This essay aims to reflect on the production of health education, in the context of distance learning courses, focused on health management, which proposes the semi-presential logic. From the axes Knowledge and Permanent Health Education, it builds arguments for a dialogue about learning and teaching at a distance. It points to a virtuality that is updated in a territory of micropolitical and technopolitical nature, as it involves changes in relationships, processes, health acts, organizations and people.
Professional training; Permanent Health Education; Health education
In recent years, distance education has been pointed out and used as a resource in different areas of knowledge. In the health field, distance education has been used as a resource for the training of health professionals, with an interesting aspect due to the short courses aimed at updating and training. A good example is the large-scale movement promoted by the Open University of Brazil in partnership with the Ministry of Health that offers different courses.
The offer is well diversified and widespread with the support of the municipal, state, and general services for all segments of the health field. In this sense, we can find free courses, paid courses, totally distance and open courses, in which the students organizes their own training trajectory, as well as courses in semi-presential format. That is, the distance education modality allows varied arrangements for its structure that adapts according to the objective and profile of the target population.
In this wake of expansion and improvement of professional qualification, we understand that it is possible and bet on the proposal of a semi-distance learning course, centered on the logic of Permanent Education (PE), on a basis that finds in work experience its main pedagogical element.
The activities contained in the daily work process present important and indispensable elements for the construction of new knowledges and learnings. An artifice that does not dispense with theoretical content and arrangements to subsidize discussion and debate, but that puts concepts as a catapult to launch the idea that comes from working experience on another level.
Training, based on distance education, promotes a design that, at the same time – in this case, a proposal that targets the health unit manager – puts into consideration the management and the generation daily life of this actor. The course proposal is in its fourth edition, was prepared by professors from the Fluminense Federal University and aims to train professionals who work in the management of Basic Health Units – Improvement Course in Management of Basic Health Units, Clinical and Care Management. The mobilization of knowledge that circulates in the process of managing a health unit requires reflection on the ways to organize, plan, delegate, conduct and exploit existing resources. In its generating portion, we identified the capacity of creation, mobilization of the team and the problematizing dimension of their own practice.
The proposal of the course on basic units management is centered on conducting PE for professionals who act directly in the role of manager in primary care, in the semi-presential mode, with the support of a virtual platform. The training structure highlights practices related to structured processes, such as unit input management, and unstructured processes, such as work process management. Increasingly, the trend of the health facility manager is related to the identification and need for activities that are closer to clinical management and care, such as the use of tracer cases, sentinel event analysis, health and disease management, singular therapeutic project, care lines management, shared consultation between generalists and specialists, case management, among others.
The demands for this actor are of the same dimension as the complexity surrounding primary care. The ordering function of care networks thickens the actions and requires attributes and guidelines that involve work, such as: territorialization, clientele and bonding, teamwork, coordination and longitudinality of care, among others, which become part of the repertoire’s activities of the manager of the Basic Health Unit.
The debate and research on the role of the manager allowed the design of three macro-competencies that structure the course proposal, seeking an alternative to the functionalist model that is presented for services, with low power to change the daily actions.
The macro-competencies work management, network management and input management help the elaboration of tool actions that enhance the manager’s actions and that may dispute another logic of clinical organization and care from the management; recognizing that management and care are inseparable actions.
The distance education of the Improvement Course in Management of Basic Health Units, Clinical and Care Management puts us in the space and ability to be a propositional proposal, with content necessary to manage and generate it. Space for creativity and reflection that generates a dense and complex daily work such as that of the health unit manager.
The construction of these spaces communicates ideas that are narrated in a story, which in the act is updated, brings to the present counted the memory of the lived, coupling in this act the reflection of the event, ways and arrangements of knowing and producing knowledge from the that was and is experienced in daily work.
The semi-presential training is brought in this text as an element associated with PE in the health field as a strategy for the formation of professionals; an essay on practice as knowledge production in semi-presential education.
The semi-presential modality and health work as a source of knowledge
A semi-presential course, in a generic way, are formations that are structured partly at a distance and partly in person. According to the Ministry of Education, the semi-presential modality is applied to courses structured as in-class courses with, at least, 20% of the total workload of distance learning in virtual environments. In the case of the Improvement Course in Management of Basic Health Units, Clinical and Care Management, we built a distance training with a total workload of 180 hours, with 48 classroom hours.
The modular structure of the course is grounded in concrete problems in the primary care management work process. The beginning of the course is a face-to-face meeting, as it constitutes the problematizing ground for the virtual dynamics. The pedagogical approach of tutors (professionals selected and trained by the Fluminense Federal University to accompany students) is accompanied by pedagogical coordination and aims at mobilizing, even at a distance, significant elements for knowledge and for the transformation of professional practice.
In this perspective, we understand that, in the daily work, we are immersed in plans crossed by knowledge of diverse origin that complement each other in the act of activity. According to Merhy11 Merhy E. Saúde: cartografia do trabalho vivo. São Paulo: Hucitec; 2002., it is in the act of activity that the living work operates and that we employ the technologies present in our technological suitcase. In this meeting worker and user, knowledge and knowledge are unfolded.
However, most of the time, we choose not to reflect on what happens to us, what touches us and puts us into reflection22 Bondía JL. Notas sobre a experiência e o saber de experiência. Rev Bras de Edu 2002; (19):20-28.. We react, often, to what happens to us mechanically, in automatic movements and attitudes, in a reactive manner, where the answers are already built and we look for them on our mental shelves during the work process, offering as a solution to the problems we can identify.
Reactive practice seeks in speech what fits into our mental shelf of ready-made answers. The choice to make available what touches, the event in the productive act of health, whether in direct attention to the user, or in management activities, enters a territory of work as what touches us, implies us; and we enter into a dynamic of doubt in dramas33 Schwartz Y, Echternacht EH. O trabalho e a abordagem ergológica: "usos dramáticos de si" no contexto de uma central de tele-atendimento ao cliente. Informática na Edu. Teoria & prática. 2007; 10(2):9-24. that asks us how much we owe, we want to put in that action, that mix of knowledge and wisdom in which user and professional are present. A part of the self, of the creative capacity that surrounds the subject, is summoned from the implication or implications of which the result is surprising, and is built and constituted in other dynamics, possibilities of being in life and being professional.
What touches us urges in our body, speaks through our mouth, without form, without text. A knowledge that takes shape and meaning when it is put into discussion in debate, in the practice of otherness. They communicate ideas that are narrated in a story, which is updated in the act, brings to the present counted the memory of the lived. In this sense, we can imagine the knowledge plans that circulate in the territory of the work being constituted of diverse colors, shapes and arrangements.
Types of knowledge that we can gather according to events and our experience in everyday work. In this sense, we can use some of this knowledge to illustrate this movement of formation in the semi-presential modality and in health work. Chart 1 below brings us closer to this idea and allows us to move forward in this construction.
Distribution of types of knowledge produced during the health work process and their main characteristics
Instituted as the moment of universality, in the dynamics of institutional analysis33 Schwartz Y, Echternacht EH. O trabalho e a abordagem ergológica: "usos dramáticos de si" no contexto de uma central de tele-atendimento ao cliente. Informática na Edu. Teoria & prática. 2007; 10(2):9-24., concerning the constitution of Laws, norms generally represent universality over something or its maximum values.
For the ergologic approach44 Lourau R. A análise institucional. Petrópolis: Vozes; 1996. self-use is present at the moment we develop our work, and we are faced with the decision between what is prescribed and what is real in the work process. In this movement between what is prescribed to be done and what the action actually takes place, the use of oneself to develop the work.
Loreau55 Lourau R. Implicação-Transdução. In: Altoé S, organizadora. René Lourau: analista institucional em tempo integral. São Paulo: Hucitec; 2004. p. 212-223. describes implication as an analysis that expands on the movement of production of the subject in action and his affections, belonging, references, motivations, libidinal investments, as well as the relations of knowledge-power always produced in the encounter.
The use of various types of knowledge is present in the daily lives of all of us workers. Thus, a semi-presential course proposal, which focuses on the production of training in service dynamics, puts us in the knowledge production plan in this territory cut by these various types of knowledge. Therefore, it is important to recognize the pedagogical dynamics in this production of this knowledge, being extracted and or building visibility for the construction of training.
Thus, the tutor, who accompanies the student of the course, has the role of opening way, of producing with the collective of students devices that cause the vibration of this knowledge. As an example, we can take the students’ narrative proposal as the focus of the reflexive dynamics, or the production of devices that question the practice, which puts under analysis what is produced every day in the service. The idea is that the tutor and student collective can exercise the experience of being knowledge producing subjects.
The different types of knowledge, when they gain visibility, expand the possibility of debate based on the work as a knowledge producer and operate and impact on the production of health work. The semi-presential structure, with meetings between the participants, allows exploring the discussion about the types of knowledge, including the devices built by the collective, such as cases, films, etc. The exchange mediated by this knowledge can be an element capable of change in the health work process; this calls for the inclusion of the semi-present modality to be also linked to the dynamics of Permanent Health Education (PHE).
The semi-presential modality and Permanent Health Education
PHE, as a basis for teaching and learning in semi-presential mode, includes these knowledge waves that circulate in services. The important thing is to talk about the practice and care that are not in the protocol, but have an effect on life and the possibility of building management that points to movements to generate sharing. Narrating what I do not tell anyone I do in my service, but that I recognize as a potent practice for my day to day life. The reflection on the acts and attitudes of my daily life, in which the practice of PHE, with its wheels, is a great invitation.
The PHE wheels move in the direction of provoking reflection on the work process of the professional, the team, relating, in this process, the dimension of management, user, social control and clinic. A quadrangle is structured to welcome in the PHE wheel the reflection of the problems brought by the participants. As a motor, this movement drives small changes in daily practice and the work process66 Ceccim RB, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004; 14(1):41-65..
The National Policy of Permanent Education in Health (PNEPS)77 Brasil. Ministério da Saúde. Portaria nº 1.996, de 20 de agosto de 2007. Dispõe sobre as diretrizes para a implementação da Política Nacional de Educação Permanente em Saúde. Diário Oficial da União. 20 Ago 2007., as a strategy of the Unified Health System for the training and development of health workers, can be understood as a continuous process, which takes place in the daily work, of revitalization and personal and professional overcoming, individually and collectively, with the purpose of qualifying, reaffirming or reformulating values, building integrative relationships between the subjects involved for a critical and creative approach.
In this way, the PNEPS reaffirms the understanding and treatment of training, not simply as a technical matter, but of a techno-political nature, since it involves changes in relationships, processes, health acts, organizations and people. A micropolitical logic present in the Improvement Course in Management of Basic Health Units, Clinical and Care Management, for inducing the course participant to reflect on their own doing.
The logic of continuing education is decentralizing, ascending and transdisciplinary. This approach can provide: institutional democratization; the development of learning, teaching and creative coping skills in health situations; working in matrix teams and permanently improving the quality of health care, as well as constituting critical, ethical and humanistic technical practices88 Ceccim RB, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis [internet]. 2004 [acesso em 2019 out 3]; 14(1):41-65.(50).
Understanding education with its permanent aspect is adopting social relationship as its main vector, recognizing that knowledge has been and is produced by different subjects and their interactions. Sprouting, in the meeting between students and teachers, what happens and that affects knowledge in its production makes us think of pedagogical tools that exercise the mediation of the subjective spaces of knowledge, besides making sense, but producing implicated and epistemic subjects in their daily work. Not as workers with autonomy, because the health work process is rich in autonomous actions by the health professional, autonomy that chooses this way or that way, offering activities regardless of the problem or health needs of the user. Therefore, autonomy, in the sense of independent decision making, we have as a professional, who is in the scientific and formatted knowledge of the hegemonic sciences that inhabit the health field. However, we are talking about and want to enter into the construction of implicated/epistemic subjects who advance in the horizontality of the pedagogical relationship by providing the different circulating knowledge in the technological valises that operate in the meeting.
In this movement, the PHE wheel incorporates the construction of collaborative pedagogical practices that can move towards non-centrality in content as an interesting path for this construction of the semi-presential dynamics of a distance learning proposal. Pedagogical practice that is focused not only on content, but on the subject of learning, in this case, the student and its mediator, as an attribute of the millennial practice of teaching; which involves different shades in this interaction of relationships that are provided from what happens and what touches when we are in the movement of producing ourselves and the world around us, we are and are in a permanent process of producing knowledge and wisdom.
A semi-presential course in the mobilizing logic of health practice
Being alive is a state of knowledge production into which we are launched from birth. The work brings us to a plan of this dynamic of learning and teaching, a double process that folds into the production of knowledge, with elements that emerge and can be expressed in various ways. A knowledge that becomes useful when it is incorporated into everyday doing, in existence, as that which causes other actions. However, it is worth noting that all knowledge has validity; The question goes through the questions of reflection on what touches us from daily practice.
Knowledge is present to the same extent as the problems we can identify. However, the problem only makes sense for the use of such knowledge when we come to recognize it in a process of problematization of practice. Therefore, we are talking about a non-hierarchy of values for knowledge or wisdom: they are all valid, the question is how to use, in what situation, which event I use of such/what knowledge. The combinations are numerous and surprising in this case the mediator/teacher gains importance in this problematization process.
Problematizing here has the design of a constant search, according to Foucault99 Foucault M. Polêmica, política e problematizações. In: Foucault M. Ditos & Escritos V: Ética, sexualidade, política. Rio de Janeiro: Forense Universitária, 2010, which constitutes a way of looking at common objects and situations seeking a distance. A distancing that is necessary for a deconstruction of the notions of true/false, right/wrong, beautiful/ugly, etc to occur. This movement allows us to rethink what is considered normal and natural. Questioning where it came from, where it appeared, and what we take for granted is not an absolute truth, but something produced from experience. A socially dated and inscribed creation, something that can therefore be questioned.
The distancing, in this logic of problematization, refers to a temporal withdrawal, because the opening in time causes the necessary detachment to look at that given production, that problem circumscribed in a given historical moment as only a production, and not as an absolute truth. This is an important process of being exercised daily, distinguishing patterns no longer as references, since there is no absolute truth.
The construction of spaces in which we can question and criticize patterns, when mediated, gains power, because it is a matter of recognizing a horizontal relationship in this process, of recognizing that the places of mediator and student are not given, but rather that they are produced in a deep movement of otherness. A movement that seeks to overcome ignorance of what is ignored, beyond the importance of knowing oneself to recognize one’s own self; and in this process, to know oneself through the recognition of access to truths1010 Foucault M. Hermenêutica do sujeito. 3. ed. São Paulo: Martins Fontes; 2010..
The mediator, by extending the experience to different levels of knowledge – like a rhizome that is now between, outside, inside – crosses, coils, folds and unfolds, conducts the mediation; producing, in this movement, paths that were never before thought or traced, but which are constitutive of the search to overcome ignorance of what is ignored.
Bringing distance education, in the semi-presential modality, is to recognize a pedagogical practice that is not centered on content, is not centered on the teacher, is not centered on the student, but is centered on the experience of knowledge that is in virtuality and updated in the meeting mediated by the experience of the world of work; and, therefore, in the collective needs of the user seeking health services.
The updated formation with a powerful mediation that incorporates the current elements around us follows the way of breaking with what is given, with the instituted in this sense, not only reading texts and articles is essential, but also small journalistic texts, videos of the web, the construction of hypertext that, built in a cooperative environment, stimulates peer collaboration, knowledge exchange and experience. Listening to the other’s experience, connecting with what has been touched and what happens to the other can be potent in the virtual environment where different forms of expression are valid, since knowledge has no single way of expressing itself, but multiple ways. Exploring these forms is recognizing mediation, but also experience, what touches and happens.
Knowledge about the micropolitics of health work built on the logic of continuing education constitutes arguments for a dialogue about learning and distance learning in the Improvement Course in Management of Basic Health Units, Clinical and Care Management. The experience of the execution of the course points to a virtuality that is updated in a territory of micropolitical and technopolitical nature, since it involves changes in relationships, processes, health acts, organizations and people.
The proposal is backed in experience, as a basis for pedagogical development. Content that can be explored and broken down into problematic dynamics, disputing another logic of problematizing managers’ actions, which is accompanied by professors from Fluminense Federal University who are linked to the pedagogical support of the course.
The presential and distance monitoring of the students boosts the reflection and the elaboration of valid knowledge for the management work in primary care. A knowledge that starts from the daily work, produces a process of collective reflection and returns with the possibility of transformation of practices.
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- 1Merhy E. Saúde: cartografia do trabalho vivo. São Paulo: Hucitec; 2002.
- 2Bondía JL. Notas sobre a experiência e o saber de experiência. Rev Bras de Edu 2002; (19):20-28.
- 3Schwartz Y, Echternacht EH. O trabalho e a abordagem ergológica: "usos dramáticos de si" no contexto de uma central de tele-atendimento ao cliente. Informática na Edu. Teoria & prática. 2007; 10(2):9-24.
- 4Lourau R. A análise institucional. Petrópolis: Vozes; 1996.
- 5Lourau R. Implicação-Transdução. In: Altoé S, organizadora. René Lourau: analista institucional em tempo integral. São Paulo: Hucitec; 2004. p. 212-223.
- 6Ceccim RB, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis. 2004; 14(1):41-65.
- 7Brasil. Ministério da Saúde. Portaria nº 1.996, de 20 de agosto de 2007. Dispõe sobre as diretrizes para a implementação da Política Nacional de Educação Permanente em Saúde. Diário Oficial da União. 20 Ago 2007.
- 8Ceccim RB, Feuerwerker LCM. O quadrilátero da formação para a área da saúde: ensino, gestão, atenção e controle social. Physis [internet]. 2004 [acesso em 2019 out 3]; 14(1):41-65.
- 9Foucault M. Polêmica, política e problematizações. In: Foucault M. Ditos & Escritos V: Ética, sexualidade, política. Rio de Janeiro: Forense Universitária, 2010
- 10Foucault M. Hermenêutica do sujeito. 3. ed. São Paulo: Martins Fontes; 2010.
- Publication in this collection
10 July 2020
- Date of issue
03 Oct 2019
16 Nov 2019