ABSTRACT

This manuscript presents a narrative of tutors from different states of Brazil regarding the experience of tutoring, from 2016 to 2018, as part of a semi-presential improvement course aimed at managers of Basic Health Units. One of the major challenges of health care is the qualification of managers to work in the Unified Health System (SUS). Managers of basic health units need skills of clinical management and care to produce effective ways to make health care in a collaborative and effective way. Management processes in the sphere of primary care require the use of tools that enable the adoption of other ways of being a manager, such as the circular process, nonviolent communication, the descriptor flowchart, the unique therapeutic project, besides the enhancement of relational technologies for the qualification of management processes. The ability of the course to activate changes in the qualification of professionals for the management of basic units is verified, considering its potential to provoke shifts of perspectives, positions and knowledge regarding the management function.

KEYWORDS
Primary Health Care; Health management; Education, distance; Mentoring

Three waves and many movements

This article is the case study of an experience lived in the mentoring exercise within the Improvement Course for Managers of Basic Health Units, Clinical and Care Management, in the semi-presential modality, developed by a public university in the state of Rio de Janeiro, Brazil, in partnership with the Department of Primary Care (DAB) of the Ministry of Health (MH). The main objectives of the course are: to qualify managers¹1 Brasil. Ministério da Saúde. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 22 Set 2017. of Basic Health Units (BHU) for clinical management and care management²2 Cecílio LCO. É possível trabalhar o conflito como matéria-prima da gestão em saúde? Cad. Saúde Pública [internet]. 2005 [acesso em 2019 mar 26]; 21(2):508-516. Disponível em: http://dx.doi.org/10.1590/S0102-311X2005000200017.
http://dx.doi.org/10.1590/S0102-311X2005... and to support the incorporation of management tools in primary care.

The role of the BHU manager, until June 2018, did not have a technical profile defined by the MH. Throughout Brazil, this position is mostly held by professionals with low schooling, with little or no knowledge of the National Primary Care Policy (PNAB), which are inserted in the BHU by political indication. Their duties are usually limited to administrative and bureaucratic aspects, with very rare interactions with the health team, community and territory in which the unit is located.

However, the management of the BHU requires qualified professionals to perform this function. In this sense, it is necessary to acquire skills so that health professionals can operate daily in the position of manager, which justifies the development of training and qualification movements of health professionals for the ‘manager’ function of BHU.

Methodology

This manuscript is a case study of the experience lived by the tutors of the Improvement Course in Management of Basic Health Units, Clinical and Care Management.

The method adopted was narrative³3 Universidade Federal Fluminense. Coordenação de Educação a Distância. Curso de Aperfeiçoamento em Gerência de Unidades Básicas de Saúde, Gestão da Clínica e do Cuidado [internet]. Niterói: UFF; 2017 [acesso em 2019 mar 26]. Disponível em: http://epubs.cead.uff.br/site/.
http://epubs.cead.uff.br/site/... , a qualitative research technique that values events. The potentiality of the adoption of narrative in research consists in a possibility of understanding the experience and usually consists of written reports or records.

This narrative describes the experience of tutors in the three editions of the course already completed (2016-2018), which had as priority target audience the managers of BHU.

The course aims to instrumentalize the practice of BHU management through the development of competencies, ranging from the management of inputs and personnel to the monitoring of health indicators. However, the course innovates by proposing the adoption of management tools based on micropolitics, valuing the adoption of light technologies. The tools worked and pointed as the most successful in their implementation in the units were the descriptor flowchart, the circular process, nonviolent communication, the adoption of care lines and the unique therapeutic project.

The waves for the qualification of primary care management processes

Since the implementation of the former Family Health Program (FHP), in 1994, to the present day, the coordination of BHU is exercised primarily by nurses who often accumulate tasks advocated by PNAB, such as managing the organization and operation of BHU and of guiding the work of Community Health Workers (CHW), these tasks that generate overload and away from the management of care with users of services.

With Ordinance nº 1.808, of June 28, 2018, of the MH, a technical profile was established for the exercise of the managerial position, as stated in art. 85-B, § 4th. Among the parameters defined in this ordinance, we highlight three: the manager must have a higher education level; 40 hours/weekly workload; and fully develop the pertinent attributions to the function contained in the PNAB⁴4 Brasil. Ministério da Saúde. Portaria nº 1.808, de 28 de junho de 2018. Altera a Portaria de Consolidação nº 6/GM/MS, de 27 de setembro de 2018, para dispor sobre o financiamento das Equipes de Atenção Básica - eAB e da Gerência da Atenção Básica, instituídos pela Política Nacional de Atenção Básica - PNAB. Diário Oficial da União. 29 Jun 2018..

Despite the ordinance instituted more than a year ago, there has not yet been an important movement of municipalities to satisfactorily meet the established parameters, and it is believed that it will still take considerable time for the services to adapt to the determinations contained in that ordinance.

However, it is important to highlight that, since 2016, DAB/MH has invested in offering training courses for the qualification of BHU managers, considering the need for a professional who can act as a health manager, inserted in the daily actions and services, that develops integration actions between service-community and that acts in conflict management, seeking a participative, inclusive and collaborative management.

Thus, the DAB/MH and the Fluminense Federal University (UFF), Niterói, Rio de Janeiro, have entered into a partnership with a view to collectively building an improvement course for BHU managers focusing on clinical and care management, based on the perspective of micropolitics and Permanent Health Education (PHE).

Inside waves

Since 2016, three editions of the course have been held for the entire Brazilian territory, called by the tutors as the first, second and third wave. A characteristic of this course is the qualification not only of managers, but also of tutors for this other way of developing Distance Education (DE). A fact that allows a dive/swim in the course proposal by the tutors is the maintenance of most of them in all editions, which favors a deep immersion in the proposal, the contents and references worked and the evaluation processes.

A remarkable space in the course related to the training for the ‘tutor’ function⁵5 Moran JM. A educação que desejamos: novos desafios e como chegar lá. Campinas: Papirus; 2007. was at the opening of each wave, when a face-to-face workshop with the participation of all tutors, coordinating members and representatives of DAB/MH took place. In these, the contents were discussed and reformulated, the tutors presented news of how the courses were happening in the states of the different regions of the Country, exchanged doubts and experiences; and with that, a bond of friendship and circulation of affection was created, which, despite the difficulties, motivated us and filled us with gas for the new wave.

The three presential meetings provided in the course design provided a learning space for managers, preceptors and coordinators, through the exchange of experiences. In these, different tools were also improved⁶6 EPS em Movimento. O aprender e o engendramento de um novo campo de possibilidades - OUTRAR-SE. Observatório de Tecnologias de Informação e Comunicação em Sistemas e Serviços de Saúde - OTICS [internet]. Rio de Janeiro: Otics; 2014 [acesso em 2019 mar 26]. Disponível em: http://eps.otics.org/material/entrada-textos-em-cena/arquivos-em-pdf/o-aprender-e-o-engendramento-de-um-novo-campo-de-possibilidades-outrar-se/view.
http://eps.otics.org/material/entrada-te... .

In order to contribute to the communication processes between team members, to establish bonds with the community, to welcome users, among others, which we believe can contribute to the improvement of BHU management processes, these meetings were powerful devices for the training of the managers of the BHU. These are the experiences⁶6 EPS em Movimento. O aprender e o engendramento de um novo campo de possibilidades - OUTRAR-SE. Observatório de Tecnologias de Informação e Comunicação em Sistemas e Serviços de Saúde - OTICS [internet]. Rio de Janeiro: Otics; 2014 [acesso em 2019 mar 26]. Disponível em: http://eps.otics.org/material/entrada-textos-em-cena/arquivos-em-pdf/o-aprender-e-o-engendramento-de-um-novo-campo-de-possibilidades-outrar-se/view.
http://eps.otics.org/material/entrada-te... we intend to share, because, during the course, we are motivated to be part of the Unified Health System (SUS) that we value and we are filled with the possibility of believing in a SUS that works.

The choice of DE contributes to making learning happen at work as it is done and in the scenarios in which it happens, since learning from one’s own experience enables the manager to effectively handle the situations he/she faces in everyday primary care.

The course, object of this report, happens in the semi-presential modality, therefore, with moments of immersion and dispersion. Its dynamics foresees three face-to-face meetings in the students’ state of residence, and take place at the beginning, middle and end of each edition, lasting two days each, spread over 24 weeks. The face-to-face meetings are fundamental as they contribute to the integration between the students and the tutor, to the exchange of experiences between the managers, and to the consolidation of bonds and networks between the students, favoring the creation of collaborative acts between managers in the same one’ state. Participation in the three face-to-face moments is a mandatory condition for certification. Distance guidance happens through an online platform, online forums, chat, email and WhatsApp.

Given the scope of the course objectives, the evaluation is procedural and formative, using various collective and individual instruments, such as discussion in online discussion forums mediated by tutors and the submission of individual activities that report the experiences related to application of the main management tools worked in the course (descriptor flowchart; circular processes; methods for materials management and control; care lines; and unique therapeutic design).

The course is organized into three major Units of Learning (UL): Health Work Process Management, Materials Management and Network Management, Care Lines and Participatory Planning. The UL integrate and interact with each other through discussion of cases and reflections of student practices.

Considering that health work processes are not tight and must be agreed between management and workers, focusing on users’ needs¹1 Brasil. Ministério da Saúde. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União. 22 Set 2017., the critical and continuous reflection of work processes and the achievement of results are fundamental to the work. The more complex and less systematized the work process, the harder it will be to reflect on it. Thus, the course proposes tools for the collective analysis of teamwork processes, understanding that this analysis produces reordering and new pacts between management and health workers.

Seeking to address the conflicts arising from work in health services as learning opportunities²2 Cecílio LCO. É possível trabalhar o conflito como matéria-prima da gestão em saúde? Cad. Saúde Pública [internet]. 2005 [acesso em 2019 mar 26]; 21(2):508-516. Disponível em: http://dx.doi.org/10.1590/S0102-311X2005000200017.
http://dx.doi.org/10.1590/S0102-311X2005... , the course proposes various tools to instrument managers in daily life, including productive meeting planning techniques, restorative practices, nonviolent communication and circular processes, which aim at the construction of groupality, as well as the optimization of the production of care with users.

For tutors, the use of a case to reflect on work processes and the production of care has been a great facilitator and practical learning exercise. Similarly, the proposal of the formulation of the work process descriptor flowchart and the experience of the circular process with team members and in the services in which the students work have provided a differentiated knowledge, valuing the experience, the interprofessional doing⁷7 Peduzzi M. O SUS é interprofissional. Interface (Botucatu) [internet]. 2016 [acesso em 2019 mar 26]; 20(56):199-201. Disponível em: http://dx.doi.org/10.1590/1807-57622015.0383.
http://dx.doi.org/10.1590/1807-57622015.... and the space of the student’s services as a priority field for the production and adoption of other management modes of the BHU.

Based on the concept of meaningful learning, the first face-to-face meeting of the course aims to: welcome the student; promote the integration/affection/bond between the participants and the tutor; present the dynamics of the course and its assessment system; establish a working pact for distant moments; assist in the elaboration of the singular curriculum; introduce the Virtual Learning Environment (VLE) and its main tools, in this case, Moodle. All of these activities are supported by the tutor. It is considered that the first meeting is strategic for the integration and reduction of professional/student dropout, with a view to welcoming and establishing bonds of affection and connection.

It is important to highlight the care taken by the coordination of the course, and ratified by the tutors, regarding the presential meetings, as the proposal is that, during its realization, the contents/tools that will be worked on in the following UL are presented in advance, aiming to facilitate their collective experimentation with the tutor and the other students.

At the second face-to-face meeting, when relations are already more established, the moment is taken to clarify doubts of the first UL. Thus, it is started from a ‘exchange and rescue wheel’, at which time students share their experiences, such as the use of work process management tools in teams, especially the circular process and the work process descriptor flowchart, problematizing the identified critical nodes and bringing to the surface the stresses and experiences of the applicability of the tools.

Following, the tutor introduces the Materials Management UL in Health Units and proposes a practical activity for the elaboration of a spreadsheet for inventory control and maintenance of material resources. In the first two versions of the course, this activity was done at a distance, but due to the perception that students had many difficulties to perform this assessment exercise and that this time coincided with a period of greater dropout, especially in the Northern and Northeast regions, it was decided to perform this activity in person. Also at the second meeting, the students won a network management tool, the unique therapeutic project, which is exercised in small groups through a clinical case.

The second meeting also proposes the formulation of an intervention project, which should be limited to the service space and/or health network in which the manager is inserted. This is the final evaluation of the course, is formulated in a procedural way, allowing the manager/student to present it in different ways (tale, poetry, string, music, film, suddenly, among others), although the narrative format is recommended.

The option for narrative³3 Universidade Federal Fluminense. Coordenação de Educação a Distância. Curso de Aperfeiçoamento em Gerência de Unidades Básicas de Saúde, Gestão da Clínica e do Cuidado [internet]. Niterói: UFF; 2017 [acesso em 2019 mar 26]. Disponível em: http://epubs.cead.uff.br/site/.
http://epubs.cead.uff.br/site/... is a bet of the course, because we believe that it allows to bring out the implications of the students, allows the capture of movements, reflections and concerns that arise during the path and conflicts that emerge in the application of tools in services. Our experience also allows us to infer that this choice is justified, among others, by the lack of experience in the academic production of most health professionals.

The finalization of the course happens with the realization of the third face-to-face meeting, with the narrative presentations, constituting a rich, differentiated and productive moment of sharing the possibilities, powers and challenges produced by the reflection of the practices and clinical management and health care.

Although the planning of the meetings is based on a script proposed by the national coordination team, the tutor has the autonomy to change it according to the regional peculiarities and needs.

At the end of each edition, workshops are also carried out for evaluation, with representatives of tutors, students, DAB/MH and members of the course coordination.

The training processes for the management of the Basic Health Units

After three versions of this course and two evaluation workshops, the tutors evaluate that the face-to-face meetings are essential for the success and quality of the course, especially the first, which is fundamental for the construction of bonds between the class members, a fact that contributes to the least dropout rates of students. The second meeting is peculiar, as it allows the rescue of some students and is an opportunity to gain new breath for a new immersion in the course.

One strategy of the course is to emphasize the proximity between coordinators, tutors and students, stimulating the establishment of bonds and taking the tutor as an articulator of affections, exchanges of experiences, considering them a tool axis for learning processes⁸8 Rodrigues LS, Gontijo TL, Cavalcante RB, et al. A evasão em um curso de especialização em Gestão em Saúde na modalidade a distância. Interface (Botucatu) [internet]. 2018 [acesso em 2019 abr 1]; 22(66):889-901. Disponível em: http://dx.doi.org/10.1590/1807-57622017.0129.
http://dx.doi.org/10.1590/1807-57622017.... .

In distance education, it is necessary to make the presential moments meaningful, which are different from the presential classes foreseen in a presential course, being necessary the adoption of dynamic activities that promote the bond and the integration, strengthening the groupness and the collaboration that tends to remain in the moments at a distance⁹9 Almeida OCS, Abbad G, Meneses PPM, et al. Evasão em cursos a distância: fatores influenciadores. Rev Bras Orientac Prof [internet]. 2013 [acesso em 2019 mar 26]; 14(1):19-33. Disponível em: http://pepsic.bvsalud.org/scielo.php?script=sci_abstract&pid=S1679-33902013000100004&lng=pt&nrm=iso&tlng=pt.
http://pepsic.bvsalud.org/scielo.php?scr... .

A low rate of evasion in the waves was perceived, and one of the factors attributed by us were the face-to-face meetings, which, in the case of this course, are remarkable moments, full of life, power, dances, music, photographs, joys, sharing and exchanges.

Considering the low student’s rate of evasion, the diversity, the quality and the potency of the intervention projects to produce changes in the ways of operating the clinic and care management in health services, in the three versions of the course, the tutors evaluate that the proposed objectives related to the qualification of management for SUS are being achieved and the course has been contributing effectively, differentiated and innovative to the adoption of other management modes of the BHU.

References

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