REVISIONES

 

Education in nursing work in Latin America

A educação no trabalho da enfermagem no contexto latino-americano

La educación en el trabajo de enfermería en el contexto latinoamericano

 

 

Da Silva, Luiz Anildo Anacleto*; Schubert Backes, Vânia Marli**; Lenise Prado, Marta**

*Ph D in Nursing. University Federal de Santa Maria. Estado de Rio Grande do Sul. E-mail: luiz.anildo@yahoo.com.br
**Ph D in Nursing. University Federal de Santa Catarina. Brasil.

 

 

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ABSTRACT

Objective: This study aims to evidence the trends of education in nursing work in Latin America.
Material and methods: It is a qualitative, exploratory and documental study, carried out by the review of 18 journals, 299 copies, 3310 abstracts and keywords, and analysis of 70 full text articles from 7 Latin American countries.
Results: The study evidences that trends of education at work are undergoing changes in conceptions, which transcend the technical aspects, aiming to reach more extensive proposals, mainly in countries like Brazil, Mexico and Colombia. Research shows intellectual production is more focused on academia.
Conclusions: Trends of education at work in Latin America are oriented for several segments, however, two convergences stand out: in one of the segments, focus is on technical training, and in the other one, there are favored the precepts of permanent education, with the intention of bringing theory and practice together, as well as the relationship between academia and services.

Keywords: Nursing; Education at work; Scientific production.

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RESUMO

Objetivo: O objetivo deste estudo esteve em evidenciar as tendências de educação no trabalho da enfermagem na América Latina.
Material e métodos: Esta se constitui de uma pesquisa de natureza qualitativa, exploratória e documental realizada com a revisão 18 periódicos, 299 exemplares, 3310 resumos e palavras-chave e análise de 70 artigos completos de 07 países latino-americanos.
Resultados: Evidencia a pesquisa que as tendências de educação no trabalho, estão passando por mudanças de concepções, transcendendo ao aspecto técnico para propostas mais abrangentes, principalmente em países como Brasil, México e Colômbia. Mostra o estudo que a produção intelectual está mais centrada na academia.
Conclusões: As tendências da educação no trabalho na América Latina estão orientadas para diversos segmentos, contudo, duas convergências se destacam: em um dos segmentos o direcionamento está na capacitação técnica e em outra fração privilegiam-se os preceitos da educação permanente com desígnio em aproximar teoria e prática, assim como, a relação academia e serviços.

Palavras chave: Enfermagem; Educação no Trabalho; Produção Científica.

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RESUMEN

Objetivo: El objetivo del presente estudio es poner de relieve las tendencias de la educación en el trabajo de enfermería en América Latina.
Metodología: Es una investigación de carácter cualitativo, exploratoria y documental, realizada a partir de la revisión de 18 revistas, 299 ejemplares, 3310 resúmenes y sus palabras claves, además del análisis de 70 artículos completos de 7 países de América Latina.
Resultados: La investigación muestra que las actuales tendencias de la formación en el trabajo están experimentando cambios en las concepciones, las cuales trascienden el aspecto técnico de propuestas más amplias, especialmente en países como Brasil, México y Colombia. El estudio muestra que la producción intelectual está más centrada en el mundo académico.
Conclusiones: En América Latina, las tendencias de la educación en el trabajo están dirigidas a diferentes segmentos, sin embargo, se pueden destacar dos convergencias: en uno de los segmentos, la dirección está centrada en la formación técnica, y en el otro, se privilegian los preceptos de la educación permanente para aproximar la teoría y la práctica, así como la relación academia y servicios.

Palabras clave: Enfermería; Educación en el trabajo; Producción científica.

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Introduction

Health and the consequent organization of health services in Latin America present a picture of diversities and complexities peculiar to each country, including factors like: the health and disease process, different epidemiological profiles in which existing and new problems are associated, education, income distribution, population distribution with increasing concentrations in large urban centers and human resource migration¹.

To establish plans and policies for the health sector, and especially for nursing, the change processes need to be recognized through a continuing analysis of the impact of globalization, economic-financial investments and the reforms in health, education and work. Mainly, however, effective investment policies in human resources need to be established, such as career and salary plans and plans for in-service education. The rapid transformations in this scenario strongly indicate the need for lifelong education to provide the nursing professionals with permanent qualification for health care, as well as educative proposals for their comprehensive development as subjects-workers and citizens.

When discussing education at work, some questions are identified and many others need to be unveiled. An analysis at different educative proposals reveals strengths and weaknesses. In this respect, the critical areas are the weakness and incipient nature of some educative proposals centered on continuing education and training, the theoretical educative approaches discordant from practices, the lack of recycling of educators and nursing service managers and the tension and dispersion of graduate education.

Potentials refer to the conception and structuring of priority development proposals of educative programs focused on the promotion and strengthening of continuing in-service education, the appropriation of theoretical premises for the strengthening of educative practices, the training of teachers and managers with different educational backgrounds, the effective insertion of education in the work process and in the systemization of nursing care, the definition of effective graduation policies and the approximation between the academy and the services.

Therefore, we depart from the understanding that education plays a central role in the composition and dynamics of the workforce, in short, in the qualification of nursing care. Turning these challenges into problem-solving actions and achieving results imply the reformulation of the educative systems, including the articulation among different education levels and the reorientation of curriculum contents for the construction of knowledge and practices. Also, pedagogical models are needed that go beyond the technical model and consider education as a form of promoting the subjects and the consequent integration between practice and theory, articulated with individual and population health needs.

As regards the services, evidence points towards the reorganization of the work process and the systemization of care through educative actions articulated with care, permitting the involvement of individuals who are systematically able to reciprocally combine care and education, with a view to more impartial and problem-solving actions.

In that sense, the objective in this study is to evidence the educational trends in nursing work in Latin America, so that the exploration of the current scenario can indicate possibilities for advances that can guarantee the professional transformations, which are linked with the populations' health needs.

 

Materials and method

This study is characterized as a qualitative, exploratory and documentary research^2,3,4. The data were collected in nursing journals published in Latin America between 2000 and 2005, which were available in print or included in virtual databases and/or libraries, such as: CINAHL- Cumulative Index to Nursing & Allied Health Literature, LAPTOC- Latin American Periodicals Tables of Contents, BDENF- Base de dados em Enfermagem, LILACS- Literatura latinoamericana em Ciências da Saúde, ERIC: Education Resources Information Center, SCIELO: Scientific Electronic Library Online, Latindex, Cuiden Plus, Periódica, ULRICH'S.

Therefore, abstracts were investigated whose descriptors or key words contained the terms: continuing education, permanent education, education at work, continuous learning, in-service training. Based on these abstract, the full versions of the articles were included in a database, specifically developed to catalogue the articles. In this study, nursing journals were investigated that were available in print and on-line in databases. In the first phase of the research, the search was undertaken through the identification of keywords and the reading of abstracts from 3816 articles, distributed across 1744 issues of 72 journals, originating in 14 different Latin-American countries.

In the second research phase, 299 issues were reviewed, with 3310 abstracts and key words, with a sample of 70 complete articles about education at work, from which 15 were extracted for exhaustive analysis. The texts that focus on educational trends at work were published in journals from seven different Latin-American countries. The contents were interpreted through the thematic analysis method^3,4,5.

 

Results and discussion

Based on the research data, a short scenario can be composed of the authors' insertion in the respective work spaces, as well as the percentage of publications focused on education at work. Eight of the articles analyzed come from Mexico, corresponding to 11.4% of the sample of articles analyzed. Five journals from Colombia were investigated, including 599 articles, 12 of which discussed education at work, corresponding to 17.2% of the investigated articles.

In Chile, one journal was investigated and 88 articles were reviewed, resulting in one article about education at work, corresponding to 1.5% of the articles analyzed. In Cuba, one journal was investigated, with 78 articles, nine about education at work, corresponding to 12.8% of the investigated articles.

In Brazil, seven journals were considered, with 2213 articles, 37 of which addressed education at work, corresponding to 52.8% of the investigated articles. One journal was investigated in Paraguay, with 15 articles, one of which was considered focused on education at work, corresponding to 1.5% of the articles analyzed. In Argentina, one journal was considered, with 98 articles reviewed, two of which were focused on education at work, corresponding to 2.8% of the articles analyzed.

The comprehensive analysis of the research data shows that most of the authors, indifferently of the country of origin, are somehow affiliated with the academy, whether as faculty members, professionals seeking qualification (Ph.D. and M.Sc.), specialization and undergraduate students, while the remainder is active in care practice. The authors holding a Ph.D. are distributed as follows: Brazil 77%, Colombia 15%, Chile 5% and Mexico 3%. Among the authors holding an M.Sc., 60% are from Brazil, 24% from Colombia, 12% from Mexico and 4% from Chile. The large majority of the authors holding an undergraduate degree come from Cuba 42%, followed by Mexico 27%, Colombia 25%, Argentina 4% and Paraguay 2%.

As regards the activity area, approximately 83% of the authors are faculty members active in teaching and research [...], while 17% are affiliated with nursing care and related activities. The percentage of articles involving education at work in Latin America corresponds to approximately two percent of all publications (2.11%) in the journals.

 

Educational trends at work in Latin America

The exhaustive reading of the texts, categorization and classification in thematic areas, as consolidated in the response structures, reveal different foci in the field of educative in nursing and health work, such as: education at work and the different levels of praxis; education in the work process; education at work and the relation between taking care and educating; education at work from the perspective of knowledge construction; education at work and educational trends. As only part of the sample could be discussed, however, the category 'education at work and educational trends' is highlighted. The description of these thematic categories was based on two trend structures: the first refers to 'educative proposals focused on technical development' and the second to broader conceptions of education at work characteristic of proposals based on the 'premises of continuing education'.

The technical trend

The technical trend can be evidenced in eight publications^{6,7,8,9,10,11,12,13} from different countries, including Brazil (Revista Eletrônica de Enfermagem, Revista Acta Paulista de Enfermagem, Revista de Enfermagem da USP); Cuba (Revista Cubana de Enfermería); Mexico (Revista Del Instituto Mexicano Del Seguridad Social) and Paraguay (Revista Paraguaya de Enfermería). The texts demonstrate that the options for education at work are linked to the range of services offered in the health systems, which imply a demand for trained professionals to act in the different areas. The objectives of this educational trend are more precisely related to the feasibility of the actions.

 

 

In the technical trend, education is linked to the valuation of know-how, to training for the skilled performance of activities, to scientific knowledge, behaviors and interpersonal relationships. In that perspective, the educative modality of training in educational programs at work is considered necessary, due to changes in the economy, globalization, productivity, quality and competitiveness, aspects in which human beings gain a fundamental role in companies' development. In this educative premise, training and the development of nursing staff are emphasized, which are normally put in practice by continuing education professionals. Thus, education is understood as a powerful instrument for professional training, independently of the adopted focus or the educational strategies used, aimed at developing skills for the appropriate performance of the work, attending to institutional requirements and improving the health services.

Some aspects characteristic of this educational modality include actions like: introduction and familiarization of newly hired workers aimed at preparation and adaptation and inclusion in the services; training for the development of more productive subjects, adaptation to the service to improve human relations and facilitate the integration; continuing education or recycling refer to the educative process, aimed at maintaining the updates needed and their application on the job; development is related to programs that grant the individuals opportunities for improvement and increased knowledge and professional skills. The choice of educational models at work that are more focused on technical training derives from different factors, including: changes in the economy, new productivity and quality requirements; adaptation to the work process; adaptation and training of newly hired workers; need to develop care protocols, systemization of nursing care; training to intervene in certain procedures.

From a market perspective, education at work takes the form of an intervention and solution and starts to be conceived for the qualification of competitive workforce in different production segments. The justification for this option is due to socioeconomic and financial situations, market competitiveness, which intend to deliver more problem-solving services, with low costs and high care quality. In this corporate perspective, the working subjects are means that need to be optimized to achieve a maximum output. The research shows that these educational conceptions appear more clearly in articles published in different countries, but it is in Chile, Argentina, and mainly in Cuba that these educational aspects stand out.

We depart from the perception that the educational programs to encourage technical recycling, whose training can be punctual, sporadic or continuous, are necessary, if not fundamental for the safety and qualification of the services. Nevertheless, one observation does not relate specifically to the educative modality or strategies, but to the systemization of programs that only focus on the technical narrowness of the subjects' development.

The trend to transform and promote the subjects through continuing education

This trend is present in seven articles^{15,16,17,18,19,20,21}, published in countries like Brazil (Revista Brasileira de Enfermagem), Colombia (Revista Aquicham, Revista Avances en Enfermería, Revista Investigación y Educación en Enfermería) and Cuba (Revista Cubana de Enfermería). Continuing education serves as an educative alternative to overcome and transform educative practices, based on the theory of significant learning, problematization and some principles of andragogy.

 

 

The transformative trend with educative premises linked to continuing education is the educative modality present in articles published in different countries. Although it is perceived that these conceptions contain orientations, forms and strategies, and sometimes similar but sometimes different interests, they are related to factors such as the socioeconomic, political and cultural situation, staff training, legislation, health policies, interests and organization of work according to each country's particularities.

With regard to continuing education at work as a possibility for transformation in education, health and nursing, it is evidenced that this educative movement permeates proposals, even though incipient, in all countries under analysis, but that it is in Brazil, Mexico and Colombia that this educative conception stands out further in the publications. In Colombia, in recent decades, the conception of continuing education at work has been emphasized and disseminated as one of the most appropriate strategies to transform health practices. The need for continuing education at work is associated with the technological revolution, transformations in the productive and organizational structures and the increasing participation of different social sectors.

Specifically in Brazil, the development of continuing education proposals²² is based on the National Policy of Continuing Education in Health. The guiding principles of the continuing education proposal in health include the transformation of the educative processes, pedagogical practices and service organization. In this conception, continuing education is aimed at a multiprofessional public and is an institutionalized part of the work process. It is articulated and constructed through the focus on daily problems in the teams' practices, in a continuous manner and aiming to transform the social practices in health.

In Brazil, the continuing education proposal recommends the articulation among education, training and services, accompanied by social control, against the theoretical background of the premises of significant learning, problematization and adult education. In this respect, the importance of further approximation between conception and execution is highlighted, that is, theory and practice with social meaning, which can serve as the differential as a strategy to go further in education at work^23,25

Continuing education proposal are educative alternatives to overcome, transform, transcend the conventional education models aimed at technical training, with a view to the transformation of educative practices, based on the significant learning model. In the continuing education proposal, theory and educative practice are inseparable, defending learning that makes the individual learn always, in a constant construction process. In this learning movement, theoretical knowledge and practical experiences coexist, and this relation has a determinant effect on actions and decisions.

The experimentation of theoretical knowledge in practice permits the construction of new knowledge. This ratifies the importance of articulating theory and practice, transforming the work environment into a learning laboratory, developing a cultural of knowledge sharing, with the construction and dissemination of professional knowledge. As a part of human beings' lives, work is understood as a source of education. Hence, it is considered that knowledge, deriving from the articulation between theory and practice, permits mobilizing the competences required in health work.

Over the last 15 years, various experts affiliated with the Pan American Health Organization^26,27,28 have developed studies about continuing education. In this conception, continuing education differs from other educative modalities by its focus, privileging the approximation between the conception and execution of educative programs.²⁷

Continuing education serves as a starting point to dignify work and put it at the citizens' service, whether these are professionals or users, reviewing and redefining roles and functions, enhancing autonomy levels, establishing work teams with high levels of critical reflection skills and defining and implementing institutional improvement projects²⁵ Therefore, with a view to the effectiveness of these programs, educative models need to be reconsidered and new competences need to be incorporated in order to achieve efficiency, efficacy and quality in health care.

The Pan American Health Organization²⁶ and other international cooperation entities have been stimulating continuing education programs in the last 20 years²⁷ These programs attend to a range of objectives, including: technical recycling aimed at learning new knowledge, introduction of new technologies, standards, which can be implemented through semi-distance courses, seminars, workshops and distance education.

The educative intervention modalities involve learning in work situations, tutorial learning and distance education. Sensitization refers to changes in foci, policies, interventions and approaches, which can be developed through seminars and observation visits. The promotion of attitude changes includes the introduction of new work forms (in teams, networks), promotion of inter-institutional and intersectoral work, treatment of ethical and citizenship issues.²⁷

In Brazil, continuing education gained further visibility based on the Ministry of Health's proposal, in which continuing education was considered in articulation with the pedagogical concept of establishing organic relations among teaching, services, social control²⁹ and health care, enhanced in the Brazilian Health Reform, aiming for articulation in the relations between education and sectorial management, institutional development and social control in health. In this proposal, continuing education in health departs from the combination among learning, critical reflection about work and problem-solving ability of clinical care and collective health promotion.²²

Similar to some conceptions recommended by authors from other Latin American countries, the continuing education proposal in Brazil departs from the premises of significant learning, which suggests that the professionals' transformations should be based on critical reflection about professional practices. In this respect, the intent is to approximate 'the world of education and work', in which the relation between learning and teaching is incorporated into the daily reality of organizations and in work. The educative processes to train health workers should be developed in the framework of people's and population's health needs.²²

Using the premises of significant learning, continuing education intends to transform the professional practices through critical reflection. The objective is to transform the professional practices and the organization of work itself, based on the needs of people's and populations' health, sectorial management and social control in health.²³

In Brazil, as from 2004, a political proposal for Continuing Education has been developed, which is aimed at transforming the professional practices based on the problems faced in reality and the subjects' knowledge and experiences. In the ministerial proposal, continuing education in health makes significant and profound changes in professional education with a view to the consolidation of the Unified Health System³⁰ (SUS), including the elaboration of projects for changes in technical, undergraduate and graduate education, residency programs, among others.²²

In Brazil, in the attempt to complete the educative process, the Continuing Education Policy in Brazil establishes the participation of different social segments, especially service providers and users, setting the consolidation and strengthening of the SUS as the paramount objective. Thus, the educative proposal is related to the principles that guide this system, that is, decentralized construction; universality; integrality and popular participation. Continuing education aims to permit personal and institutional development, as well as the strengthening of educative actions, accompanied by service management and social control.²²

Due to these facts, it is considered that the educative proposals need to be socially constructed, with a decentralized decision process that is articulated with the local realities. The concept of continuing education in general is linked to the transformation of educative practices and the reorganization of the work process. The restructuring of the work process, including the educative culture based on the premises of continuing education, will entail new ways of projecting and structuring the work, with a systemized relation among teaching, learning, care delivery and management, in which the actions are reciprocally strengthened.

Some reflections about continuing education permit understanding that training is a broad process that affects learning; it is a product of reflections, experimentation, previewing new practices, skills and competences; the methodology intends to question the work practices and move beyond the trend to seek fast and easy solutions. The changes in people and teams do not happen in a single action, but as part of a chain of actions.²⁶

The objective of continuing education is transformation in the work process, with a view to qualification, equity in care and access to health services. The educative proposal aims for the development of educative actions that produce knowledge and attitudes based on the problems identified in daily work. Departing from reflections about the educative processes at work, it can be concluded that continuing education is not restricted to a space that distinguishes it from other educative processes. As an educative and health work process, it departs from the social demands, outlined by the limits, possibilities, difficulties and interests in the organization of the educative processes, the organization of work and the relation with society.

 

Final considerations

The nursing context in Latin America shows a range of situations, which can include: different courses and qualifications, professional and social participation, staff dimensioning and determination in relation to the population, concentration in certain regions, migration of nurses from Latin-American countries, mainly to North America, Europe and Oceania. This picture is associated with the quantitative and qualitative shortage in most country and the concentration in large urban centers, enhancing the human resource difficulties in certain regions. Nevertheless, action proposals are evidenced to solve these issues, which have been recommended and permeated by professional entities, philanthropic foundations, private entities, governmental entities and international organizations like PAHO (Pan American Health Organization) and WHO (World Health Organization). In a joint declaration with health ministers and secretaries, these launched the Health Agenda for the Americas 2008-2017, including a list of intentions to propose problem-solving actions in critical areas, in accordance with the priorities and particularities of each region³¹

The study shows that the educational trends at work in Latin American countries emphasize technical care. Nevertheless, it should be noticed that this educative modality is linked to the urgent need for trained professionals and for the systematic review of different forms of practice. The objectives of this educative modality are more punctual and determined. This educative sense is projected and constructed based on the care practices, has problem-solving intentions and the focus is determined, final and punctual. It should be emphasized, however, that this educative modality is very important for the qualification of nursing care.

On the other hand, a trend towards the valuation of more comprehensive proposals is perceived, such as continuing education. Most theoreticians in this area are college professors, professionals seeking further qualification and undergraduate students included in studies and research projects. The objectives of this educative modality are more comprehensive and diversified. An approximation movement is observed between the academy and health services. This interaction can serve as the starting point for the construction of an educative proposals for the development of joint actions, which can lead to individual, collective, institutional and social empowerment.

The study highlights the importance of distinguishing educative proposals. In this respect, it is of no interest to establish benchmarks or define the educative modalities or proposals in quantitative and qualitative terms. Instead, they should be considered in an integrated manner, in accordance with the needs of the proposals and populations.

Due to the spatial range, the different cultures, socioeconomic situations and policies found in Latin America, it should be kept in mind that the different modalities are somehow linked with these factors. Finally, a movement towards the implementation of educative proposals is perceived which are based on the premises of Continuing Education, which PAHO and WHO have been recommending over the years, with distinguished experiences according to the needs and particularities of each region, the subjects and workers and the populations in general^1,31.

 

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