CONTINUING EDUCATION EXPERIENCE FOR AUXILIARY NURSES AS A MANAGEMENT

This paper describes the experience of continuing education for nursing assistants at a Maternal and Child Hospital from June to October 2012. It is a qualitative study whose data was collected through participant observation and recorded in a field diary following a specific roadmap. It focussed on the participants’ attendance, on the use of action-reflection-action model and on evaluation. The project was approved by the research ethics committee of the School of Medicine of Marilia, under protocol No. 638/12. Data were analysed using thematic content analysis. Discussion of results used Paulo Freiré s concepts (1987). After data analysis using units of meaning and categorization process, two main themes emerged, namely: experiencing action-reflection-action in continuing education groups; and weaknesses of the process of continuing education. Such experiences demonstrate that continuing education in the health services is a powerful strategy to promote changes in work processes, since continuing education programs contribute to a more active stance of individuals, promote co-management and the horizontality of power relations within institutions.


INTRODUCTION
The need for the reframing of management models in health services led the technical board of the Maternal and Child Unit II of the Clinical Hospital of Marilia (HMI) to propose the implementation of participatory management.Such policy privileges comprehensiveness in hospital management, i.e. it gives more autonomy to the teams aiming at the integration between management and care.Amongst its principles there is a wide-ranging clinical vision focused on the patient´s needs that aims at establishing links between the professionals and decentralizing decision making.
Changes in the management model require investment in workers, so that they are prepared to work safely, responsibly and participate in decision making.
As laid down in Art 69 of the Code of Ethics for Nurses, it is the responsibility and duty of the nurse to "encourage, promote and create conditions for the technical, scientific and cultural improvement of nursing professionals under his guidance and supervision." The quest for competence, knowledge and professional development in nursing is essential to the professional formation of those responsible for education and quality care.Currently, it is possible to find nursing professionals with a poor ability for reflection on their own practice and, especially, with difficulties to change established caregiving patterns.The contribution of continuing education to the nursing practice is reflected on the professionals´ attitudes during the caring process, among which is a personal pledge towards the search for self-knowledge, for professional improvement and development aimed at improving patient and community care. 1 To consider continuing education as a strategy to change practices is to regard it as learning in the workplace, i.e. learning and teaching incorporated in the organizations´ work processes.It is accomplished through actual experienced problems and taking into account people´s experiences and prior knowledge.This allows the development and training of health workers to be guided by the health needs of the population. 2 Continuing education uses questioning and meaningful learning in educational processes, since it aims at changing the professional practice.Such changes can happen when the individual apprehends and understands reality and is not reduced to a mere spectator or a puppet on a string. 3cording to Ricaldoni and Sena 4 , "[…] the challenge of continuing education is to stimulate in the professionals the development of consciousness about their context through their responsibility in their ongoing process of education." In view of the importance of continuing education, the Department of Health, via the Office for Work Management and Health Education, established in 2003 a policy on further education in health with the aim of improving the country´s health care system.The policy was already in place and employed in the continuing education centres of the various health areas.With the publication of Ordinance GM/MS No. 1.996 dated August 2007, the system was decentralized and regionalized further and the National Policy on Continuing Education was aligned with the guidelines of the National Health Pact. 2 The National Policy on Continuing Education in Health, dedicated to the training and development of Unified Health System employees, is a plan of action that can contribute to the necessary transformation of educational processes, health practices and the health services organization.It is a partnership between the health system management and educational institutions that aims at identifying and, subsequently, solving everyday problems. 2ontinuing education -a practical tool for permanent reflection that enables the problematization of work processes -was introduced at the Maternal and Child Unit of the Clinical Hospital of Marília in 2010 and it is addressed to nurses and nursing assistants.
Projects of continuous education for nursing assistants contributes to the development of a critical professional, able to work in a team and to take into account the social reality in which they live, thus providing human and quality care.
5][6] The nursing assistant team demonstrate inability to reflect on the work process.Although they are part of a shared management model they still do not see themselves as essential and participative players in the work process.They consider themselves instead as hand labour, i.e. their contribution is seen as mechanical, technicist and indifferent to the real health needs of patients and community.This context informed the decision to imple-trabajador que tiene la oportunidad de estar en un grupo de EP se ve y se coloca de modo más activo y participativo, proporcionando una gestión más compartida y un poder más horizontal en las instituciones.Palabras clave: Educación; Enfermería; Educación en Enfermería; Aprendizaje Basado en Problemas.
at the Mother and Child Hospital.All participants signed the term of free and informed consent.
Considering the merits of the exchange of experiences between participants from different units, three groups with eight nursing assistants each were organized.The selection criterion was availability in the shift schedule.The participants were asked to avoid asking time off work or getting it changed, barring unexpected circumstances.
Each group was coordinated by three facilitators -two nurses and one resident nurse from the Nursing Multidisciplinary and Integrated Residency.
Data was analysed using thematic content analysis that encompasses the following stages: pre-analysis; exploration of the material and treatment of results/inference/ interpretation. 11l first stage: organization process.The researcher begins with skimming the text, allowing herself to be invaded by its impressions and guidance, in order to have an overall view.Further steps are: to grasp the details of the material to be analysed; to develop early hypotheses to serve as guides for analysis and interpretation; to choose forms of categorization; and to determine the theoretical concepts that shall guide the analysis. 11second stage: exploration of the material.Encoding corresponds the transformation -made according to precise rules -of the raw text data, via aggregation and enumeration, allowing them to achieve a representation of the content.11 The registration units were coded and the categories connected.
In this phase, categories to provide, by condensation, simplified representation of the raw data were established.This categorization is the classification of the elements that constitute the group; it is performed through differentiation and regrouping, according to gender, using previously established criteria. 11he categorization of the material was performed from analysed data and emerged from the grouping of the encoded material.
The third stage aimed at distributing sections of the text by categorization.Other objectives were: to make a dialogic reading of parts of the text; to identify the registration units; to analyse the different registration units to identify the units of meaning, which will form the basis for the articulation with the theoretical concepts underlying the analysis. 11he unit of meaning that comes out naturally of a text depends on the theory that informs its reading; it corresponds to a thematic rule that is not provided, since it depends on the level of analysis and not on regulated formal manifestations. 11ach nursing assistant was identified by the letter A, e.g.A1, A2, A3…; each group was identified as G1, G2 and G3… and each meeting by M1, M2, M3….; the author´s notes in the field diary are identified as OB (observer).ment a management tool that favours reflection and practice changes in the nursing assistant team.

OBJECTIVES
This research aims at describing the implementation of continuing education projects amongst nursing assistants of the Mother and Child Unit of the Clinical Hospital.It intends also to recognize and identify the limits and potentials of this management strategy and to encourage reflection on the care practices of those employees.

METHOD
This is a qualitative study.According to Minayo 5 , this method of research: […] works with meanings, motives, aspirations, beliefs, values and attitudes.This set of human phenomena is understood here as part of the social reality, because human beings stand out not only through their actions, but through the thinking about what they do, interpreting their actions within and from their lived and shared experiences with their peers.
Data was collected through participant observation which, according to Minayo 7 , is "that which is freely done, although the field researcher should focus on what constitutes the object of study".Data was registered in a field diary within a specific roadmap.The researchers observed the participants´ attendance; the group guidance, focussed on the action-reflexion-action model; and the evaluation.This process is a stage in the problem-posing education that aims at changing professional practice.
The main elements here are the manner of action and interaction, verbal and nonverbal language, and the internal and external environments. 8he research was performed at the Mother and Child Unit which belongs to the Healthcare Centre of the School of Medicine of Marília (FAMEMA), of the IX Regional Health Department of Marília which comprises five health micro regions (Marília, Assis, Ourinhos, Tupã e Adamantina) and 62 municipalities with an estimated population of 1.073.007inhabitants. 9he research was approved by the Committee for Research Ethics Concerning Human Subjects of the School of Medicine of Marília, under protocol No. 638/12, on 28 th May 2012.The study followed the guidelines and standards that control research involving humans, according to Resolution No. 196/96 of the National Health Council. 10 The study subjects were nursing assistants participating in continuing education programs from June to October 2012 Discussion and analysis of results were based on Freire´s theories.It is the authors' belief that this theoretical framework contributes to a better understanding of the methodology of the problem-posing education.

RESULTS
Three continuing education groups were followed between June and October 2012.Each group had, on average, two monthly meetings.Twenty-two nursing assistants participated in the research.
All subjects received technical training in nursing, but worked in the institution as nursing assistants; 85% were female; their ages varied between 24 and 53 years and the time of employment in the institution ranged from 11 months to 19 ½ years.
After analysing the data via unit of meaning and categorization process, two main themes emerged, namely: experiencing the process of action-reflection-action in the continuous education meetings; and weaknesses detected in the continuous education process.

DISCUSSIONS Experiencing the process of action-reflection-action in the continuous education meetings
Ordinance GM/MS No. 198 dated 13 th February 2004, establishes the National Policy for Continuing Education in Health as a Unified Health System strategy for training and employee development.It proposes that the training of health workers should be based on the health needs of the population.The preferred methodology is the problem-posing education involving: identification of problems; reflection on identified problems; search for a referential that could explain them; return to practice with a differentiated proposal aiming at transformation. 12s stated earlier, continuing education incorporates significant learning mechanisms that operate as a constructive form of permanent reflection on the everyday practices of health professionals.It involves shared learning considering the professionals´ previous knowledge and experiences.It assumes that rethinking the care practice allows professionals to change and, consequently, change their care practices. 13ccording to Freire 3 , education must be seen as a practice of freedom, as opposed to a practice of domination.
Educational practices should not be guided by the notion that knowledge is deposited into empty individuals (banking education); they should instead problematize the individu-als´ relationship with the world.A problem-posing education is grounded in the dialogical relations between educator and learner. 3he problem-posing method considers action-reflectionaction as the axis of the process.
Continuing education´s preferred methodology is the problem-posing approach that constructs knowledge from meaningful experiences, and its fundamental principle is critical reflection on the professional practice aiming at practice transformation.
Over the course of the meetings, various problems in working processes were identified:

One of the participants reinforces the need of a more careful assessment of new employees´ abilities (OB, G1, M3). […] there is lack of commitment and organization. A patient can wait for 4 hours to be moved after delivery. We call and no one comes. […] (A4, G1, E5).
The nursing assistants participating in continuous education develop a critical and reflective stance on the working process.Freire 3 maintains that this reflection is about the individual's relationship with the world.The process increases their perceptual ability and changes their points of view.Therefore, something that already existed but was not noticed becomes a challenge to be faced.
Reflecting upon the working process, i.e. coming in contact with a problem, develops the individuals' consciousness of the situation and enables them to take ownership of it, becoming thus able to transform the practice. 3uring the process, there were times when the groups felt motivated to conduct a more detailed examination of the issues discussed and even raised some learning issues.Some of these moments can be exemplified by the following sentences:

The group observed and reported improvements in the working processes of the materials department after the arrival of the HCI nurse (OB, G1, M4).
The group understand that the reform in the materials department happened thanks to the meetings and they feel their participation was key to the change (OB, G1, M9).

One of the participants suggests humanization should apply not only to patient care but to the relationship between the hospital´s employees. I think the group likes the idea and people are keen to try it. (OB, G3, M9).
Freire 3 states that true practice transformation depends on critical insertion in reality.Individuals tend to deny reality as it actually is.This rationalization is a defence mechanism that removes objective basis of the fact so that it ceases to have a concrete existence and becomes a myth that hinders a critical insertion in reality.
During the continuing education meetings the actionreflection-action model was respected.The researchers consider that the participants feel truly committed to that work process.It is important to emphasize the facilitators' performance that managed to arouse in each participant the ability and willingness to change their practice.Active learning processes ensure exchange of views and experiences to all those involved; it gives them the attention they need; it increases individual autonomy; it creates responsibilities; it demythologizes beliefs; it improves knowledge. 15

Weaknesses detected in the process of continuing education
In the current hospital system scenario, domination mechanisms are asymmetrically set.Medical hegemony in that context means that the practice of other team members is underrated.Biological aspects of care, new technologies and specialties tend to override other health care values. 16 this meeting we discussed the difference between further education and continuous education.(OB, G1, M8).
[…] it was good, I thought they were the same and now I understand (A1, G1, M8).
The participants understand and consider important that all employees are aware that the ethics committee is not punitive (OB, G3, M4).
[…] I didn´t know we would discuss such important issues; I think it is an opportunity to think (A3, G2, M4).
[…] Health prevention doesn´t work well.(A2, G3, E7) […] the population used to be more argumentative; today we are apathetic, there is no inflation, the economy is strong […] we have vaccines […] it is necessary to take better care of all this money […] (A2, G3, M7).
[…] I feel sad when we I watched that movie… my mother used to tell me parts of it…… at that time, people used to fight for their ideals […] (A1, G3, M8).
The facilitator reflected on the individual and the collective point of view of the population and asked: what is equity?Participants are supposed to bring the findings the next meeting (OB, G3, M8).
Freire 3 emphasizes the need for educators to designate the conditions for the students' construction of knowledge as part of a process where teacher and student are not restricted to being each other's object.Teaching does not mean to transfer knowledge but to create the possibilities for its production or construction.According to the author, this line of reasoning exists because as human beings we are aware that we are unfinished, which encourages us to research, understand critically and modify what is conditioned, but not determined; we can become then subjects and not just objects of our history. 14fter identifying problems, reflecting about the working process and searching for references to better understand them, the researchers detected proposals and even actions that promote changes in these professionals´ practices, as exemplified by the following experiences:
The group appears quieter and participates less in the discussions.This has been addressed in the evaluation (OB, G3, M3).

I noticed that the group wasn´t very keen in participating in the discussion. Interventions were limited to nurses and facilitators. (OB, G3, M4).
Unwillingness to assume co-responsibility for the problems was another difficulty:

[…] I am tired of taking a position, because then I become the problem (A4, G1, M1).
The whole group agrees that talking to the head nurse won´t solve the problem.They would be putting themselves on the line (OB, G1, E5).

[…] I pin point the issues here so you can solve them […] (A2, G1, M3).
The notion that taking a stand on a conflicting situation or disagreement amounts to a personal exhibition that can generate future problems demonstrates the assistants' insecurity and it is an aspect that needs to be better discussed with them.It involves the establishment of power relations and the interest and organization shown to change this reality.
Freire 3 defends that the quest for change depends on the learner´s true commitment that is more powerful than the nursing assistant´s so-called participation.For that to happen it is undeniably important that continuing education should enable the employees to be really inserted in its process.
Continuing education is a process and as such susceptible to flaws.It is important to work on these flaws so that, gradually, they can be addressed and understood as part of the learning process.Furthermore, it is important to highlight that the main aim of continuous education is the promotion of a critical, reflective and powerful employee in order to In his book "Pedagogy of the Oppressed", Freire 3 states that learners are oppressed when they are part of a process of domination whose educational method is the oppression.When an educational practice is constructed on such basis it becomes a barrier to educational possibilities, for it inhibits the learner´s reflective ability.
In the hospital context, nursing assistants are the oppressed element.They are part of a working process in which power is held by those who have more knowledge.Freire 3 addresses the issue of fear of freedom, i.e. danger of awareness: the learning process can transform a naïve individual into a critical one that recognizes an injustice.
The researchers observed that some employees refused to participate because they were used to mechanistic practices whose ultimate goal is the production, i.e. to meet the service demands, as related below: We noticed the absence of employees from many units; do the respective nurses not appreciate the importance of the project?Did colleagues demonstrate lack of interest?Was there a preference for the simultaneous course on blood products?(OB, G1, M3).

Some workers couldn´t take part due to work demands (OB, G1, M5).
Before the start date it was necessary to call some units and request the employees' attendance.(OB, G3, M1).Amongst the absentees there is an ICU employee that never came because of the workload; the others didn´t manage to come for the same motive.(OB, G3, M4).

Absences were justified yet again by workload. (OB, G3, M6). […] Nurses don´t cooperate; they don´t release the assistants so they can come […] (A3, G1, M7).
Another important aspect according to Freire 3 is the need to understand the concept of freedom of oppressed individuals, in this case the nursing assistants.They must be convinced that their liberation depends not on a revolutionary leadership, but on their own consciousness; it is not bestowed by someone, quite the contrary, it is one´s own.Liberation requires an active and responsible individual, not a slave or a piece of well-fed machine.
Liberation depends on people wanting it and it does not come easily.The researchers identified moments and pieces of discourses that exemplify this difficulty: The group didn´t show up with the task from the previous meeting ready: "what makes you happy?" (OB, G1, M6).