Abstract

Introduction

Care-centered health services have challenged educators, managers and workers in demands related to the need for professional training and qualification, aiming to facilitate multiprofessional teamwork in Primary Health Care (PHC), involving several categories, such as pharmacists.

The National Policy for Continuing Education in Health (PNEPS) has among its guidelines the professional development, in order to guarantee the offer of comprehensive care to the population and the strengthening of the Brazilian National Health System (SUS), covering from technical training to post-graduate studies, enabling the teaching-service integration to adapt the educational processes to the world of work¹1 Torres KRBO, Luiza VL, Campos MR. A educação a distância no contexto da Política Nacional de Saúde da Pessoa Idosa: estudo de egressos. Trab Educ Saude. 2018; 16(1):337-60. .

Pharmaceutical Care (PC), especially pharmaceutical services (SEFAR) – focused on providing services in the pharmaceutical field to ensure comprehensive, integrated and continuous care of the health needs and problems of the population – plays a relevant role in the solvability of health actions²2 Araújo PS, Costa EA, Guerra AA Jr, Acurcio FA, Guibu IA, Álvares J, et al. Pharmaceutical care in Brazil’s primary health care. Rev Saude Publica. 2017; 51 Suppl 2:6s.,³3 Araújo SQ, Costa KS, Luiza VL, Lavras C, Santana EA, Tavares NUL. Organização dos serviços farmacêuticos no Sistema Único de Saúde em regiões de saúde. Cienc Saude Colet. 2017; 22(4):1181-91..

In 2009, PHC was expanded in the municipality of Rio de Janeiro (MRJ) by increasing the coverage of the Family Health Strategy (FHS)⁴4 Howe A, Anderson MIP, Ribeiro JM, Pinto LF. Reforma da Atenção Primária à Saúde no Rio de Janeiro: comemorando os 450 anos de fundação da cidade. Cienc Saude Colet. 2016; 21(5):1324-6.. One of the challenges was the training of a large number of professionals in a short period of time, with minimal damage to the supply of services.

In the case of SEFAR, this PHC model required the expansion of the human resources (HR), as well as professionals prepared for the proposed activities⁵5 Silva RM, Pereira NC, Mendes LVP, Luiza VL. Assistência farmacêutica no município do Rio de Janeiro, Brasil: evolução em aspectos selecionados de 2008 a 2014. Cienc Saude Colet. 2016; 21(5):1421-32.. The refresher course on Pharmaceutical Services in Primary Health Care (SFAPS) was offered to qualify pharmacists to work in the Municipal Health Secretariat of Rio de Janeiro (SMS-RJ).

Knowing the perspective of these graduates on their training, seeking to understand how the knowledge produced was used in practice, can allow effective contributions both to the service and to the process of professional training and continuing education, by identifying and filling knowledge gaps based on the reality of work, by adopting knowledge translation mechanisms.

It is believed that studies evaluating professional education from the perspective of graduates and other stakeholders are strategies for obtaining information on the quality and adequacy of student education in relation to the needs of health work, particularly in PHC.

This article aims to analyze the contributions of the SFAPS course, especially regarding its strengths and weaknesses for the professional practices and work management of its graduates and other key actors.

Methodology

A descriptive study with a qualitative approach was developed. Self-reported electronic questionnaires were applied by the course graduates, as well as a focus group meeting (FG) with other key actors.

The PHC expansion project in MRJ involved the hiring of Social Organizations, which, among other aspects, managed the hiring of professionals under the Consolidation of Labor Laws regime, which allowed rapid expansion of HR, with challenges to the qualification of professionals.

Between 2011 and 2019, the SFAPS Course, in face-to-face format, had 13 classes and trained 328 students, with a workload between 72-88 hours; the target audience being PHC pharmacists from SMS-RJ. It was held in partnership between the Sérgio Arouca National School of Public Health (ENSP, as per its Portuguese acronym) and SMS-RJ. The curricular structure⁶6 Silva RM, Luiza VL, Souza CPFA. Manual do Facilitador - Curso de Atualização em Serviços Farmacêuticos na Atenção Primária em Saúde. Rio de Janeiro: Escola Nacional de Saúde Pública Sérgio Arouca; 2019. of the last offer of this course is shown in Chart 1. Prior to the offer of the first class, there was an improvement course (184 hours) aimed at the training of teachers/facilitators and the production of standardized didactic material⁷7 Dóczy AP. Curso Serviços Farmacêuticos na Atenção Primária em Saúde no Município do Rio de Janeiro: um estudo da formação profissional [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2020..

The questionnaire applied to graduates was composed of blocks: (1) general aspects of the course, (2) contributions, (3) strengths and (4) weaknesses/challenges. The profile and professional performance of the graduate were explored in the initial block, as well as a final block for comments and suggestions, not explored in this article.

The questionnaire was made available on the Google platform between 12/11/2020 and 01/29/2021. The invitation was sent to the e-mail addresses of graduates and also through the WhatsApp application in networks made up of potential respondents.

Most of the questions were presented in the form of statements for the participant to indicate his/her degree of agreement through a numerical scale organized with values from 0 to 5, in addition to the option “I do not know how to give an opinion”, where the number 5 indicated a higher degree of agreement. The block on the strengths and weaknesses/challenges of the course involved open-ended questions, which had to be completed.

The FG was conducted remotely with three former teachers (participation in more than one offer) and three former course coordinators, coded as FG1, FG2, FG3, FG4, FG5 and FG6. The dynamics of the FG were guided by triggering questions: (a) course structure/organization and contribution to the general education of students; (b) contribution of the course to the professional practice of PHC pharmacists; (c) strengths and weaknesses of the course in relation to the needs of students and PHC.

The FG meeting was recorded and later transcribed. This material, as well as the answers to the open questions of the questionnaire, was examined according to the criteria of thematic content analysis⁸8 Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2011. ,⁹9 Minayo MCS, Deslandes SF, Gomes R. Pesquisa social: teoria, método e criatividade. 22a ed. Petrópolis: Vozes; 2003., using the steps (a) pre-analysis, (b) content exploration and (c) treatment of results, inference and interpretation.

Data from the questionnaire were stored and processed in an Excel® spreadsheet, analyzed by simple frequencies and percentages. The results of the application of the Likert scale were aggregated into zero degree of agreement; from 1 to 3; and 4 and 5. The analysis was divided into four equal parts of 25%, where the agreement located in the fourth quartile (75% and more) was particularly valued.

Strengths, weaknesses and the contribution of the course to professional practice were categorized based on the content of the answers to the open questions of the questionnaire and the speeches of the key actors of FG. The perspectives were analyzed in a comparative way, allowing their integration.

The study was approved by the Research Ethics Committee of ENSP (opinion nº 4.277.912).

Results

Participation was obtained from 109 graduates (33.2% of the total). Most (74.3%) were female and 86.2% had post-graduate studies (specialization, master and doctorate degrees). More than half were still working in PHC of SMS-RJ (56.0%), with CLT (Consolidated Labor Laws) links (56.9%) and with exclusive activities in PHC (49.5%) (table 1).

Concerning the ‘general aspects of the course’, the degrees of agreement 4 and 5 in the last quartile were the most prominent, with emphasis on ‘clarity of theoretical content’, ‘topics covered allowed reflections for professional practice’, ‘exercises and case studies contributed to learning’, ‘new knowledge that improved understanding of PHC’, ‘welcoming relationship with tutors’ and ‘personal growth’. In contrast, the contributions ‘putting into practice an intervention project presented as the final work of the course’ and ‘expanding job opportunities’ showed a higher proportion of results in the second quartile, with respect to degrees of agreement 1 to 3 (table 2).

In FG, there was mention of the expectation and commitment assumed by the course with the ability to offer training aligned with the new paradigm of PC, that of working in PHC according to its logical and conceptual structure.

Another point involved the methodology of the course, which was based on the use of pedagogical strategies of problem-based teaching, through the discussion of cases, the execution of practical exercises in groups and the production of discussions with emphasis on themes derived from the experience of students.

Regarding the contributions to technical and care activities (table 3), it was observed that the degrees of agreement 4 and 5 were mostly in the third quartile range (between 50-75% of respondents) and only two statements reached the fourth quartile: ‘performing qualified dispensing of medicines [...] involving user welcoming [...]’ and ‘performing therapeutic guidance [...]’. The lowest proportion of degrees of agreement 4 and 5 was found for the statement on ‘conducting home visits’, with 52.3%.

It is worth underlining that some key actors referred to the low insertion of pharmacists in the execution of clinical-care activities, since many actions would still focus on aspects of the logistical and managerial component of SEFAR, although the course contributed to a care performance.

The expansion of the humanistic view for professional practice in the valorization of pharmaceutical care based on continuous and comprehensive, safe and responsible care to users of health services was present.

Regarding technical-managerial activities (table 3), most of the statements (9 out of 10) did not reach percentages higher than 75% in the degrees of agreement 4 and 5, except for the contribution of the course to ‘medicine stock management’. The two ranges of degrees of agreement 0 and 1 to 3, when added together, reach almost 50%, indicating that the course, from the perspective of graduates, did not bring comprehensive contributions to the ‘management of health services waste’.

Regarding the contribution of the course to the work in PHC and to SUS, it was observed that the percentages of degrees of agreement 4 and 5 were in the last quartile for almost all statements, except for ‘recognition of the social determinants of health’ and ‘development of communication and information strategies in PHC services’ (table 3). Despite this, the graduates of the course explained the importance of this topic, considered structural for public health and PHC:

Both the answers of the graduates and the key actors highlighted the role of the pharmacist as a member of the health team in PHC for the qualified provision of SEFAR:

Among the eight thematic categories related to the strengths of the SFAPS course identified in the open response field, the ‘expansion of knowledge’; the ‘pedagogical aspects of the course (teaching methodology, curriculum, evaluation)’ and the ‘improved professional performance and/or conduct’ together accounted for more than 50% (frame 2).

Some of the categories of strengths were reported in the speeches of the key actors, linked to ‘improved professional performance and/or conduct’, ‘pedagogical aspects’, and ‘qualified teaching staff’, respectively:

Regarding the weaknesses of the course pointed out by the graduates (Chart 2), manifestations about ‘course hourly workload’ were higher than 50%. In addition, FG highlighted the existence of weaknesses that were related to those mentioned by the graduates, such as ‘workload’; ‘low valorization, dismantling of PHC and dismissals’ and ‘little space for periodic updating or continuing education’, respectively:

Discussion

This study revealed aspects of the contribution, strengths and weaknesses from the perspective of a portion of graduates and key actors of the SFAPS course. Both emphasized that updating professional practice is indispensable to account for the numerous (and constant) changes in the routine and in the daily work process, since the density and complexity of the health field involve compartmentalization of very specific knowledge for integrated action in multiprofessional teams.

The SFAPS course was conceived and operationalized as a strategy for training pharmacists in line with the classic attributes of PHC, including the recognition of social determinants in the health-disease process, the subjectivity of the individuals and the resolution centered on work in multiprofessional teams of PHC units⁷7 Dóczy AP. Curso Serviços Farmacêuticos na Atenção Primária em Saúde no Município do Rio de Janeiro: um estudo da formação profissional [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2020.. Nevertheless, it also presented the PC field as a transversal area that runs through many moments of the health care process, involving a range of actions where medicine converges from a set of efforts and procedures in the integration of health professionals.

Most respondents were still working in SMS-RJ, revealing an interest in the continuity in public services, as well as the resilience of these professionals, given the problems in PHC between 2017 and 2020, such as delays in salary payments¹⁰10 Melo EA, Mendonça MHM, Teixeira M, Melo EA. The economic crisis and primary health care in the SUS of Rio de Janeiro, Brazil. Cienc Saude Colet. 2019; 24(12):4593-8.. In addition, there is a high level of education, which, even with the expressive share of lato sensu post-graduates, the stricto sensu training of the master degree stands out and demonstrates the potential for the development of teaching and research actions in the services.

More general contributions derived from the SFAPS course allowed the identification of training effects on the professional trajectory of former students. The acquisition of knowledge and its impact on professional life, when based on the understanding of an educational program based on the reality of the students, reverts into important contributions to the development of the teaching-work-community articulation¹¹11 Engstrom EM, Hortale VA, Moreira COF. Trajetória profissional de egressos de Curso de Mestrado Profissional em Atenção Primária à Saúde no Município de Rio de Janeiro, Brasil: estudo avaliativo. Cienc Saude Colet. 2020; 25(4):1269-80.,¹²12 Santos RS, Carmo LA, Jorge JTB, Faria L, Chavez Alvarez RE, Guimarães JMM. Equipes de aprendizagem ativa na educação em saúde: ensino-serviço-comunidade na prevenção da contaminação por Covid-19. Interface (Botucatu). 2021; 25 Supl 1:e210047. doi: 10.1590/interface.210047.
https://doi.org/10.1590/interface.210047... .

The good evaluation of graduates on the contribution to personal growth is consistent with data from an exploratory survey on graduates of Professional Master classes in PHC, which obtained an impact rate of over 75%¹¹11 Engstrom EM, Hortale VA, Moreira COF. Trajetória profissional de egressos de Curso de Mestrado Profissional em Atenção Primária à Saúde no Município de Rio de Janeiro, Brasil: estudo avaliativo. Cienc Saude Colet. 2020; 25(4):1269-80.. It is worth mentioning that the SFAPS course had a much-reduced workload compared to the stricto sensu training at the master degree.

Despite the adoption of active teaching-learning methodologies using case studies to bring theory closer to practice, the graduates attributed lower degrees of agreement on the contribution of the course in terms of putting into practice topics discussed in the classroom or intervention projects arising from exercises and final works. This result may be associated with the low governance of graduates regarding the organization/management of their work processes and in multidisciplinary teams.

The theory-practice relationship can be enhanced using problematizing methodologies, when the subject to be taught is integrated into everyday life, allowing the student to build mutual relationships between theory and practice¹²12 Santos RS, Carmo LA, Jorge JTB, Faria L, Chavez Alvarez RE, Guimarães JMM. Equipes de aprendizagem ativa na educação em saúde: ensino-serviço-comunidade na prevenção da contaminação por Covid-19. Interface (Botucatu). 2021; 25 Supl 1:e210047. doi: 10.1590/interface.210047.
https://doi.org/10.1590/interface.210047... .

It is a national challenge to carry out technical-care actions of PC to support users and health staff regarding the correct use of medicines. Two studies²2 Araújo PS, Costa EA, Guerra AA Jr, Acurcio FA, Guibu IA, Álvares J, et al. Pharmaceutical care in Brazil’s primary health care. Rev Saude Publica. 2017; 51 Suppl 2:6s.,³3 Araújo SQ, Costa KS, Luiza VL, Lavras C, Santana EA, Tavares NUL. Organização dos serviços farmacêuticos no Sistema Único de Saúde em regiões de saúde. Cienc Saude Colet. 2017; 22(4):1181-91. also present difficulties, such as the low performance of pharmacotherapeutic follow-up of patients and the low participation of pharmacists in meetings with the health team, although there is emphasis on educational activities for health promotion.

The graduates did not point out a great advantage of the course to support them in terms of conducting home visits (HV). The FHS proposes this activity as an instrument in the work process of teams, which may include the participation of the pharmacist. HV – aimed mainly at users with difficulty traveling – can be important for the health team to draw up therapeutic plans and action strategies, including medicine use, through pharmaceutical consultations with users in their homes¹³13 Santos JB, Luquetti TM, Castilho SR, Calil-Elias S. Cuidado farmacêutico domiciliar na Estratégia Saúde da Família. Physis. 2020; 30(2):e300229..

The course did not have a central focus on technical-managerial issues⁷7 Dóczy AP. Curso Serviços Farmacêuticos na Atenção Primária em Saúde no Município do Rio de Janeiro: um estudo da formação profissional [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2020., where the logistical functionalities of PC are prominent; however, these, together with management, are inexorably important, since they provide greater visibility and expectation for managers, health staff and, especially, users⁵5 Silva RM, Pereira NC, Mendes LVP, Luiza VL. Assistência farmacêutica no município do Rio de Janeiro, Brasil: evolução em aspectos selecionados de 2008 a 2014. Cienc Saude Colet. 2016; 21(5):1421-32.. In addition, weaknesses in these activities can have harmful consequences on the offer and availability of medicines.

The management that orders interventions to minimize the environmental impacts of the various types of waste produced (including medicines) was not well evaluated by the graduates. This may be explained by its low implementation in health facilities, which seems to be associated with a lack of awareness and information¹⁴14 Delevati DS, Castro MMRS, Ries EF, Bayer VML, Rocha VMP. Desafios na gestão de resíduos de estabelecimentos de saúde públicos perante a RDC 222/18. Saude Debate. 2019; 43 Spec No 3:190-9..

Regarding the contribution of the course to the work in PHC and SUS, some points such as communication and information with the health team can be highlighted as especially challenging, especially in terms of identifying situations for qualified health interventions. Communication is strategic for SEFAR, but there are obstacles to an effective exchange of information, such as conflicts generated by the lack of clarity of professionals from other categories regarding the performance and the objectives of SEFAR, especially in care-related actions¹⁵15 Caetano MC, Silva RM, Luiza VL. Serviços Farmacêuticos na Atenção Primária em Saúde à luz do modelo ambiguidade-conflito. Physis. 2020; 30(4):e300420..

Furthermore, another aspect is teamwork. The pharmacist is not part of the minimum FHS team; however, SMS/RJ promoted its incorporation into the teams of the units, resulting in the offer of SEFAR. Nevertheless, it is important to remember that health actions seek to meet the multiple and varied demands of users, with the involvement of multiprofessional teams, characterized by the performance of autonomous members who have their technical expertise, but who interact to provide comprehensive care and correct functioning of services. Accordingly, for the integration of the pharmacist into the team to occur, it is necessary to have encouragement and support from managers and other actors, legitimized by the health team, which, when identifying advances in the structuring of the pharmacy and its HR, become an ally of SEFAR on the issue of promoting pharmaceutical care¹⁶16 Melo DO, Castro LLC. A contribuição do farmacêutico para a promoção do acesso e uso racional de medicamentos essenciais no SUS. Cienc Saude Colet. 2017; 22(1):235-44..

In the context of the strengths, the methodology adopted by the course was highlighted, making it possible to build an educational-reflective process based on the significant experiences of participants in the health reality. The construction of potential spaces for renovation, discussion and reflection on health work provides the use of creativity, spontaneity, construction and deconstruction of new and old utopias in the practice of workers.

According to Paulo Freire¹⁷17 Freire P. Pedagogia da autonomia: saberes necessários à prática educativa. 49a ed. Rio de Janeiro: Paz e Terra; 2014., “critical reflection on practice becomes a requirement of the theory/practice relationship, without which theory can become blah-blah-blah and practice an activism” (p. 24). Thus, the training process needs to foresee and enable moments of reflection on and based on practice, from the perspective of in-service learning.

Another strong point was related to the teaching staff (facilitators/tutors). Mendonça et al.¹⁸18 Mendonça FF, Nunes EFPA, Garanhani ML, González AD. Avaliação de tutores e facilitadores sobre o processo de formação de facilitadores de Educação Permanente em Saúde no município de Londrina, Paraná. Cienc Saude Colet. 2010; 15(5):2593-602. also pointed out the importance of the strategy of prior training aimed at tutors and facilitators, which enhances the systematization of knowledge involved with the topic and the opening of possibilities for discussion and work practice, as occurred in the SFAPS course.

It is important to observe that the set of statements in the question sections was consistent with the competencies expected to be achieved by the course, centered on the contextualization of professional practice for SUS, with emphasis on the social determinants of health and safe use of medicines. Moreover, these questions seem to demonstrate that there have been important acquisitions in this sense⁶6 Silva RM, Luiza VL, Souza CPFA. Manual do Facilitador - Curso de Atualização em Serviços Farmacêuticos na Atenção Primária em Saúde. Rio de Janeiro: Escola Nacional de Saúde Pública Sérgio Arouca; 2019.,⁷7 Dóczy AP. Curso Serviços Farmacêuticos na Atenção Primária em Saúde no Município do Rio de Janeiro: um estudo da formação profissional [dissertação]. Rio de Janeiro: Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz; 2020..

The contribution of the course to professional performance and conduct is related to work processes and reflects aspects that reaffirm the effects of vocational training on the construction of competencies required by professional practice, something that can result in knowledge translation, through feedback from the organization and operationalization of training processes according to their applicability.

The workload was pointed out as the main weakness, since the clientele was made up of workers in service, and the limitations imposed to carry out longer courses are understandable, due to the difficulties of the prolonged departure of workers on the edge.

The scarcity of continuing education mechanisms is an issue that should not be seen as a weakness of the course itself, but with the reduced training spaces of SUS workers in general and pharmacists, specifically, whose training is marked by the technicist model, without concerns with patient care activities¹⁹19 Possamai FP, Dacoreggio MS. A habilidade de comunicação com o paciente no processo de atenção farmacêutica. Trab Educ Saude. 2007; 5(3):473-90..

Another weakness, ‘low professional valorization, dismantling of PHC and dismissals’ reflects, especially, the municipal management from 2017 to 2020, marked by several problems in PHC, such as: dismissal of health professionals (including pharmacists), reductions in the number of FHS facilities and the opening hours of the units. This combination of events led to a sharp reduction in the population coverage of FHS, which went from 62% in 2017 to 55% in 2019, with repercussions on the provision of services, patient care and decreased health conditions of the population, especially the poorest, who mostly depend on SUS²⁰20 Fernandes L, Ortega F. A Atenção Primária no Rio de Janeiro em tempos de Covid-19. Physis. 2020; 30(3):e300309..

A limitation of this study is related to the amount of respondents (30%), which may not have exhausted and captured other relevant issues.

Final considerations

The contributions of the SFAPS course were especially present on the increased perspective of the graduated pharmacist regarding his/her health role in PHC, as an actor of care with the team, indicating the successful construction of professional, social, political and humanistic values.

The humanization of the work process that involves the performance of technical-care activities contributes to the expansion of spaces for health education activities in the territory and/or multiprofessional team, another reference of the logical and conceptual structure of PHC.

The regular offer of new training on specific topics in the logic of continuing education, support for intervention projects to strengthen pharmaceutical services and the creation of discussion groups between pharmacists working in nearby geographical areas can be considered as strategies to overcome the weaknesses identified in the work.

Acknowledgements

We thank the graduates, teachers and coordinators of the SFAPS Course for their support and contribution, without which this production would not be possible.

References

Publication Dates

History