Suffering and pleasure in the process of forming multidisciplinary health residents

Sufrimiento y placer en el proceso de formación de residentes multiprofesionales en salud

Abstracts

Objective:

to identify situations of pleasure and suffering in the process of training multidisciplinary health resident.

Method:

qualitative research, developed in the Multiprofessional Residence Program in Health at a university from the south of Brazil. Data was collected in 2013 through focus groups with nine residents, and analyzed according to a thematic analysis.

Results:

The situations of suffering were stimulated by negative situations undergone by the health workers such as difficulties in participating in other professional training activities, excessive number of activities the residents commit to as health workers, lack of knowledge and hindered integration in the areas of Residency. The situations of pleasure were a result of the multiprofessional activities developed and the resident's larning possibility.

Conclusion:

The situations of pleasure and suffering identified can help in the planning of institutional actions that contribute to a professional training process and the overall wellbeing of the residents.

Nursing; Internship, nonmedical; Occupational health; Health manpower

Objetivo:

identificar situaciones de placer y sufrimiento en el proceso de formación de residentes multiprofesionales en salud.

Método:

investigación cualitativa, realizada en un Programa de Residencia Multiprofesional en Salud de una Universidad del sur de Brasil. Los datos fueron recolectados en 2013 a través de equipos de nueve residentes y considerados según el análisis temático.

Resultados:

las situaciones de sufrimiento fueron estímulos negativos de los trabajadores de la salud, dificultad en participar de actividades de formación profesional, actividades en demasía, falta de reconocimiento y dificultad de integración de áreas de la Residencia. Las situaciones de placer fueron el desarrollo de actividades multiprofesionales y la posibilidad del aprendizaje de los residentes.

Conclusiones:

Las situaciones de placer y sufrimiento identificadas pueden ayudar en el planeamiento de acciones institucionales que contribuyan en la formación profesional que favorezca el aprendizaje y el bienestar de los residentes.

Enfermería; Internado no médico; Salud laboral; Recursos humanos en salud

Objetivo:

Identificar as situações de prazer e sofrimento no processo de formação de residentes multiprofissionais em saúde.

Método:

Pesquisa qualitativa, realizada em um Programa de Residência Multiprofissional em Saúde de uma universidade do sul do Brasil. Os dados foram coletados em 2013, através de grupos focais com nove residentes, e analisados conforme a análise temática.

Resultados:

As situações de sofrimento foram estímulos negativos dos trabalhadores de saúde, dificuldades de participação em outras atividades de formação profissional, excesso de atividades que os residentes assumem como trabalhadores dos serviços de saúde, falta de reconhecimento e dificuldades de integração das áreas da Residência. As situações de prazer foram o desenvolvimento de atividades multiprofissionais e possibilidade de aprendizado dos residentes.

Conclusão:

As situações de prazer e de sofrimento identificadas podem auxiliar o planejamento de ações institucionais que contribuam para um processo de formação profissional que favoreça o aprendizado e o bem-estar dos residentes.

Enfermagem; Internato não médico; Saúde do trabalhador; Recursos humanos em saúde

INTRODUCTION

The Unified Health System (SUS) is health care model originated from the Brazilian Health Reform, a movement that began in 1970 and established itself as the institutional framework in the VIII National Health Conference in 1986, which points to a expanded concept of Health ⁽¹⁾. Such concept intends for the individual to be contextualized in their environment, as well as the understanding of the multiple causes of morbidity processes, both individually and collectively⁽²⁾.

In this context, the Multidisciplinary Residency Program in Health (RMS), regulated as a Sensu Lato Graduate Program aims to break paradigms with regard to training workers for SUS and promoting more skilled labor in this field of action. These programs support the use of active and participatory methodologies, and lifelong learning as a teaching-learning axis ⁽³⁾.

The residency programs aim to meet the guidelines and principles of SUS, and transform the training model offered to workers. To do this, it considers the issues surrounding the teaching-learning process, the contents and teaching strategies, and those related to the technical care model, such as knowledge, practices and relationships that involve a way of intervening in health care itself (a specific way of working)⁽⁴⁾.

The multi-professional residencies and those in professional healthcare have been created since the enactment of Law n. 11,129 of 2005⁽⁵⁾. They aim to contribute to the process of changing the prevailing health care model, which takes place through conventional practices in health services and have determined a lack of resoluteness in the health system⁽⁶⁾.

In the advent of this study, the residency programs seek to recognize contributions made by the residents through multiprofessional and interdisciplinary work, aiming to develop intersectorial actions of management, attention, health education and training⁽⁷⁾. The multidisciplinary team work implies that employees in different professions act collectively and share their knowledge with the objective of promoting health⁽⁸⁾. Interdisciplinary work is responsible for providing the opportunity for systematic knowledge exchange between subjects that have something in common with their field, enabling the collective construction of new relationships and practices ⁽⁸⁾.

Universality enables care practices to be directed towards the valuation and production of life and not just the gain of health or the eradication of diseases, making the work field a privileged space for building comprehensive care for users ⁽⁸⁾. It is believed that nursing can contribute with the other areas of knowledge to achieve the actual implementation and consolidation of SUS principles, and, subsequently contribute health care best practices.

For these reasons, it is considered that the work and relationships that originate in the training of residents are permeated by challenges that emerge from this type of training. Such challenges can trigger distress or constitute a source of pleasure and psychosocial and professional development for the workers in training.

Suffering happens when tthe worker's expectations are not considered, that is, when the result of man's relationship with the labor activity is a clash between the individual's personality, individual project and orders imposed by the work organization. Pleasure occurs when there are spaces for the expression of subjectivity, creativity and worker development potential ⁽⁹⁾.

The proposal of this study originated from experiences of the authors in vocational training programs as residents, mentors and tutors, which sparked concerns about the situations experienced by residents during their training process. From this perspective, the rationale for this study was to contribute in strengthening action planning in the health care training process, especially that of multidisciplinary residents, aiming to help build a more pleasant teaching and learning process.

Although some research addresses the experiences in the training process of multidisciplinary health care residents ^{(2 to 3.10)}, to this moment, no studies that address such aspects in view of the psychodynamics of work have been identified. The dynamic relations between the work organization and the employee's subjective processes is the object of study of this theoretical framework⁽¹¹⁾, in this case, residents who were attending one of the Residency Programs.

Thus, the objective of the research was to identify situations of pleasure and suffering in the process of training multidisciplinary health care residents. The study' guiding question was: What are the situations of pleasure and suffering in the process of training multidisciplinary health care residents?

METHOD

It is a descriptive, exploratory study with a qualitative approach ⁽¹²⁾. The qualitative approach was used to obtain subjective data, ie, it attempts to grasp a reality, motives, beliefs, values and attitudes, incorporating the question of meaning and intentionality as inherent to acts, relations and social structures. It is a historical form of theoretical search and practice in the field of social research where they need to understand the context in which it is inserted ⁽¹²⁾.

The study comes from a master's degree thesis ⁽¹³⁾ and was developed with an RMS program at a public university in southern Brazil, including: Multidisciplinary Integrated Residency in Management and Hospital Care (RMIGAH) Multidisciplinary Integrated Residency in Public Health System (RMISPS) and Multidisciplinary Integrated Residency in Mental Health (RMISM).

The PRMIGAH is subdivided in attention to chronic degenerative health, mother-baby and onco-hematology; the PRMISPS is subdivided in primary care/family health and health surveillance and PRMISM is not subdivided into areas.

These programs are characterized as lato sensu graduate courses, lasting two years, with 60 hours a week of activities, 80% practical activities and 20% theoretical activities, forming a total workload of 5760 class hours. They cover the following areas of training: nursing, dentistry, physiotherapy, psychology, nutrition, physical education, speech therapy, social work, occupational therapy and pharmacy.

Training activities are carried out in the morning, afternoon and evening, in a regime of exclusive dedication. To do so, residents receive a monthly stipend, which is made possible by meeting 100% of practice hours and 75% of the theoretical workload.

The inclusion criterion for the study was to be a multidisciplinary health care resident enrolled in the second and final year of the residency programs. This choice was due to the fact that these residents have already attended all the academic subjects and experienced different situations in practical activities. Another reason was that, during the second year, residents have already had experiences in more than one field of practical activities. Residents who were on leave of any kind during the period of data collection were excluded from the study before the draw.

OPRMIGAH had 59 residents; PRMISPS, 16 residents; and PRMISM, 19 registered residents. Five residents of each program were drawn, totaling 15 possible participants, who were invited to take part in the research. The draw took place manually and randomly from a list provided by the Program Coordination, which contained the names of residents, specific area of vocational training, electronic address, telephone number and the respective area in which they were enrolled. The use of the draw is justified by the intention to cover all areas of residency and enables similar chances to all residents who met the inclusion criteria to participate.

Among the residents invited to participate in the study, nine participated in data collection, among them, two from the Management Program in Hospital Care, three from the Program in Public Health and four from the Program in Mental Health. It is noteworthy that the other six participants did not express interest in the study.

The Focus Group (FG) was used to collect the data, in which, from the utterances of members of the group, information is gathered on the topic of interest ⁽¹⁴⁾. The groups took place in April of 2013, and the meetings lasted an average of 120 minutes. In addition to the residents, researchers responsible for the conduct of thematic and two observers participated in the meetings. The number of participants in the focus groups can range from six to 15 people; the duration should be up to two hours; the place where it takes place must be neutral, outside of the work environment, easily accessible, pleasant and noise free; the ideal is that the members sit in a circle to facilitate field of view and interaction in the group ⁽¹⁴⁾.

Three FG sessions were held, and in each, the issue leading to the discussion was proposed. This role was played by the moderator, responsible for research and stimulating dialogue and driving it to the focus of the study. In addition, the two observers were responsible for taking notes that would identify the speeches of the residents by name, nonverbal expressions and the synthesis of the discussion content. This synthesis was read at the end of the sessions, when residents could corroborate or suggest alterations.

The sessions were guided by the following question: What are the situations of pleasure and suffering in the perception of multidisciplinary health care residents regarding their training process and relationships with faculty (mentors, tutors, teachers), health service workers, users and managers?

The meetings were recorded with the consent of the participants and the data were transcribed literally in a text editor. Subsequently, the material was analyzed from the thematic content analysis⁽¹²⁾, fulfilling the steps of pre-analysis, material exploration and treatment of results from the pre-determined categories which referred to situations of pleasure and suffering in resident training process. We used the theoretical framework of the workplace psychodynamic ^(9.11) to assist in data analysis and categorization of results, which was performed in a wider sense, ie encompassing the three residency programs, since there were no differences in the data regarding the proposed theme.

Participants were identified by the letters R and M, initials of the words "resident" and "multi" followed by an Arabic number (RM1, RM2, RM3 ...). There was fulfillment of the current ethical recommendations for conducting human studies. All participants signed the Free and Informed Consent Form, The study was approved by the Research Ethics Committee of the institution under the General Certificate for Ethics Assessment (CAEE) number 3934413.8.0000.5346 of March 25, 2013.

RESULTS AND DISCUSSION

From the utterances of multidisciplinary residents in health, it has been possible to list the situations of pleasure and suffering present in their training process. Below are the categories that constituted the study.

Suffering in the training process

Residents participating in the study were experiencing situations of suffering while trying to deploy new actions in their respective scenarios. This happened, mainly, due to the lack of support and motivation of some members of the health services.

We see ourselves trying to carry out actions and there are discouraged people in the service who tell you: "This is not going to work". They pour cold water on the situation and that also makes me sad and hinders the service, it is disencouraging (RM 9).

Residents reported suffering from negative stimuli transmitted by team members of the health services where they were performing their practical activities. This may happen due to increased responsibilities for employee's with their educational activities, because you realize that residency moves practices and relations traditionally established, which should lead health workers to rethink their actions and seek new ways of working as a team.

Residency intends to contribute to new knowledge, stimulating interdisciplinary work, permanent educational actions in health and strengthening the junctions between education, service and management, aiming to build a skilled network to respond to the population's health demands⁽⁷⁾. In this sense, multidisciplinary and interdisciplinary work through the teaching-service integration enables new ways of working, in which knowledge of different professional cores allow you to enlarge the look on people's needs and, from that, collectively build effective solutions for natural situations.

To achieve this, residents need to participate in scientific, academic, social and educational activities, among others. However, they reported found difficulties in carrying out such activities, which caused suffering, as the speech below elucidates:

Programs should encourage this exchange, this output. How does it limit the meetings I will attend, the conference I'll go? This is very complex. I do not know if work processes changes this way (RM 2).

Currently, the health labor market needs workers with new skills and competencies such as team work, the use of active and participatory methodologies and the ability to give full and humane care⁽¹⁵⁾. Participation in educational meetings and activities can foster the acquisition and improvement of these skills and competencies, which refers to the experiences that caused suffering during the process of training before the limitation to participate in such activities.

According to what the residents pointed out, the Residency Program established, for the purpose of internal organization, that each resident could participate in about two events per year, a matter agreed to in educational orientation and tutorials. However, this limitation can compromise the training process by limiting the socialization of knowledge, necessary for the knowledge of other realities and new experiences.

Study participants reported that care practice caused suffering when they assumed the activities as if they were employees of the team. In this sense, the participants mentioned that they should be productive at work, with no room for questions with tutors, mentors and the health team.

Sometimes, the advantage is to be a busy worker, the team is keen to show you this ... you have to produce and work hard (RM 2).

The responsibility is always entirely ours, although there is a professional responsible for this service (RM 7).

According to participants, sometimes the take on shifts, especially for lack of workers to meet the existing demands in health care. Thus, compliance with scales and task performance within the professional core of every resident, may undermine the achievement of field activities with the other residents.

A study ⁽¹⁶⁾ reports that one of the challenges to the implementation of RMS is that many of the tutors and teachers did not have multidisciplinary work and the search for integral care grounded in their academic teaching methodologies. Such aspect may compromise the focus in conducting training processes based on RMS.

The statements showed that residents helped with their workforce in health services where they were inserted. Thus, in the research institution, it seemed still that there was no full understanding by the teams of the RMS proposal, what could be translated into suffering by residents.

Study participants also reported suffering from lack of recognition for their work, which caused feelings of injustice and indignation:

Everyone has potential and often this is not developed, it is not recognized. You have to do it, if you do not do it. So help me God! But to recognize something, encourage it, never! (RM 8).

A systematic review study on the factors influencing job satisfaction of residents during participation in residency programs mentions recognition as one of the elements that have a positive impact on satisfaction over the training process ⁽¹⁷⁾. Similarly, research showed that the multidisciplinary health care residents showed satisfaction at the appreciation and recognition from users, who showed that their health demands were met and that they recognized the role of residents ⁽²⁾, aspects not identified in this study.

Yet, the participants mentioned that they felt excessively demanded with multiple functions:

There is no understanding from them [workers' health services] that we have no time for anything, because something is always thrown for us to do, as if we had all the time in the world (RM 7).

Residents said the difficulty of comprehension of some health workers about the learning spaces in the tasks undertaken in daily work. This caused discontent, because they felt they were seen only as executors of assistance activities, shifting the focus of the RMS proposal.

Recognition is seen as a central element in the constitution of the workers' psychic integrity, enabling the attribution of meaning to the experienced suffering and thus converting it into pleasure⁽¹¹⁾. As such, when a worker mobilized and engages with work, but their actions do not manage to promote an exchange dynamic in order to viabilize the individual and collective objectives to be achieved, lack of recognition takes place, and as consequence, suffering at work.

Residents mentioned that they experienced suffering in their professional training when they could not cover all responsibilities assigned to them by the Residency Program, producing feelings such as fatigue and wear, according to the following speech:

I got very worn out as well, it is a low of responsibility to deal with and I was very stressed (RM 4).

Research on burnout in residents mentions that young people in vocational training processes may have fewer skills to overcome the wear from personal and professional situations. The wear can be related to consequences tied to the Program conformation, such as sleep deprivation, fatigue, excessive work load, excessive administrative activities and problems related to quality of education and the educational environment ⁽¹⁰⁾.

Institutions and health services related to training need to exchange experiences aimed to qualify health care training and work. Therefore, it is essential to meet public interests and comply with the academic-scientific, ethical and humanistic responsibilities for professional performance. For this, one must take into account the economic and social dimensions of health workers in order to instrumentalize them to better address the issues involved in the process of health and population disease, by stimulating multidisciplinary action that respects SUS principles and guidelines ^(18).

In this context, the integration of residency emphasis areas and the need to establish dialogue between them still constitutes a challenge. This causes suffering to the residents, as pointed out in the following speech:

There is a gap between the lines [of the residency program], that's really bad, and impedes you from advancing in the work process (RM 3).

It should be considered that the residents must fulfill certain functions defined and guided by the theoretical conceptions that that support the residency programs of the institution under study. However, in the daily life of their training in health services, residents are faced with real work, which is one for which they are being prepared. The pre determined work is one that needs to be done by workers following standards and precise definitions, meaning it is the task at hand; since real work is what escapes that which is pre determined. Real work is unforeseen, unexpected, but the worker manage it ⁽⁹⁾.

From this perspective, in some situations, a dichotomy is established between theory and practice in the training process, ie, a gap between what the program recommends as ideal and what actually happens in the fields of practice. Such situations occur when residents are faced with issues and emerging themes of practical experiences in the field, and when analyzing the reality presented, confront the contents and guidelines met with the practices instituted in services. Therefore, we must invest in greater integration between teaching and service, with the effective participation of workers in the discussions, which can be granted by inserting these workers as tutors and mentors in class and field, giving them responsibility as partakers in the training of residents.

Thus, it is in the work situation that we can grasp its collective dimension. This is due to the fact that it is here that employees bring into play not just what is prescribed for the execution of a task, but other resources that can be useful to them in order to deal with the unexpected, ie, not prescribed ⁽¹¹⁾. Thus, the conflict generated between the desire of the worker and the reality of work may cause blockade and suffering. This conflict is expressed in the following statement:

I thought the residency would give full support for people to complete their tasks, that it would support, be flexible, but we do not have the support of the program itself (RM 6).

Therefore, this existing gap between the prescribed and the real and interpersonal relations at work, emerging aspects that can be a source of pleasure or suffering for workers and, in this study, for multidisciplinary health residents. Suffering happens due to the encounter of a subject that has a unique and individual trajectory with a work organization that often limits the subjectivity of the worker and prescribe a specific operating mode⁽⁹⁾.

Thus, it is reiterated that work is never neutral with regard to the workers' health, the dynamic articulation of pleasure and suffering experiences can be positive and balancing or result in destabilization and weakening of the individual's health^(9.11). To be a source of health, one must recognize the efforts of those who works in order to make sense of the suffering experienced by the workers and as the possibility of converting this suffering into pleasure, seeking to lead the individual to build their identity and self-realization ⁽⁹⁾.

In this sense, education at work presents itself as an important strategy of residency because it puts workers in a continued exercise of analysis of the meaning of the practices at production sites. Thus, it has the challenge of breaking the social reproduction of hegemonic practices and establishing flexibility within established procedures ⁽⁸⁾.

Pleasure in the training process

Working in a multidisciplinary team takes shape in the relationship between technical interventions and the interaction of actors from different professional fields to develop collective actions that make a full practice in health possible ⁽¹⁹⁾. The residents have experienced the pleasure for completing actions as a multi-professional team in the quest for complete heath actions. This can be observed in the statements below:

I am very happy in my residency for making contact with other professions. I have learned a lot, things that I never learned in college and has no idea of what they were (RM8).

The best part is when we are able to interact with other residents (RM9).

In addition, interaction and sharing of knowledge in an interdisciplinary way can also contribute to integrality in all aspects of their training. In this sense, it confirms that the multidisciplinary and interdisciplinary work are key elements in addressing the complex health needs of the population ^(8.18) , which may favor the residents' learning and pleasure experiences throughout the training process.

The Residency can trigger a construction process of integrated care in health services. This process depends on the way workers interact and articulate their labor relationships and how they establish teamwork ⁽⁶⁾.

Today we do not work much in the professional core, it's mostly field work. Today I do not see myself working alone, I don't even think I can work alone anymore, and this is very good (RM 3).

A Canadian study with social service and nursing residents and interns in primary health care services shows that, during interdisciplinary practical activities, tutors identified a better understanding of the contribution of each professional and atmosphere of trust among the participants. Students confirmed that they were optimistic about the future and, faced with the possibility of working in teams with collaborative practices between workers with different backgrounds ⁽²⁰⁾, which is in line with the results of this study, where it was identified that residents value and realize the importance of teamwork, combined with the pleasure provided by integration in multidisciplinary work.

In this sense, the need to think about the appreciation of multidisciplinary work and its implications for comprehensive care and training of health workers is shown. Thus, multidisciplinary residents felt happy about the learning opportunities offered by the Residency, recognizing the importance of this training.

I think the big advantage of the Residency program is that after you graduate, you only reproduce technical activities. You´re a complete technician.. In residency, you learn to take a detailed look on different situations that you may come to be faced with. For anything you need today, we are prepared to look at it in at least a different way than we would if we had not been through the residency experience (MR 1).

The report indicates that the residency contributed to the specialization of workers and to the improvement in the quality of care in health services. The recognition of such aspects gave way to pleasure in the process of residency training.

The institution also went through some transformations, for "Residency distances your work from a routine" (RM 2). This new view provoked questions that could generate changes in the health care process. Therefore, "the challenge is to infiltrate, looking, questioning how it affects and if it does, because the daily production of health care actions is not something that comes pre-made in books or from prior knowledge; It is an option, a desire^"(8:110). In this context, residency provides a daily opportunity to reinvent work, energized by the conflicts experienced in the reality of health care services.

Residency is a milestone in the training of health care workers, established through an innovative proposal that seeks commitment to SUS principles, through multidisciplinary and interdisciplinary work that allows attention that is qualified in its different levels of care. This is a way for multidisciplinary health care residents to feel more prepared to deal with the challenges in the activities, allowing them to think of their practices in the position of protagonists.

FINAL CONSIDERATIONS

The study aimed to identify situations of pleasure and suffering in the process of training multidisciplinary health care residents. Suffering situations were found to result from negative stimuli from health workers such as excess activities that residents took as service workers, the difficulties that exist in participating in other training activities, the little recognition as team members and the integration difficulty between areas of residence. Pleasure in vocational training occurred through the possibility of developing multi-professional activities in areas in which residents were inserted and given the opportunity to learn, considering the different areas of knowledge that make up the RMS programs.

Thus, the situations of suffering seem to stand out from those of pleasure in the professional training of multidisciplinary health care residents. This result points to the constant need to maintain and enable new spaces for dialogue between residency programs and health services, in order to encourage integration among workers and residents by building collective actions aimed at transforming health practices.

Identifying situations of pleasure and suffering in the training of residents can assist RMS Programs in qualifying this experience. Moreover, it aims for the knowledge of these aspects to contribute in enhancing action planning, helping build a training process that fosters learning, pleasurable experiences and the well-being of residents.

The impossibility of generalizing results was pointed out as a limitation to the study, considering the research approach used and due to the fact that it is the specific reality of a public university in southern Brazil. Furthermore, it is mentioned that the subject matter contemplates subjective aspects and, therefore, is potentially influenced by momentary characteristics and/or individual participants. The limitations mentioned, as well as the findings, give rise to new studies that include the training process of multidisciplinary health care residents in other settings, so that the results can be confronted, rediscussed and expanded.

The need to strengthen the health care training process to overcome challenges that still persist such as the disarticulation of the different areas of training, the existing gap between theory and practice and the difficulties of the service workers to recognize the peculiarities and assist in this process is confirmed. Overcoming or minimizing such challenges can qualify the work processes of the teams, workers' training and subsequently contributing to the comprehensiveness of health actions.

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Publication Dates

• Publication in this collection
  Oct-Dec 2015

History

• Received
  10 Oct 2014
• Accepted
  24 Sept 2015