ABSTRACT

This article aims to present the elaboration of the Improvement Course in Management of Basic Health Units, Clinical and Care Management, in the Distance Learning (EaD) modality. For this, the experience report was used as a method. The course was prepared by professors from the Fluminense Federal University (UFF) based on a request from the Ministry of Health, between 2016 and 2019, and adopted as a basis, in the Political-Pedagogical Proposal (PPP), the micropolitics of work. To achieve the PPP, some tools were created or incorporated, teaching material was prepared by the teachers themselves, strategies for the formation of tutors were built, as well as some concepts related to the development of autonomy for life in the construction of the tutor-student relationship. It was concluded that students built activities and graduation works that made explicit micropolitical activities in the work process. Furthermore, it was possible to highlight that the fact that the coordinating members actively participated in the whole process of the course, in addition to allowing permanent education for each one, favored the construction and strengthening of the course’s institutional identity, enhanced the actions and pedagogical interventions to support tutors and facilitated changes from evaluations and reassessments.

KEYWORDS
Education, distance; Health management; Primary Health Care; Permanent health education; Micropolitics

Introduction

The change in the Brazilian health model began with the Health Reform in the 1970s, culminating in the Unified Health System (SUS) ensured from the Federal Constitution in the late 1980s; and the laws enacted still in the 1990s made possible the rearrangement of the health system that until then was strongly hospital-centered and physician-centered. One of the main rearrangements occurred and occurs in the first level of care, in Primary Health Care (PHC), and had an important enabling factor: the Family Health Program. The proximity with the community, with the family, with the physical and existential territory of people has changed the dynamics of the construction of health care provision. A certain widening of eyes, which occurred concurrently with the expansion of coverage in the last three decades¹1 Giovanella L. Atenção Primária em Saúde e coordenação dos cuidados na rede assistencial. Divulg. saúde debate [internet]. 2014 [acesso em 2019 ago 30]; 51:30-37. Disponível em: http://cebes.org.br/site/wp-content/uploads/2014/12/Divulgacao-51.pdf.
http://cebes.org.br/site/wp-content/uplo... .

PHC growth does not occur or only occurred in territorial expansion. This level of health care, which was seen as of little importance, now represents the main gateway for users in the SUS, being the care coordinator and having the responsibility for ordering care in the Health Care Network (RAS)²2 Bousquat A, Giovanella L, Campos EMS, et al. Atenção primária à saúde e coordenação do cuidado nas regiões de saúde: perspectiva de gestores e usuários. Ciênc. Saúde Colet. [internet]. 2017 [acesso em 2019 ago 30]; 22(4):1141-1154. Disponível em: http://www.scielo.br/pdf/csc/v22n4/1413-8123-csc-22-04-1141.pdf.
http://www.scielo.br/pdf/csc/v22n4/1413-... . Faced with such growth and responsibility, the question that arises is: how prepared are PHC professionals to perform and develop the necessary activities?

The management of the Basic Health Unit (BHU) is mostly performed by nurses³3 Galavote HS, Zandonade E, Garcia ACP, et al. O trabalho do enfermeiro na atenção primária à saúde. Esc Anna Nery Rev Enferm. 2016; 20(1):90-98.

4 Ferreira SRS, Périco LAD, Dias VRFG. A complexidade do trabalho do enfermeiro na Atenção Primária à Saúde. Rev bras enferm. 2018; 71(1):752-757.^-55 Matumoto S, Fortuna CM, Kawata LS, et al. Nurses' clinical practice in primary care: a process under construction. Rev Latino-Am Enfermagem. 2011; 19(1):1-8.. However, regardless of the professional who assumes the management function, it is exercised in the activity of assistance. In addition to the function, with rare exceptions, the occupation of ‘position’ occurs without their qualification. This is an important fact given the expansion of primary care in SUS, the direction for this level of care to coordinate the care that should take place in a network, which increases the complexity of action⁶6 Silva JAM, Ogata MN, Machado MLT. Capacitação dos trabalhadores de saúde na atenção básica: impactos e perspectivas. Rev. eletrônica enferm. 2007; 9(2):389-401., and the need to organize care in the health unit itself.

The Ministry of Health (MH), recognizing the unique and important role to be played by the manager of the BHU and the limited offer of specific training over the years – even in the face of decentralization and proposal building and recognition of active participation and responsibility for part of the state health secretariats in training human resources for this level of management⁷7 Brasil. Conselho Nacional de Secretários de Saúde. SUS 20 anos [internet]. Brasília, DF: CONASS; 2009. 282 p. [acesso em 2019 ago 28]. Disponível em: https://www.conass.org.br/bibliotecav3/pdfs/sus20anosfinal.pdf.
https://www.conass.org.br/bibliotecav3/p... ^,88 Andrade MC, Castanheira ERL. Cooperação e apoio técnico entre estado e municípios: a experiência do programa articuladores da atenção básica em São Paulo. Saúde Soc. 2011; 20(4):980-990. – established a partnership with the Fluminense Federal University (UFF) to develop and conduct a refresher course for primary care managers in the Distance Education modality (EaD).

The partnership established occurred with the group of teachers from UFF that develops activities in the field of public health and has been preparing distance education courses since 2013 with a centralized approach in the micro-policy of health care. Embodying micropolitical experimentation in distance learning has been our main marker and differentiator, given that the very concept of micropolitics still seems impalpable and subjective to some. Developing, as allies to sensitive experimentation, material to be used in the non-content learning process that favors the encounter is what we have been trying to do.

Building EaD learning tools that draw attention and captivate the student and that, at the same time, can provoke reflections and development of new looks and posture review for themselves and their relationship with others, especially the user of the subject. SUS, is challenging. However, the challenge was heightened when we thought and elaborated material for a distance education course that presented use value for the workers, that encompassed, welcomed and met the unique Brazilian territorial difference, as well as the ethnic, cultural, demographic and existential diversity of the population of each corner of this continental country, as well as each health professional. Here, in the case of primary care, with so many different daily confrontations and the construction of being and professional action in the construction of care, this challenge called each one of them involved to constant reflections and search for new arrangements.

This article, therefore, aims at presenting the construction developed for the Improvement Course in Management of Basic Health Units, Clinical and Care Management, conducted in the semi-presential distance learning modality by group of teachers of the UFF between the years of 2016 and 2019. During the course elaboration, tools were developed with the intention of building reflection by the professionals about their work process, among other points, such as causing strangeness and, perhaps, the construction and search of other ways. To achieve the proposed objective, we will present the development of the adopted pedagogical structure, the strategies used and the tools we adopt for each learning unit. Thus, we will use the case report to approach the experience developed.

Development

The methodology adopted for this text is an experience report of one of the members of the course coordinator who participated in the preparation of the proposal and who, with other professors from UFF, held an EaD for PHC professionals who held a management position.

Dialoguing with Larrosa⁹9 Larrosa J. Notas sobre a experiência e o saber de experiência. Rev Bras Educ. 2002; 19:20-28., we can take the word experience as something that happens to us, happens to us, knowledge cut into practice and thus can be a vivified experiment. Thus, the experiment cannot be controlled as when conducting a laboratory experiment, because it is something that affects us and crosses us.

As Simon¹⁰10 Simon AA. Sistematização de processos participativos: o caso de Santa Catarina. Rev. Bras. Agroecologia. 2007; 2(1):540-543. points out, sharing experiments and constructions of knowledge and learning is necessary and could be due to its simple socialization and democratization, but it is not only at this point. Reporting the lived experience is to put the author in a process of reflection on his/her acting and doing and, thus, producing theory and new perspectives. A construction of otherness as a whole.

Thus, the idea is to share the paths taken by us and the constructions of reflections that we perform as a group that, when building the course, is built, constituted and strengthened as a group. The first experimentation took place and occurs in each of us.

The problematization was the pedagogical basis, as it allows the student to reflect on his work process while building improvement elements for the quality of care and care.

The Political-Pedagogical Proposal (PPP) was elaborated based on the work performed in PHC management, understanding that it does not move from work to care, but that there is a direct relationship, a coupling between both dimensions of the operation of health networks. Understanding that work activity necessarily involves learning, and this is the assumption of the pedagogical method of the course, justifies qualifying it as a process of continuing education. The practice scenarios were inputs of the content discussed in the course, and enabled their agreement within the fundamental themes addressed.

We adopted the micropolitics of work as a driving axis, both in the construction of didactic material and in the training of tutors. We take micropolitics as a bet that, in the relational process with the other, we constitute spaces and processes of subjectivation that happen in the territory of the meeting in health, either in care or in health management, in which acquisition and incorporation of new knowledge constitute singular relationship between two entities, which corroborates the formation of each one of the involved not only in the space of academic formation, but even in the life space¹¹11 Guatarri F, Rolnik S. Micropolítica: cartografias do desejo. 8. ed. Petrópolis: Vozes; 2012.^,1212 Feuerwerker LCM. Micropolítica e saúde: produção do cuidado, gestão e formação. Porto Alegre: Rede UNIDA; 2014..

The PPP that has the micropolitics of work as a foundation happens intertwined with the concepts of Paulo Freire¹³13 Freire P. Pedagogia da autonomia: saberes necessários à prática educativa. 43. ed. São Paulo: Paz e Terra; 2011.^,1414 Freire P. Pedagogia do Oprimido. 50. ed. Rio de Janeiro: Paz e Terra; 2011. regarding the autonomy of the other, a recognition that all ‘are known’; and thus the construction and incorporation of a horizontal pedagogical practice. Here a bet was made on the highest possible activism of the participant ‘learning to learn’, that is, a protagonism in the search for knowledge, and this was explored to the fullest by the course that prioritized and stimulated the study of problem situations, management cases, challenges and innovations, considering the field of management and care.

If we want respectful, responsible and affective relationships between the PHC manager and the user, between the manager and the healthcare professionals, and between the professionals and the users, we need to incorporate this desire into the training or updating of professionals, in continuing education processes that invite each other to reflect and develop new skills and constructions in front of the other.

The proposal focused on the construction of a course aimed at SUS managers linked to the BHU and health professionals working in PHC. The systematization of this process was based on an initial survey of the manager’s functions and the identification of the use value of these activities. To approach, two workshops were held in Brasília with health professionals, representatives of the MH and members of the coordination of the UFF course, in which were defined the main areas that represented challenges for the manager.

Thus, the course works with three macro-competencies and presents some tools (about tools we will cover later). Macro competencies are related to work management, input management and health network management. From the definition of macro-competencies, the course proposal and the didactic material were elaborated in three Units of Learning (UL):

The didactic material was developed by the coordinating members (professors of UFF) who were divided among the three UL. The idea that accompanied us and directed us was the elaboration of didactic material that allowed conversation, that provoked reflection in the student/professional; and so we developed the following points: Content is not the flagship, it is input, it needs to be timely and objective, there is no hierarchy between the UL, there is a possibility of leveling the student by discipline, supports learning from a set of strategies and activities. This time, the UL were developed with direct interfaces with the world of PHC management and care, with cases inspired by real cases. Another important point that accompanied us during the elaboration of the UL was that the material was light, inviting and talked with different regional realities, but especially with the daily life of the manager.

Within this perspective, we built the pedagogical structure of the course, associating the dynamics of micropolitics in health to organize tutors training workshops and the pedagogical support of the proposal, having as its fundamental axis that the world of work is a school; and, therefore, the problematization of daily life supported the actions of the course.

The option of the MH for distance education, in semi-presential mode, was intended to offer and make the course feasible to as many PHC professionals as possible, since they could access the content and the tutor according to their availability. Coupled with this option and having as a marker the objective in the formation, organization of networks and health care, we decided to adopt some guiding axes such as: Autonomy, Singularity and Subjectivation Process.

The EaD, when stimulated, can develop and promote collaborative learning¹⁵15 Santos EO, Carvalho FSP, Pimentel M. Mediação docente online para colaboração: notas de uma pesquisa-formação na cibercultura. Educ Temat Digit. 2016; 18(2):23-42.. When we look at health managers, collaborative learning, when experienced and learned, can also become a tool for everyday work in health beyond the Virtual Learning Environment (VLE) and face-to-face meetings, as it can nurture or expand activities in the health work environment, where collaboration and co-responsibility are the desired and expected tonic.

The stages for the development of the adopted pedagogical structure, strategies used for its accomplishment, elaboration of the didactic material, followed: construction of the pedagogical workshop with tutors, construction of support group for the tutors, virtual platform, proposal of accompaniment of the activities of the continuing education course and proposal with coordination members and tutors.

Validation of the UL content took place at the Tutors Training Workshop held by members of the national course coordination, which took place over a two-day intensive period with all course tutors. We consider that this actor, the tutor, needed to develop a broad look, differentiated listening and adopt in the meetings (face-to-face and virtual) a certain plasticity and keen perception of the other. Thinking about the training of tutors involved this.

In addition to the elaboration of teaching material, preparation and implementation of the training workshop, a support structure for tutors was set up, in which, for each group of up to ten tutors, a coordinating member was offered in the coordination of pedagogical performance (support). The pedagogical coordinator had, among other duties: to participate in the classroom moments of the course, when possible; collaborate with the selection of students and tutors for the course; accompany, support, guide the work of tutors with students and respond to teaching questions.

About the tools

Each UL presented, at least, one tool that was intended to enhance the manager’s actions in each of the macro-competencies; in another logic of clinical organization and care based on management (recognizing that management and care are inseparable actions) and that had use value.

Chart 1 below briefly refers to each of the UL, the intended competencies for each UL and the tools developed for the development of the intended objectives and competencies.

Teaching and learning management and pedagogical strategies for course development

The teaching and learning management was built to develop and consolidate the tutor-student relationship. The relationship of the tutor is of facilitator of the learning, in this sense, he/she helps, motivates, guides and stimulates the development of autonomous learning of the one who is specializing. Autonomous, but not lonely, since stimulating group work or the search for solutions or solutions to problems is part of the tutor’s stimulation for students¹⁶16 Martins AC, Falbo Neto G, Silva FAM. Características do Tutor Efetivo em ABP - Uma Revisão de Literatura. Rev bras educ med. 2018; 42(1):103-112.; using, among other means, technological resources such as VLE, a tool in the tutor-student relationship.

The course counted on face-to-face moments and use of the internet platform. Three face-to-face meetings were held, with a two-month interval, in a decentralized manner and as close as possible to the graduated classes. The number of presential meetings was the differential of the course, which was intended to strengthen the building of bonds between the participants as each student try the tools with the tutor and the other students in the class; and later, at the time of dispersal, exercise with their work teams and share with the class and tutor.

Respecting the regional differences, in the states with more than one class, it was sought that the first face-to-face meeting was held in the same place in each state, aggregating all students and tutors to enable greater approximation to the proposal, familiarize with the internet platform, and stimulate the establishment of relationships and bonds between those involved during the two days and, at the same time, work knowledge and networking. From this first moment, the course was developed with the internet platform (Moodle platform) and other distance communication tools.

The third face-to-face meeting was held in all classes, whenever possible, in the same places as the previous ones, and corresponded to the completion of a closing seminar when the participants’ course conclusion works were presented.

Assessment system

In this course, we work and merge the summative assessment and the formative assessment. The assessment was worked as a permanent and critical-reflexive activity in the teaching-learning process, in educational actions, since it should not be seen as a separate chapter, since it is part of the learning process path¹⁷17 Antunes, C. A avaliação da aprendizagem escolar. 10. ed. Petrópolis: Vozes; 2013.. We adopt assessment throughout the teaching-learning process and thus we can realize the advances, detect difficulties, the chances of acting even during the course, redesign, offer continuous actions to qualify the process and achieve the results expected by both the student, as per each of us, professionals involved.

In the assessment process it was important to think of the three basic aspects: locating progress, locating needs and locating potentialities. The ability to assess the achievements and advancements of each manager (both male and female students) during the learning process, can work as a two-way driver, as they can strengthen the self-esteem of the tutor and the student/manager because it prepares new learning; it identifies the gaps, the needs, the errors, the difficulties in becoming aware and overcoming them, right here comes the intervention. The third aspect is the subtler, which was not foreseen in terms of purpose and, thus, does not apply to the category of right or wrong, which are the potentials, captured with a sensitive eye.

One of the key points in the evaluation process we have adopted is that it makes no sense to perform a detached evaluation of an intervention proposal, just as we think about health planning. For intervention, in educational practice, the main element is sensitivity, the question of the gaze that carries intentionality¹⁸18 Vasconcellos CS. Avaliação da Aprendizagem - Práticas de Mudança: por uma práxis transformadora. 10. ed. São Paulo: Libertad; 2013..

We tend to have a classificatory eye. The classificatory eye, of the Gaussian curve, or the normal distribution precludes seeing the person as he/she is. Seeing the other as a human being, with rights, with potentialities, believing that he/she can learn, that he/she can grow, not denying him/her that right and, from that point of view, building the difference. The bonding issue is very important. In order to build, to make this assessment, we need people who are also willing to assess themselves. Assess and be assessed. Before talking about the intervention in the other, we need to talk about our intervention. Before assessing the other, we need to perform self-assessment, autonomy, authorship, the tutor to do. These aspects of the assessment that we decided to take on in the course were presented and worked with the tutors during the training workshop and remembered, when necessary, during the pedagogical accompaniment.

We adopted narrative as a cross-sectional assessment tool. It is a light form of writing, as if we were telling a story to a person who could not be present but who is interested in knowing what happened. Cross-sectional because every activity from each UL fed the narrative that was built along the course. The constant elaboration corroborated the idea of formative evaluation, as it allowed the tutor to follow the progress and progress of each student, as well as to make and update agreements and interventions. In the third face-to-face meeting, the closing moment of the course, each student presents his narrative course throughout the course and can use different forms of expression, including artistic. It is worth mentioning that the gatherings have been very rich.

In addition to the assessments made throughout and at the end, we adopted a reevaluation at each end of course, each end of ‘wave’ (denomination we have for each edition of the course). For the construction of the re-assessment, we elaborate and make available via Google Forms®, for all tutors and students, who carry out evaluation of the course, platform, tutor, coordination, each UL and the proposed assessment activities in each UL. After quantitative and qualitative analysis of the material, we organized and conducted a course evaluation workshop in which we invited representatives of students, tutors, representatives of the proponent (MH) and members of the coordination. The practice of reevaluation is in line with what Levy¹⁹19 Levy S. Six factors to consider when planning online distance learning programs in higher education. OJDLA. 2003; 6(1):1-19. pointed out, which deals with the advances of the distance education proposal aligned with reevaluation.

Conclusions

The construction of an EaD course that proposed to incorporate micropolitics in the construction of the pedagogical proposal presented multiple challenges, which began in the construction of appealing didactic material that was not too basic or too academic, and went through the formation of tutors who could transit existential territories’ distinct and; From these, work the power in each of the involved. A highlight was the fact that students built activities in the workspace and, later, concluding works that made explicit the micropolitical exercise in the work process.

The fact that the coordinating members actively participate in the whole process of the course, besides enabling permanent education during construction, given that it updated and has updated us, favored the construction and strengthening of the course’s institutional identity, enhanced the pedagogical actions and interventions of support for tutors and facilitated changes from re-assessment.

It was possible to evaluate very positively the bet made on the pedagogical coordination in the monitoring of ten tutors. It was possible to ensure the development of the PPP of the course, as well as fundamentally providing continuing education with tutors in the face of daily situations that arose during the course.

The construction of a proposal of also formative assessment was fundamental. Even during the training of tutors, it was possible to receive feedback regarding the ‘new’ possibility of looking at the question of assessment and thus new looks at the other, whether the student, tutor, coordination or even the user of the health system.

The tools used presented and have presented potency in the discussion of learning and fostered change in the management work process, as well as in building relationships with people (professionals and users). Some were very well assessed, especially the Circular Process that deals directly with team organization and conflict. The Singular Therapeutic Project (STP) is the tool that, at first, largely arouses moderate interest, given that most professionals consider that they already know, and only during discussion and presentation that interest gains other proportion and use.

The EaD enabled managers from different states and municipalities in the Country to receive the course offer; and thus the opportunity to exchange ideas about care management, conflict, network and inputs. Many managers reported being the first time they attended a training and that some words they heard and repeated in some meetings came to make sense, such as the discussion and implementation of the STP and that they recognized how much the RAS theme needed to be present in the training. day by day of what they were doing, as well as not letting go or running away when conflict arises.

References

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