Revisiting Paths: the Insertion of the Multiprofessional Residency
In the HospitalEnvironment

Revendo Caminhos: a Inserção da Residência Multiprofissional no Âmbito Hospitalar

Revisando Caminos: La inserción de La Residencia Multidisciplinar enel âmbito del Hospital

Maria Edilania Matos Ferreira Furtado
Odemir Pires Cardoso Junior
Benedita Jales Souza
Renata Belizário Diniz
Kamila Maria Maranhão Sidney
Raissa Rabelo Marques Rebouças
Maria Teresa Aguiar Pessoa Morano

ABSTRACT

Objective: This study aims to describe the insertion of the Integrated Residence in Health in the hospital environment, in order to share the experience of its deployment. Description of the experience: The experience occurred at a Cardiopneumogy referral hospital in the city of Fortaleza, in the period of two years (2014-2016). The experience was crossed by shared knowledge and practices and among the challenges and achievements it was possible to realize the greatness of interprofessional work, especially with regard to the differencial that this performance can provide to users of the service. Conclusion: The Residence can be attributed not only to the technical and scientific improvement of professionals, but above all the personal-ethical one, enriched by the exchange of knowledge, so relevant in the promotion of integral health care.  

Keywords: Unified Health System. Competence-Based Education. Patient Care Team.

RESUMO

Objetivo: O presente estudo objetiva descrever a inserção da Residência Integrada em Saúde no âmbito hospitalar, no intuito de compartilhar a experiência de implantação desse fazer. Descrição da experiência:a vivência ocorreu em um hospital de referência em cardiopneumologia da cidade de Fortaleza, no período de dois anos (2014-2016). A experiência foi atravessada por saberes e fazeres compartilhados e entre os desafios e conquistas foi possível perceber a grandeza do trabalho interprofissional, especialmente no que concerne ao diferencial que essa atuação pode oferecer aos usuários do serviço.Conclusão:pode-se atribuir à residência não apenas o aprimoramento técnico-científico dos profissionais, mas sobretudo o ético-pessoal, enriquecido pela troca de conhecimento, tão relevante na promoção de um cuidado integral em saúde.

Palavras-chave: Sistema Único de Saúde. Educação Baseada em Competências. Equipe de Assistência ao Paciente.

RESUMEN

Objetivo: El presente estudo tiene lo objetivo de describir la inserção de la Residencia Integrada em Saúde en el ámbito del hospital, com el intuito de compartilhar la experiência de implantação de esa acción. Descripción de la experiência: La experiencia se llevó a cabo en un hospital de referencia en cardioneumología en la ciudad de Fortaleza, en el período de dos años (2014-2016). La experiência fue atravesado por el conocimiento y las prácticas compartidas y los desafíos y logros fue posible comprender la grandeza de la obra interprofesional, especialmente en relación a la diferencia que esa acción puede proporcionar a los usuários del servicio. Conclusión: Se puede asignar a la residencia no solo lá mejora técnica y científica de los profesionales, pero sobre todo lamejora ético y personal, enriquecido por el intercambio de conocimientos tan importante en la promoción del cuidado integral en la salud.
 
Palabras clave: Sistema único de Salud. Educación basada en competencias. Equipo de Atención al Paciente.

INTRODUCTION

The Unified Health System (SUS) emerges as a proposal to offer comprehensive care ranging from the most basic needs to those of high complexity, prioritizing promotingand protectivehealth actions. The integrality of attention, therefore, is the fundamental principle of this system and comprises a set of integration actions between the primary, secondary and tertiary levels, which, in turn, play a role of interdependence in the health problem-solving of the population1.
Faced with a new approach in the scope of the brazilian public health, there is a need for integration between the fields of health and education, as well as the accomplhishment of changes in educational standards2. Thus, in order to meet these needs, the National Permanent Health Education Policy was created with the purpose of transforming the work practices of organizations and health professionals based on the problems faced in the scenarios of practices in actions aimed at meeting the needs of the subjects and collectivities3.
Interprofessional Education (EIP) emerged as an innovative strategy, whose proposal is to prepare professionals with skills for teamwork, capable of developing collaborative practices necessary for integrality in health care4-5.
In this sense, the Multiprofessional Residency in Health, characterized as Interprofessional Education, constitutes a teaching activity of post-graduation lato sensu in the modality of in-service training. Regulated by Law nº 11.129, of June 30 of 2005, and guided by the principles and guidelines of the Unified Health System (SUS), the Residency Program has as its proposal the implementation of changes in health care6.
The Residence Programs are funded by the Ministries of Education (MEC) and Health (MS). They have a minimum duration of two years, with a total workload of 5.760 hours, distributed in 60 hours a week, 20% of which are allocated to theoretical activities and 80% to in-service training, in accordance with Resolution nº 3, of May 4 of 2010, of the National Commission of Multiprofessional Residency in Health (CNRMS)7.
Believing in the possibility of change of the technical-assistance design of the SUS and giving consistency to the role of health institutions in the training of these professionals, in a proposal that covers the birth of a new worker8, the School of Public Health of Ceará (ESP-CE), linked to the municipalities and hospitals of the state of Ceará, instituted the Integrated Residency in Health (IRH) with the proposal of offering a curriculum based on knowledge, skills and attitudes9.
The IRH has its process based on management, attention, teaching and research, counting on the following areas of strategic concentration on health care: Family and Community Health, Mental Health, Collective Health and, in the hospital environment, Cancerology, Infectology, Obstetrics, Neonatology, Pediatrics, Urgency and Emergency, Neurology and Cardiopneumology.
The interprofessionality is the differential of this Residence, which is characterized by the inclusion of different professional categories in the health area aiming at collective training, in service and in a team, in order to promote the integrality of the care to the user. This way of operating aims to expand the field of work, without, however, giving priority to and respecting the specific nuclei of knowledge of each profession. However, each institution can adapt the Residence Program to its reality, which leads to differences in its operationalization10.
Such program innovates by recommending the passage of professionals through all levels of health care as a way of understanding the organization of the SUS in an interconnected network of reference and counter-referral. To this end, the hospital, community and mental health emphases share their scenarios.
In order to share the experience of implanting a residency in a hospital environment, the present study aims to describe the insertion of the Multiprofessional Residency of the Hospital ofMessejana Dr. Carlos Alberto Studart Gomes (HM) with its advances, impasses and perspectives.
The relevance of this report is to share the experience of a multiprofessional team, believing that studies of this nature, besides bringing knowledge and practices in an interprofessional practice can contribute to the production of scientific knowledge.

DESCRIPTION OF THE EXPERIENCE

The present study is configured as a report on the experience of inserting the first group of Integrated Residency in Health (IRH) of the School of Public Health of Ceará (ESP-CE) in the area of ​​Cardiopneumology, carried out from May 2014 to May 2016, comprising nine professional categories: Psychology, Nutrition, Physiotherapy, Nursing, Pharmacy, Speech Therapy, Dentistry, Social Work and Occupational Therapy.
The initial proposal of the IRHhas occurred with the accomplhishment of a course that preceded the practical activities in service, with the intention of familiarizing and ensuring that the resident professionals appropriated the conceptions that support it, as a space of viabilization of teaching in service, the principles and guidelines of SUS.
The experience had as a practice scenario the Hospital ofMessejana Dr. Carlos Alberto Studart Gomes, an institution of tertiary level that is an integrant part of the network of hospitals in the state of Ceará linked to the Health Department of the State of Ceará (SESA) that carries out diagnosis and treatment of cardiac and pulmonary diseases, outstanding for cardiac and pulmonary transplantation services in the North and Northeast of the Country. It was pioneer in the Northeast in artificial heart implant and ventricular assist device.
It is important to clarify the functions performed by each institution. The School of Public Health (ESP/CE) comprises the training institution, and the Hospital of Messejana Dr. Carlos Alberto Studart Gomes (HM) represents the executing institution in the practice scenario, and each institution is represented by a coordination.
In this scenario, it was noticed that because the hospital residency came from the model of residency in family and community health, some terminologies differed from what was routinely used in the hospital, among them emphases (substituting specialties), care lines (instead of units), core groups (replacing clinical sessions), field groups (instead of multidisciplinary meetings), collegiate group (to designate coordinators meeting), tutorial group (indicating meeting of tutors) and cross-sectional contents (replacing issues related to collective health). In order for these nomenclatures to be internalized it was a gradual and intense process.
Unlike the medical residency, the Multiprofessional Residency began its activities in HM with the territorialization, which caused concern and questioning on the part of some hospital professionals, either for lack of knowledge or for the desire to visualize the professionals acting to meet the needs of the service.
Territorialization is nothing more than a process of “inhabiting a territory”. The act of dwelling produces as a result the embodiment of knowledge and practices.

It is necessary to explore it [the territory], to make it yours, to be sensitive to its questions, to be able to move about with joy and discovery, detecting changes in landscape and in relation to diverse flows – not only cognitive, not only technical, not only rational – but political, communicative, affective and interactive in the concrete sense, detectable in reality, in which the objective and the subjective can dialogue and be dialectically constructed11 (p. 175, free translation)

The process of territorialization began by means of a visit to the units during which it was sought, observationally, to understand health care, social determinants and power relations existing in the knowledge of the organization chart, the flow chart and the hierarchical path of the institution. This moment allowed, also, to know the profile of patients and how this unit is organized to meet their needs.
In the course of the territorialization the routine of intense work was perceived, so that the arrival of the residents was seen as a possibility of strengthening the assistance. However, the hegemonic model, still predominant in the hospital environment, with punctual practices and the use of hard and light-hard technologies, showed the challenge to be faced by residents12.
In-service training is composed of practical activities and theoretical modules. Throughout the Residency, modules were provided with the following themes: territory and health, collaboration and multiprofessional performance and work processes, integrality, intersectoriality, attention networks and lines of care, equity in health and human rights, popular participation, social movements and social control in the SUS, health promotion and popular education, health surveillance, health management, planning and evaluation, knowledge construction – methodology of the scientific work for the construction of the work of conclusion of residence.
The presence of the residents reflected in the daily life of the service, given the differential of their training, fomented both by the content that preceded the insertion of the Program in the Hospital and by those provided during the experience.
On the other hand, ESP/CE as a training institution, starting from a model of residency in family and community health, tried to adapt the programmatic contents to the hospital reality, which could not be applied in its entirety, given the peculiarities that make up each scenario.
Initially, the contents covered in the field groupscaused strangers to residents, since they contemplate contents transversal to all categories. This form of approach, when everyone craved specific knowledge of the emphasis, generated challenges in the participation of these moments of study.
Due to this, after some meetings on the subject, it was established that the hospital institutions would have the autonomy to manage their specific contents during field groups, not forgetting to address the initial proposal to prepare health professionals to work in the SUS.
It was also observed that some preceptors had difficulty understanding their assignments and those of the residents, expressing their fear of relying/allowing them to practice certain therapeutic actions within the service by confusing them, often, with trainees. Such difficulty can be attributed to the fact that, in addition to being the first multiprofessional residence group in the hospital, the training of the preceptors occurred concurrently with the training of the residents.
In addition, the political-pedagogical proposal of the Residence,contributes to the generation of conflicts regarding the posture of the resident, sometimes as a professional, or as a training specialist. This was notorious when they needed to leave the service to meet theoretical hour load, as a prerequisite to training.
It was observed that, based on the construction of a relationship guided by trust and competence, the insertion of a joint work in the service routine between the residents and the professionals of the service was encouraged. This bond was more difficult to establish in the first year of residence, especially for some categories, and only in the second year the recognition of the professional role of the residents by the preceptors was strengthened.
The work process proposed in the pedagogical project of the Program is the interdisciplinary action. The differential of this performance is what gives a bold and creative character to multiprofessional residency programs. This operational determinant has the purpose of group formation within the same work context, without, therefore, not respecting and privileging the knowledge of each profession.
However, the initial division of resident teams caused inquietudein relation to a greater exchange of knowledge. In the first year, the teams were composed of three professionals of different categories, acting in the three lines of care: Pediatrics, Pulmonology and Cardiology. In the second year, with the empowerment of the real competencies and with the perception of the needs of the scenario, the training process was finalized with the performance in teams composed of six professionals of different categories.
In this direction, it was tried to intensify the visit to the bed, carried out only in some spaces, enabling a moment of integrated and expanded discussion of cases by the multiprofessional team, in the perspective of knowledge exchange, however, still fragile by the dependence of the medical professional, demonstrating, with it, a conservatism of power.
In this way, it was sought to sensitize the professionals belonging to the functional picture of the institution to the importance of teamwork, making it possible the accomplishment of changes in the perspective of health care, especially regarding the benefits for patients, since the training is fragmented, for emphasizing the care destined to the disease and not to the subject.
The residents, in turn, used the hospital space to develop actions that promote and produce health, such as the formation of therapeutic groups and educational activities. These activities ranged from orientations through waiting rooms to more complex explanations about technological devices used in the intensive units, such as expository lectures and interactive and playful games, facilitating knowledge.
The experiences proposed by the IRH outside the practice scenario contemplate, in addition to a mandatory workload, totaling 132 hours in the SUS, an elective stage, of optional compliance. In it, the resident chooses a health unit, which can be public or private, nationally or internationally, according to the personal/professional need of approximation with the reality of some service.
Thus, as a way of understanding the functioning of the health network apart from the hospital environment, residents experienced the Primary Health Care Unit (UAPS), outpatient services and mental health devices, as a prerogative of the proposed rotation. This experience allowed them to perceive the need for network care and the integration of the various levels of health care.
It was observed that the integrality of the care can only be obtained in a network, since the line of care thought in full form crosses innumerable health services, each operating different technologies13. In this sense, the hospital could be seen as a fundamental “station” in the circuit that each individual traverses to obtain the integrality that he/she needs.
It is a pressing concern the need for greater connection of the hospital to the other devices of the health services network, because it must be considered the fact that the integrality of care can only be achieved with the responsibility that corresponds to each sphere. The hospital, because it is not self-sufficient in this production of care, needs critical reflection that encourages the breaking of paradigms, giving more emphasis to the subject and not to the disease.
Through the challenges faced in the practice scenario, it was perceived, during the participation of the theoretical modules together with the other multiprofessional residents of the hospitals linked to RIS, the importance of the existence of a democratic coordination that teaches, supports, stimulates and contributes to the co-responsibility for the organizational process of teamwork .
In this context, it should be pointed out that, over the two years, the coordination of the  Multiprofessional Residency of the HM was indispensable for professional and personal maturation, collaborating for the insertion of the residents with the medical team, promoting their autonomy to develop different care technologies and, above all, in the introduction of new spaces not yet inhabited by some professional categories of the service.

DISCUSSION: ADVANCES, DEADLOCKS AND PERSPECTIVES

The integrality of care can only be achieved by recognizing the limit of each specificity. Recognizing the need for shared work is to realize the complexity which constitutes the continuous health-disease-care. In this sense, the interprofessional action is par excellence the way of taking care in the health scenario10.
In addition, as Peduzzi argues14 (p.108, free translation), “Teamwork does not presuppose abolishing the specificities of the work, because technical differences express the possibility of contribution of the division of labor to the improvement of services provided [...]” which is well applied in the health field.
Academic knowledge is essential to professional practice, but knowledge without attitudes and skills is meaningless. According to Aguiar and Ribeiro9, the handling of situations that require rapid resolution requires an intuitive trust in order to apply theoretical knowledge to work practice, which consists of a multiplicity of demands.
Transiting through the practice scenarios allows the joint living of collaborative experiences, which occur when workers from different health professional categories exchange knowledge, through participative planning and sharing of cases, in the quest to provide better quality to health services, respecting the specificity of each profession4-5.
In order to do so, the expanded and shared clinic enables the defragmentation of knowledge, by promoting the qualification of communication between health professionals and those with the users of the SUS, thus narrowing relations in a humanized way and including the subject and his context in an unique way as important facilitators and transformers of the reality of health in Brazil15-16.
As Merhy cites, “[...] in one way or another, all Health workers practice [...]”, and all work is mediated by technologies. The author classifies the technological apparatus and its mode of use in three types of technologies: hard, light-hard and light. The first corresponds to machinery; the second to professional knowledge, which at the same time allows the action is structured in protocols; the third signalizes the relationship, which by means of speech and listening allows the construction of bonds.
Depending on how these technologies are used in the work process, one can have more creative, relationship-centered processes, or procedures that are more tied to the logic of hard instruments (such as machines) and structured technical know-how (light-hard technologies) , at the interface of a dead work17.
It is considered that a “care producer” model, centered on the user and his/her needs, should be operated centrally from light technologies, based on an intense interpersonal relationship, reaching out to subjectivities (bond production, autonomization and reception), resulting in a live-in-act work, done in act, beyond the merely technological dimension18.
Focusing on a model that promotes care, the development of activities that were not routine in the HM reality were prioritized. Novelties such as the practice of clinical Pharmacy, the insertion of the psychologist and dentist in the daily routine of the ICUs, the increase in the attendance of the demands of Speech Therapy were implanted, as can be seen in the reality of that context.
With this, it was noticed that the initial concern of the professionals of the HM with the arrival of the residents gave rise to the recognition of the necessity of certain categories in spaces with reduced multiprofessional team.
The performance of the Multiprofessional Residency in HM was also crossed by a work focusing on light-hard and light technologies, in which listening and reception were the primary objectives of the activities performed12. These, in turn, mostly in a group, whether with patients or relatives, always included residents of two or more professional categories, recognizing the possibility of each one’s contribution with specifics inherent to their formation. Independently of the space (outpatient, infirmary or ICU) used, the privilege was in activities of health promotion nature.
It is not intended, with this, to emphasize the absence of activities similar to those carried out by the residents, but only to point out that, due to their in-service training, in addition to the increase in the quota of some categories, innovative practices could be improved, fostering the rescue of the caregiving notion.
In addition, as said earlier, as residents received theoretical training, so did the preceptors. This reality, despite the difficulties experienced initially, allowed, throughout the experience, a greater appropriation of the pedagogical proposal of IRH, both by the preceptorship and the other professionals who made up the teams and also were in contact with the residents.
Despite the challenges imposed to the insertion of the Multiprofessional Residency in the scenario of the MH, it was possible to perceive the expansion of the clinic, from a view focused on the disease to the possibility of visualizing a sick person, with his/her multiple social determinants. A closer approximation was sought with the reference and counter-referral system, which is still a challenge to be overcome, either by the organization of health devices or by the lack of sharing of practices among professionals in the various scenarios that make up the network health care.

FINAL CONSIDERATIONS

It is imperative to say that all the effort, all the energy and the investment was worth it. As a result of a collective construction, the merit of the implantation of IRH in HM can be attributed to residents, tutors, preceptors, service advisers, other collaborators, especially to the coordination of Multiprofessional Residency in HM.
This two-year journey could be crowned in many moments, the most special of them is the realization of the I Multi-professional Journey of the HM. On the occasion it was possible to better appropriate of how much it has grown, built and transformed, since it is the first RIS group in HM. This is because the singularity of this experience allowed us to seek the resources necessary to overcome the challenges that were presented.
Participation in national and international events through the elective stage was substantial during this two-year period, allowing residents to present papers and contribute as speakers at scientific events.
Reviewing the paths of this experience, one can attribute to Residence not only the technical-scientific improvement, but above all the ethical-personal, indispensable aspects when doing interprofessional, in which to recognize the personal limit is to recognize the need of another knowledge, as well as the importance of the exchange of knowledge in the promotion of comprehensive health care.

REFERENCES

1 Hartz ZMA, ContandriopoulosAP. Integralidade da atenção e integração de serviços de saúde: desafios para avaliar a implantação de um “sistema sem muros”. Cad. Saúde Pública. 2004;20(Supl 2):331-6.

2  World Health Organization (WHO). Transforming and scaling up health professional education and training. Geneva: WHO; 2013.

3  Ministério da Saúde. Portaria nº 198/GM/MS, de 13 de Fevereiro de 2004. Institui a Política Nacional de Educação Permanente em Saúde como estratégia do SUS para a formação e o desenvolvimento de trabalhadores para o setor e dá outras providências. Brasília: Ministério da Saúde; 2004.

4   World Health Organization (WHO).Framework for action on interprofessionaleduation& collaborative practice.Geneva: WHO; 2010.

5Batista NA. Educação Interprofissional em Saude: Concepções e Práticas. Caderno FNEPAS. 2012;2:25-8.

6   Brasil. Presidência da República. Lei nº 11.129, de 30 de junho de 2005. Institui o Programa Nacional de Inclusão de Jovens – ProJovem; cria o Conselho Nacional de  Juventude  –  CNJ  e  a  Secretaria  Nacional  de  Juventude;  altera  as  Leis  nº 10.683,  de  28  de  maio  de  2003,  e  10.429,  de  24  de  abril  de  2002;  e  dá  outras providências. Brasília: Diário Oficial da União de 1º de julho de 2005; 2005.

7   Ministério da Educação. Comissão Nacional de Residência Multiprofissional em Saúde. Resolução nº 3, de 4 de maio de 2010. Dispõe sobre a duração e a carga horária dos programas de Residência Multiprofissional em Saúde e de Residência em Área Profissional da Saúde e sobre a avaliação e a frequência dos profissionais da saúde residentes. Brasília: Ministério da Educação; 2010.

8   Nascimento DDG, Oliveira MAC. Competências profissionais e o processo de formação na residência multiprofissional em Saúde da Família. Saúde e Sociedade. 2010;19(4):814-27.

9  Aguiar AC, Ribeiro ECO. Conceito e avaliação de habilidades e competência na educação médica: percepções atuais dos especialistas. Rev. bras. educ. med.2010;34(3):371-8.

10Basso K. Residência integrada multiprofissional em saúde do Hospital de Clínicas de Porto Alegre: iniciando a jornada. (Trabalho de Conclusão de Curso de Especialização).Porto Alegre: Universidade Federal do Ro Grande do Sul;2010.

11Ceccim RB. Educação permanente em saúde: desafio ambicioso e necessário. Interface– comunic, saúde, educ. 2005;9(16):161-177.

12Merhy EE. A perda da dimensão cuidadora na produção da saúde: uma discussão do modelo assistencial e da intervenção no seu modo de trabalhar a assistência. In Reis AT, Santos AF, Campos CR, Malta DC, Merhy EE, Organizadores. Sistema Único de Saúde em Belo Horizonte: reescrevendo o público. São Paulo: Xamã; 1998. p.103-20. parte II.

13 Cheade MFM, Frota OP, Loureiro MDR, Quintanilha ACF. Residência multiprofissional em saúde: a busca pela integralidade. Cogitare Enfermagem. 2013;18(3):592-5.

14 Peduzzi M. Equipe multiprofissional de saúde: conceito e tipologia.Rev Saúde Pública. 2001;35(1):103-9.

15 Campos GWS. A clínica do sujeito: por uma clínica reformulada e ampliada. Disponível em: <http://www.pucsp.br/prosaude/downloads/bibliografia/CLINICAampliada.pdf >. Acesso em: 12 de fevereiro de 2016. 1996/1997.

16Ministério da Saúde. Secretaria-Executiva. Núcleo Técnico da Política Nacional de Humanização (PNH). Brasília, DF: Ministério da Saúde; 2013.

17 Merhy EE, Franco TB. Trabalho em saúde. Material produzido para a EPJV/FIOCRUZ; 2005.

18 Reis VM, David HMSL. O fluxograma analisador nos estudos sobre o processo de trabalho em saúde: uma revisão crítica. Revista de Atenção Primária a Saúde. 2010;13(1):118-25.