing the institutional practices. The educational opening for this debate assumes that courses are not enough to solve the scarcity and lack of technical knowledge of professionals, but instead training to interfere with the (low) ability of analysis-intervention at work, in the horizon of multidisciplinary work, in the organization and management of processes and practices. The main purpose of training-intervention is to expand the network of subjects able to intervene in the ways of managing and caring. Therefore, it proposes interference in the work, in it and with it, articulating the production of knowledge, attention and management practices, inseparably producing health and subjects. According to its understanding, training is equivalent to intervening in work situation, which is always collective⁷7 Barros MEB, Barros RB. A potência formativa do trabalho em equipe no campo da saúde. In: Pinheiro R, Mattos RA, Barros MEB, organizadores Trabalho em equipe sob o eixo da integralidade: valores, saberes e práticas. Rio de Janeiro: IMS/UERJ, CEPESC, ABRASCO; 2007. p. 75-84.^,88 Heckert AL, Neves CAB. Modos de formar e modos de intervir: quando a formação se faz potência de produção de coletivo. In: Brasil. Ministério da Saúde (MS). Formação e intervenção. Brasília: MS; 2010. p. 13-27. (Série B. Textos Básicos de Saúde).. In the methodological path of these training processes, the evaluation assumes a strategic function in the articulation of the formation-intervention-evaluation triad⁹9 Santos Filho SB. Avaliação e Humanização em Saúde: aproximações metodológicas. Ijuí: Unijuí; 2010., and the aim of this study is to present the methodological articulation between these fields, bringing guiding axes of the evaluation practice together with training, dialoguing with the challenges of the work in delivery and birth care.

Articulating the fields of training, work and evaluation from a training-intervention perspective

In the articulation between training, work and evaluation, these references intersect in the direction of the training-intervention processes and their political-pedagogical axes⁹9 Santos Filho SB. Avaliação e Humanização em Saúde: aproximações metodológicas. Ijuí: Unijuí; 2010.^,1010 Brasil. Ministério da Saúde (MS). Formação e intervenção. Brasília: MS; 2010. (Série B. Textos Básicos de Saúde).. Thus, we take the concept of transversality¹¹11 Guattari F. Psicanálise e transversalidade. Aparecida, SP: Ideias e Letras; 2004., subsidizing the required connections between such fields of knowledge and practices. The following topics define the training and work referential and then advance on the evaluation bases, considering their strategic insertion in the follow-up of the entire training process. Therefore, the evaluation is presupposed, and unfolded, in the direction of research-intervention¹²12 Passos E, Barros RB. A cartografia como método de pesquisa-intervenção. In: Passos E, Kastrup V, Escóssia L, organizadores. Pistas do método da cartografia: pesquisa-intervenção e produção de subjetividade. Porto Alegre: Sulina; 2010. p. 17-31.^,1313 Santos Filho SB. Pesquisa em humanização: articulações metodológicas com o campo da avaliação. Saude Transform Soc 2014; 5(2):1-10. and with the input of elements of institutional analysis and related knowledge¹²12 Passos E, Barros RB. A cartografia como método de pesquisa-intervenção. In: Passos E, Kastrup V, Escóssia L, organizadores. Pistas do método da cartografia: pesquisa-intervenção e produção de subjetividade. Porto Alegre: Sulina; 2010. p. 17-31.^,1414 Lourau R. A análise institucional. Petrópolis: Vozes; 1995.

15 Deleuze G, Guattari F. Mil platôs. São Paulo: Ed 34; 1995.

16 Baremblitt GF. O inconsciente institucional. Belo Horizonte: FGC/IFG; 2011.

17 Rolnik S. Cartografia sentimental. Porto Alegre: Sulina/ UFRS; 2006.^-1818 Kastrup V. O funcionamento da atenção no trabalho do cartógrafo. In: Passos E, Kastrup V, Escóssia L. Pistas do método da cartografia: pesquisa-intervenção e produção de subjetividade. Porto Alegre: Sulina; 2010. p. 32-51., adding value to the evaluation process.

Intervention training from the perspective of transversality

Paulo Freire's perspective will always be present in the references that value education in its political dimension and conceiving the pedagogical practice associated with the transformation of reality. In the same direction, the National Humanization Policy (PNH, Política Nacional de Humanização) added a conception of intervention-formation to its theoretical-political framework, placing it in the qualification challenges of SUS¹⁰10 Brasil. Ministério da Saúde (MS). Formação e intervenção. Brasília: MS; 2010. (Série B. Textos Básicos de Saúde).^,1919 Brasil. Ministério da Saúde (MS). Humaniza SUS: documento base para gestores e trabalhadores do SUS. Brasília: MS; 2008.. This agenda opens space for the discussion about the known and harmful distance between teaching and service, adding strategies for overcoming it. In delivery and birth care, gaps are observed in the emphasis given to the technical preparation of nurses, with little regard to the framework of teamwork and to interfere in work/management processes that continue to exclude or limit their insertion into practice. It is in this scenario that the intervention-training becomes meaningful.

It focuses on training that does not turn a blind eye to the complex context of organization of work and care in the real services, which is not reduced to a technicist training, that does not neglect institutional relations or that does not separate care and management. It focuses on a training that problematizes new modes of care and work management, analyzing the traditional ways of working and managing and discussing aspects involved in the practice segmentation. The tradition of centralized and vertical models of management and training is reproduced in bad care practices. Thus, change involves movements to simultaneously alter the practices of care, management and training, seen as inseparable. Therefore, it is stated that training is not restricted to the acquisition of knowledge and skills in an abstract way, but that it develops based on reality and work experiences, requiring the expansion of theoretical and methodological frameworks for its reflection.

By assuming as inseparable the ways of caring, managing and training, the concept of transversality¹¹11 Guattari F. Psicanálise e transversalidade. Aparecida, SP: Ideias e Letras; 2004. is then evoked as a path to these connections, prompting the rupture of boundaries and segregating and fragmenting specialisms, of the concentration and verticalization of knowledge and powers, and supporting the activation of instituting forces to build bridges between areas, knowledge, practices, services and subjects/teams under the logic of transdisciplinary and multiprofessional work²⁰20 Ceccim RB. Conexões e fronteiras da interprofissionalidade: forma e formação. Interface (Botucatu) 2018; 22(Supl. 2):1739-1749.. From this conception, new designs of training projects and teaching-service integration are derived, creating conditions to increase the degree of participation and protagonism in the spaces in which they circulate (of training and work).

To operate with the transversality in the qualification of nurses for their insertion in delivery and birth care is to bring into the training scene the elements that intersect in the work field, opening discussions that go through the technical preparation, but also through the traditional relations of knowledge and powers that interfere with (non) acceptance and effective inclusion of this professional from the perspective of teamwork and, on the other hand, through the analysis of the macro forces that converge to maintain the hegemonic model of care and management.

Work and acting power of the subjects

The conception of work in the relationship between the prescribed and the real is present in several authors²¹21 Dejours C. O fator humano. Rio de Janeiro: FGV; 1997.

22 Zarifian P. Mutação dos sistemas produtivos e competências profissionais: a produção industrial de serviço. In: Salerno MS, organizador. Relação de serviço: produção e avaliação. São Paulo: Senac; 2001. p. 67-94.

23 Zarifian P. Valor, organização e competência na produção de serviço: esboço de um modelo de produção de serviço. In: Salerno MS, organizador. Relação de serviço: produção e avaliação. São Paulo: Senac; 2001. p. 95-149.

24 Schwartz Y, Durrive L. Trabalho e ergologia: conversas sobre a atividade humana. Niterói: EdUFF; 2007.^-2525 Clot Y. Trabalho e poder de agir. Belo Horizonte: Fabrefactum; 2010., having in common the understanding that work operates from antecedent norms, which define and guide what and how it should be done (scope of the prescribed), but in a permanent process of reinvention of these norms and rules, a mechanism that reflects what the subjects perform in their daily work, incorporating their experience and subjectivity in the production process. Work means the production of expertise and practical knowledge, a field of permanent training, where the subjects become competent by facing the demands and situations lived, creating strategies for that. The understanding of competency appears in the direct relationship with the practice of doing-learning²¹21 Dejours C. O fator humano. Rio de Janeiro: FGV; 1997., not in the restricted sense of values or skills of professional prescription, but as attitudes, positions, actions and learnings constituted in the confrontation of subjects with the situations they experience.

Health work is a space where these connections and meetings between the production subjects are achieved: workers among themselves and with managers and users. Thinking of this work is to affirm transversality as a communicational widening between the subjects. This conception addresses the challenge of active and inventive participation of actors, knowledge and services that are shared, facing the problems that emerge in daily work. It tells of an individual and collective learning that takes place with the lived situations, developing the competency²³23 Zarifian P. Valor, organização e competência na produção de serviço: esboço de um modelo de produção de serviço. In: Salerno MS, organizador. Relação de serviço: produção e avaliação. São Paulo: Senac; 2001. p. 95-149. with the real work processes. This is a context considered as a power producer, that is, as the degree of transversality increases, the power of action of workers' collectives increases¹⁵15 Deleuze G, Guattari F. Mil platôs. São Paulo: Ed 34; 1995.^,2525 Clot Y. Trabalho e poder de agir. Belo Horizonte: Fabrefactum; 2010..

To highlight this meaning of work in nursing education is to bring to the training scene the analysis of ways of working. The work that is performed in taking care of the other (woman-child) and in the relationship with peers/colleagues (scope of work processes, management and permanent learning) is not guided solely by technoscientific rationality, prescriptions and protocols, nor obedience restricted to rules and norms. It is an activity involving all of this but taking place in an act of (re)creation and individuality, where each subject is based on their knowledge, their history, their culture and their values. It is through this understanding that one opens up the perspective of analyzing habits, choices, adherence to different types of practices, resistances, explicit and implicit boycotts and the displacements that subjects make by modifying their own subjectivities based on the new meanings that are being built about delivery and birth. It is worth noting that, like health work in general, obstetric and neonatal practice happens amid the so-called modernizations in the productive system, growing in technological incorporation, pharmacomedicalization and standardization, straining the care relationship, with the loss of the autonomy of users and the professionals in their activity²⁶26 Gomes RM. Humanização e desumanização no trabalho em saúde. Rio de Janeiro: Fiocruz; 2017..

On the other hand, in the tradition of the technical and social division of labor, there remains a marked asymmetry of knowledge/powers between the professional categories, between these and their managers, and between all these and the users. To overcome it, therefore, technical qualification and individualized action are not enough; it is necessary to affirm autonomies in interdependence²⁷27 Peduzzi M. Equipe multiprofissional de saúde: conceito e tipologia. Rev Saude Publica 2001; 35(1):103-109. or in a balance between individual and collective autonomy²¹21 Dejours C. O fator humano. Rio de Janeiro: FGV; 1997., hence increasingly demanding a training that opens up to teamwork, to be co-responsible when facing these trends. A new model of care demands from educational practices the ethical and political commitment to bring about changes in the world of work and in the training itself, based on real needs.

Evaluation and transversality

The evaluation will be explored in the following topics, understanding its strategic role in the operationalization of the training-intervention, bringing the work to the center of the analysis. An insertion is said to be as the nexus of the pedagogical practice (its constituent), instead of the usual position of 'annex; with nexus in the sense of articulating the elements of the training process/practice⁹9 Santos Filho SB. Avaliação e Humanização em Saúde: aproximações metodológicas. Ijuí: Unijuí; 2010.. Operated as an evaluation follow-up, it is instituted by assigning value to the training, inclusive and emancipatory character of evaluation, arising from the participatory and constructivist approaches²⁸28 Guba EG, Lincoln YS. Avaliação de quarta geração. Campinas: Editora da Unicamp; 2011.. The emphasis is on the way of doing it, with contributions that expand the evaluation action, enhancing techniques, strategies and participation of the subjects. Regarding the 'way of doing' it is established as a path that promotes inclusion, valuing the points of view of multiple subjects, associating inclusion with a differentiated quality of participation, as a co-author of the entire evaluation process²⁹29 Santos Filho SB, Souza TP, Gonçalves L. Avaliação como dispositivo de humanização em saúde: considerações metodológicas. In: Onocko Campos R, Furtado JP. Desafios da avaliação de programas e serviços em saúde: novas tendências e questões emergentes. Campinas: Ed. Unicamp; 2011. p. 257-278..

Regarding the courses in question, those involved have different types of insertions in the world of work, talking about the place of workers-students, teachers, tutors, service professionals, managers, etc. It is from these places that they are summoned to the co-authorship in the evaluation processes, building the analytical directions of movements and transformations envisaged in the training journey. These are directions to overcome the tradition of evaluation practices that are supposedly neutral, external (attached), with focuses of interest (im)posed by an external actor-researcher and not committed with the desired transformations in the process. It is an inclusion movement in which all subjects are referred to the condition of investigators-researchers. And it has a (trans)formation character through its interferences in the process itself, course corrections and alterations in the subjectivities of those involved. Returning to the conception of work in the relationship between the prescribed and the real, the evaluation is present in this between, that is, appearing between the norm and the renormatization³⁰30 Schwartz Y. Manifesto por um ergoengajamento. In: Bendassolli PF, Soboll LA. Clínicas do trabalho: novas perspectivas para a compreensão do trabalho na atualidade. São Paulo: Atlas; 2011. p. 132-166.; the assessment as nexus.

Methodology

Articulated components in the methodological path

This methodological proposal was developed having as field the multicentric specialization courses in obstetric nursing coordinated by UFMG between 2016 and 2018, covering: 20 decentralized courses in the states, 1,150 professionals (students, teachers, coordinators, tutors, preceptors, monitors), 400 health services (internship fields and hospitals where the students work).

The following items highlight the articulated foci on the methodological path, through strategies, techniques and evaluation instruments, with concepts that support the path in the molds of research-intervention. Once the foci are demarcated, it follows with the dimensions of analysis that accompany the experiments.

Evaluation monitoring as a co-responsible function

Operated as a strategy and structuring logic of the courses, the evaluation is not the responsibility of a person/expert, but of all the subjects involved and as a guiding thread in the projects. It is developed to be performed cross-sectionally. There are supporters from the planning and evaluation field, as a theoretical and methodological reference, but this very support has the function of offering a new way of performing an evaluation. The articulation of support and training does not refer to an external specialized evaluation look, in parallel, but to an inclusion (in the team and in the strategy of conducting the courses) of a shared look and producer of knowledge together with the group itself. Support that endorses the collective analysis of the work and helps the courses to be configured as a training process for the whole team and promoting co-authorship in the evaluation process. One of the pedagogical senses is to create a co-responsible evaluation culture, surpassing the tradition of punitive, supervisory and exclusionary practices.

In the courses, due to the wide territorial coverage and autonomy of the collaborating institutions, emphasis was given to agreements in initial workshops of alignment with the coordinations, followed by local agendas included during the course.

Evaluation follow-up to interconnect planning, development and monitoring and articulate process-effects

In the transversality of evaluation monitoring, Planning, Monitoring and Evaluation (PMA, Planejamento, Monitoramento e Avaliação) are proposed as inseparable, integrated to the structuring of plans (of course activities, action in services, etc.), analysis and support to the plan implementation. The integrative function of the evaluation allows stitching the elements distributed in the planning and development of the activities (pedagogical work). It has a directed focus on what and how the training process is delineated, followed byin what/how it is apprehended or created, shared, attained, in terms of movements and effects of subjectivation¹⁶16 Baremblitt GF. O inconsciente institucional. Belo Horizonte: FGC/IFG; 2011., that is, in the sphere of things that are produced, practices, etc. and in the emancipation and autonomy of the subjects in training. The integration of PMA is also a way to involve the professional in learning from the inseparable action of planning-implementing-evaluating, placing them as a permanent scholar-apprentice of the work, which increases the power to interfere with it. Strategic instruments (diagnostic-evaluation and planning) help in the management of this protagonist function or in an ergo-engagement, as Schwartz understands³⁰30 Schwartz Y. Manifesto por um ergoengajamento. In: Bendassolli PF, Soboll LA. Clínicas do trabalho: novas perspectivas para a compreensão do trabalho na atualidade. São Paulo: Atlas; 2011. p. 132-166..

The design of the courses shows the cross-sectional mode of articulation of the PMA, in a gear of collectives (of centrally conducting teams and decentralized schools/states/services) in interaction flows (project formulations, actions, strategies, plans and their adjustments), working with mutual interventions and all spaces and processes understood as evaluation-training spaces. It is worth mentioning the challenge of the willingness of the educational institutions and teachers to train simultaneously in several learning areas.

Evaluation follow-up between the norm and renormatization

The evaluation follow-up has as one of its starting points the norms for the training processes, understanding as norms (prescribed) the goals-principles of the development of courses. But the evaluation perspective can be used for adjustments, so it is not a simple ex-post verification, of compliance, but a shift of focus to the problematizing/continuous adjustment of the experience. It is restated that the emphasis is on how to do, including the evaluation exercise, referring to co-managed, participatory and co-responsible ways of discussing and conducting processes (in health/education and evaluation). The evaluation activity moves to a special place, being between the norm and the necessary renormatizations, at the function of the adjustment to real.

Evaluation follow-up as an analysis-intervention practice

In the first place, the notion of intervention is evoked, which highlights an essential assumption of evaluation, which is its commitment to the transformation of realities. At the institutional analysis¹⁴14 Lourau R. A análise institucional. Petrópolis: Vozes; 1995., the intervention is always associated with actions and devices that promote changes in the instituted processes, that is, effective to produce subjectivations associated with changes. An evaluation practice is only justified by the willingness to make changes. This alignment paves the way for several useful approaches to the evaluation field in the courses and directs the continued operational foci as follows.

Collective analysis of the work

According to Clot²⁵25 Clot Y. Trabalho e poder de agir. Belo Horizonte: Fabrefactum; 2010., the analysis is performed to increase the action power of the collectives over the work environment and over themselves, with the purpose of understanding in order to transform. In this sense, the evaluation process goes through the collective analysis of work, highlighted here in the function of unveiling the relationships that the subjects establish with work, which mobilize their desires and interests and focus on the construction of autonomy and co-responsibility with innovations and reality transformation. By engaging in the coproduction of the analyses, with the unveiling of their realities, one advances in the engagement of (new) subjects, elements and resources to broaden interpretations, and the facing of situations.

By provoking these analyses in obstetric neonatal work, it is possible to bring to light the multiple subjects of interest and multiple values that permeate it. One discloses not only gaps in the qualification (and needs) for the practice, but, in an inseparable way, the factors of work organization, which explain the known difficulties of inclusion of nurses and their role in teamwork.

Indicators as job analyzers

The institutional analyzers¹⁴14 Lourau R. A análise institucional. Petrópolis: Vozes; 1995. are proposed to overcome or dialogue with the classic concept of indicators, which are not always capable of reflecting complex realities, sometimes decontextualized from them. These are elements that reveal the institutional singularities, show what is hidden, the powers and forces present in the apparently neutral modes of organization and work relations. The evaluation produced with and by the analyzers produces destabilization and changes in the current order and in the evaluation process itself. In this sense, in its way of doing, the evaluation encourages the subjects to qualify/train, raise, build, invent and agree with situations, goals and analyzer-indicators that guide the work renewal²⁹29 Santos Filho SB, Souza TP, Gonçalves L. Avaliação como dispositivo de humanização em saúde: considerações metodológicas. In: Onocko Campos R, Furtado JP. Desafios da avaliação de programas e serviços em saúde: novas tendências e questões emergentes. Campinas: Ed. Unicamp; 2011. p. 257-278.^,3131 Santos Filho SB. Perspectivas da Avaliação na Política Nacional de Humanização: aspectos conceituais e metodológicos. Cien Saude Colet 2007; 12(4):999-1010..

In the courses in question, the workshops of collective analysis are effective moments to produce work organization analyzers. The frequent reports of being out of care or underused, or disqualified by others, provide an opportunity to analyze the factors involved in this condition of marginality, giving rise to the elements present in the established logic of work and acceptance of this condition/submission, even if one has the training, technical preparation and legitimacy for professional practice. These are elements related to the work and subjectivations in its context, dimensions encompassed in an evaluation committed to change. It is this movement that subsidizes displacement and increases the power to act. Therefore, one can see the nurses throughout the courses, growing in their ability to better analyze their position in the workspaces, an essential step for repositioning themselves and their situations.

Evaluation follow-up and process-effect cartography

By emphasizing one way of doing, one is mainly saying about what kind of movement was established along the way. The cartographic character of the evaluation follow-up is emphasized. For Rolnik¹⁷17 Rolnik S. Cartografia sentimental. Porto Alegre: Sulina/ UFRS; 2006., the cartography is a drawing that accompanies and is performed at the same time as the landscape transformation movements occur. During the movement of the courses, these cartographic directions are very important, aligned to the idea of evaluation as a nexus, that is, stitching the elements of the training process and producing action-knowledge of how the process is instituted and its consequences. More than that, knowing-constructing the object itself. About this object courses, for instance, it can be stated that it would not be possible to know-building them by traditional evaluations, but only by means of evaluation follow-up, walking with them, helping them to be constituted, whereas they help the evaluation performance.

The courses generate an incessant production of movements, in an effectively rhizomatic logic¹⁷17 Rolnik S. Cartografia sentimental. Porto Alegre: Sulina/ UFRS; 2006., in flows that cross multiple territories (health services and schools, but also the councils and entities of class, social and gender organizations, church, family, friends, community, public ministry, etc.). They are an expanded production of networks, impossible to be known if not for the cartographic opening. These flows are made visible through the singular experiences, in act, in the different spaces and through the production of narratives that disseminate as forms of communication in a network. Diverse movements that go beyond the classroom are covered. They encompass multiple situations in which nurses start to perform a procedure (taking care of childbirth, as the protagonist at a pregnant woman's admission/hospitalization, deciding on the indication of a particular practice, being in certain previously prohibited spaces, etc.), as situations that required facing the established order in one place, thus reflecting displacements of the subjects in training in the work contexts. They include being the protagonist in the search for class entities to potentiate intervention in a service or the public ministry to help in a given situation. Such movements are understood as the effects-process or products-process of the courses, and the most useful function of evaluation follow-up is to help bring about such action-process-effects.

Evaluation instruments as training devices

In these training proposals, two instruments play a special role in converging their development and assessment: situational diagnosis and intervention plans. They are the main strategy for bringing work to the center of the scene. They are strategic in many ways, as triggers of an evaluation look at their own work and as a means for workers-students to engage all involved (teachers, tutors, service teams) to discuss the work. They are special devices because they prevent you from learning abstract or decontextualized contents. They trigger collective analysis and place workers as researchers of their own craft. And also, they function as strategic devices not by describing reality, but because they are instituted by awakening the view to realities that can be (trans) formed. They allow the worker-student to experience (and bring out) their affectations from/with those scenarios. They make a cartographer-evaluator exercise the evaluation attention that is not focused on the simple collection and selection of information in reality, but fluctuating and open attention to the elements of surprise in the process and the signs “that indicate that something happens”²⁵25 Clot Y. Trabalho e poder de agir. Belo Horizonte: Fabrefactum; 2010..

Also noteworthy is another important mediator tool of the experience: the field diaries. Empowered as a device³¹31 Santos Filho SB. Perspectivas da Avaliação na Política Nacional de Humanização: aspectos conceituais e metodológicos. Cien Saude Colet 2007; 12(4):999-1010., it allows to restore, in language, the lived experience, as a production of knowledge about the process, at the same time being a guide of adjustments in its path. This is not just an informative record of actions, observation data, etc. It is the record of what was lived, not limited to valuing only the final results.

Analytical Dimensions in Evaluation Tracking

When problematizing work and its purpose as a production of service, Zarifian²²22 Zarifian P. Mutação dos sistemas produtivos e competências profissionais: a produção industrial de serviço. In: Salerno MS, organizador. Relação de serviço: produção e avaliação. São Paulo: Senac; 2001. p. 67-94.^,2323 Zarifian P. Valor, organização e competência na produção de serviço: esboço de um modelo de produção de serviço. In: Salerno MS, organizador. Relação de serviço: produção e avaliação. São Paulo: Senac; 2001. p. 95-149. postulates as a necessary the interaction of resources and people, learning from their own doing and generating results considered valid and useful by people (users and professionals). Here we highlight the essential challenge of the service courses, the strengthening of protagonism and autonomy to contribute to changes in the work/care model. In this sense, the evaluation in the courses and their usefulness as a service production involves the crossing of several elements in the dimensions articulated in Chart 1. The transversalization of the dimensions broadens the investigative perspective, associated with learning that interconnects organizational spheres (of the course and health services) and the subjectivities of workers. This is not about thinking of competencies/skills (of workers) and organizational process changes in an idealized and abstract plane, but, as already mentioned, evaluation placed between the norms and renormatizations, focusing on what one learns-implements with lived situations; what emerges as initiatives and assumption of (co)responsibility in the situated activity – what the collectives of workers learn and put into operation to be able to work and care.

Several situations may illustrate this production of service in delivery and birth care training. The training-care that takes place within the services and in the team-user relationship is expressed in the courses ability to produce interference in the work processes, in the adoption of good practices, in new modes of teaching-service integration, in the construction of networks and modes of interactions and bonds that go beyond assistance in a narrow sense, making a difference in the lives of the subjects involved, users (pregnant women) and workers, in such a unique moment of the meeting of these subjects. In this context, we highlight the necessary expansion of the evaluation look in different areas of processes and effects and overcoming the focus centered on productivity, worker-student performance and other restricted indicators of efficiency, efficacy and effectiveness. It is about expanding indicators-analyzers tuned to autonomy gain, protagonism and new ways of managing and caring.

The broadened horizon of usefulness (of work and evaluation) is then channeled into three dimensions in a cross-sectional-transdimensional approach, in Chart 1: through dimension I, we focus on the foundations of the training process, placing it under analysis for adjustments and validations of its pedagogical planning/action axes; through dimension, II we analyze its scope in the training of workers/students, understood as subjects in the context of the work process and training; and through dimension III, the repercussion in the organization of services and care to users. They open up to explore the capacity of the course, as an intervention, to generate effects in different and inseparable senses: changes in processes, health practices, subjects and relationships. In this line, the evaluation follow-up occurs by creating spaces for analysis, taking as inseparable the production plans of the services and the subjects. It is a movement that, as mentioned before, enables the subject, object and strategies to be created at the same time.

Conclusion: network-producing practices

The objectives of training-intervention converge to expand networks in different directions: networks of subjects with greater capacity to intervene in ways of managing and caring, by articulating teamwork and inter-teams, interconnect activities, products, knowledge, actions, services, these and the schools (in new modes of teaching-service integration) and also connection with the surrounding entities.

It is allows the ONs to recognize themselves as strategic actors for the change of the model still being used, inducing the system and its actors, in the joint construction of public policies (health and training), to agree in the effective integrated action. And, through new team interactions, with pregnant women, families and society, making it possible to advance in a multidisciplinary training committed to resignification and renewal of the meanings of giving birth and living, valuing the scientific evidence, but contributing to the de-medicalization of care.

The evaluation follow-up and methods integrating the training allow us to follow-investigate the reality, weaving and unveiling the networks that constitute it and enhancing its rhizomatic perspective. Therefore, these are methods/practices that generate networks, emphasizing the understanding of the network as physical, technical, political and affective arrangements, or care arrangements in a broad sense, underlining lines of strength to sustain grupalities, movements of affectations and of co-responsibility.

It is worth reinforcing the close interlocution of this methodological proposal with theoretical and political fields of special importance in the discussion of health in Brazil. In this sense, the field of permanent education is articulated in the horizons in which Brazilian authors approach it in the SUS²⁰20 Ceccim RB. Conexões e fronteiras da interprofissionalidade: forma e formação. Interface (Botucatu) 2018; 22(Supl. 2):1739-1749.^,2727 Peduzzi M. Equipe multiprofissional de saúde: conceito e tipologia. Rev Saude Publica 2001; 35(1):103-109.; it connects with the field of humanization in the ethical-aesthetic-political sense brought in its conceptual framework and its experiments in SUS⁹9 Santos Filho SB. Avaliação e Humanização em Saúde: aproximações metodológicas. Ijuí: Unijuí; 2010.^,1010 Brasil. Ministério da Saúde (MS). Formação e intervenção. Brasília: MS; 2010. (Série B. Textos Básicos de Saúde).^,1313 Santos Filho SB. Pesquisa em humanização: articulações metodológicas com o campo da avaliação. Saude Transform Soc 2014; 5(2):1-10.^,1919 Brasil. Ministério da Saúde (MS). Humaniza SUS: documento base para gestores e trabalhadores do SUS. Brasília: MS; 2008.^,3232 Benevides R, Passos E. A humanização como dimensão pública das políticas de saúde. Cien Saude Colet 2005; 10(3):315-325.; it aligns with the concept of health co-management as a method to articulate and form work teams³³33 Campos GWS, Cunha GT, Figueiredo MD. Práxis e formação Paideia: apoio e cogestão em saúde. São Paulo: Hucitec; 2013.; and it is part of constructivist evaluation lineages²⁸28 Guba EG, Lincoln YS. Avaliação de quarta geração. Campinas: Editora da Unicamp; 2011. that inspire researchers and workers in different experiences in SUS. Also, in the more specific field of delivery/birth care and the scope of obstetric nursing, the proposal brings the potential to respond to the methodological challenges (old and recurrent) that are imposed on the training processes committed to the transformation of the current care model³3 Costa AANM, Schirmer J. A atuação dos enfermeiros egressos do curso de especialização em obstetrícia no nordeste do Brasil - da proposta à operacionalização. Esc Anna Nery 2012; 16(2):332-339.^,55 Amorim T, Gualda DMR. Coadjuvantes das mudanças no contexto do ensino e da prática da enfermagem obstétrica. Rev Rene 2011; 12(4):833-840.^,66 Pereira ALF, Nicácio MC. Formação e inserção profissional das egressas do curso de residência em enfermagem obstétrica. Rev Enferm UERJ 2014; 22(1):50-56.^,3434 Gama SG, Viellas EF, Torres JA, Bastos MH, Brüggemann OM, Theme Filha MM, Schilithz AO, Leal MD. Labor and birth care by nurse with midwifery skills in Brazil. Reprod Health 2016; 13(Supl. 3):123..

In this sense, the training and evaluation processes are made in connection with the production of networks, and such production is mainly performed by listening to different points of view along the way, becoming a spiral of negotiation between subjects. Therefore, this is a process of instituting contractualization in the organization, destabilizing instituted objects, recognizing and redistributing functions, knowledge and powers, and the collectives taking the co-authorship of the evaluation process²⁹29 Santos Filho SB, Souza TP, Gonçalves L. Avaliação como dispositivo de humanização em saúde: considerações metodológicas. In: Onocko Campos R, Furtado JP. Desafios da avaliação de programas e serviços em saúde: novas tendências e questões emergentes. Campinas: Ed. Unicamp; 2011. p. 257-278..

An important direction of the evaluation follow-up is its alignment with the premise that every pedagogical experience brings with it an investigative perspective of permanent inquiry. As Paulo Freire says³⁵35 Freire P. Pedagogia da autonomia: saberes necessários à prática educativa. São Paulo: Paz e Terra; 1996., the acts of training and research are inseparable. In these senses, the perspective of not separating training and evaluation-research-intervention on the pedagogical practice itself is reinforced. The usefulness of this mode of evaluation lies not only in learning and process adjustments, but also because it subsidizes or coincides with the production of both training and evaluation methodology. These courses/experiences are proposed as training practices and (ergo)engaged evaluation research, with the expectation of appropriation of processes and effects by the collectives, converging on the co-production of knowledge-action.

As interinstitutional projects and in the commitment of transformations in reality, the courses in the perspective of ON training-intervention should be subjected to evaluations capable of indicating their potential and contributing both to their implementation and to the production/legitimation of knowledge about the pedagogical action and evaluation. Evidently this practice brings challenges, in a careful exercise, requiring implications analysis¹⁴14 Lourau R. A análise institucional. Petrópolis: Vozes; 1995. and multiplying evaluation-formative-participatory spaces to put in the analysis the evaluation itself, recognizing its limitations. For the enhancement of these experiences, other evaluation perspectives must be opened, recalling the unquestionable relevance of the plurality of approaches.

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