ENSAYO / ESSAY / ENSAIO

The Altadir Method of Popular Planning as a management teaching instrument in nursing

El método Altadir de planificación popular como instrumento de enseñanza de la gestión en enfermería

O Método Altadir de Planificação Popular como instrumento de ensino da gerência em enfermagem

Vanessa Denardi Antoniassi Baldissera¹; Herbert Leopoldo de Freitas Góes²

¹ RN, PH.D. Professor, Nursing Department, Universidade Estadual de Maringá (UEM), Brazil. email: vanessadenardi@hotmail.com.br.

² RN, PH.D. Professor, Nursing Department,UEM, Brazil. email: hlfgoes@uem.br.

Receipt date: May 19^th 2011. Approval date: March 23^rd 2012.

Subventions: none.

Conflicts of interest: none.

How to cite this article: Baldissera VDA, Góes HLF. The Altadir Method of Popular Planning as a management teaching instrument in nursing. Invest Educ Enferm. 2012;30(2): 253-259.

ABSTRACT

This paper presents the Altadir Method of Popular Planning (MAPP), which is considered an effective tool for nursing management teaching and learning. When using traditional knowledge-transfer centered methods, the teaching on this subject does not arouse the same interest as technical education. The MAPP is a powerful planning tool for students who are finishing their education process, as it provides theoretical and practical experiences similar to what students will be confronted with later as professionals.

Key words: nursing; nursing, education; health planning; planning techniques.

RESUMEN

Este artículo presenta el Método Altadir de Planificación Popular (MAPP), considerado una herramienta eficaz para la enseñanza y el aprendizaje de la gestión de enfermería. La enseñanza de esta asignatura por métodos tradicionales centrados en la transferencia e conocimientos, no despierta los mismos intereses que la formación técnica de la carrera. Sin embargo el MAPP es una potente herramienta de planificación para aquellos estudiantes que están terminando su proceso de formación, pues promueve experiencias teóricas y prácticas a las que más tarde estarán enfrentados como profesionales.

Palabras clave: enfermería; educación en enfermería; planeación en salud; técnicas de planeación.

RESUMO

Este artigo apresenta o Método Altadir de Planejamento Popular (MAPP), considerado uma ferramenta eficaz para o ensino e a aprendizagem da gestão de enfermaria. O ensino desta matéria por métodos tradicionais centrados na transferência de conhecimentos, não acorda os mesmos interesses que a formação técnica da carreira. No entanto o MAPP é uma potente ferramenta de planejamento para aqueles estudantes que estão terminando seu processo de formação, pois promove experiências teóricas e práticas às que mais tarde estarão enfrentados como profissionais.

Palavras chaves: enfermagem; educação em enfermagem; planejamento em saúde; técnicas de planejamento.

INTRODUCTION

Nursing education in Brazil establishes the applicability of knowledge in practice, permitting its contextualization. In this sense, the National Education Council and the Chamber of Higher Education,¹ affiliated with the Brazilian Ministry of Education, issued a Resolution to set the National Curricular Guidelines for Undergraduate Nursing Programs. These guidelines appoint, among other recommendations, the need to include supervised training at general and specialized hospitals, outpatient clinics, primary health service networks and communities during the last two semesters of the course curriculum, in addition to the theoretical and practical contents offered during the education process.¹ Teaching-service partnerships are emphasized as extremely important for the education of future nurses and the improvement of services.

One of the skills and competences undergraduate students need to develop refers to nursing service administration and management. In this sense, future nurses should be able to: ''take initiative, manage and administer both the workforce and physical, material and information resources, in the same way as they should be apt to serve as entrepreneurs, managers, employers or leaders in the health team''.¹ It is for management and administration purposes that the Altadir Method of Popular Planning (MAPP) is used as a strategy that permits the application of planning concepts to contextualize problem-situations and select solution operations. It has turned into an effective tool for nursing management teaching-learning and for teaching-service integration, articulating different phases and permitting shared planning among the stakeholders.

In most studies on the MAPP, the use of the method has been restricted to places where popular participation is necessary for its application. It can be highlighted, however, that the contributions of this management strategy go beyond community barriers, which have historically supported its applicability. Hence, its importance is not restricted to a certain usage condition or environment, but can be applied at different health care levels, even those that are considered more technological. In this context, the aim of this reflection was to present the results and contributions of the MAPP as an effective tool for nursing management teaching-learning and for teaching-service integration at different care levels.

Nursing management teaching-learning and the MAPP

As a premise, nursing tasks include management activities, considered as actions to direct an organization or a group of people.² Nevertheless, Nursing uses management as a tool in its work process, adapting administrative models to its daily reality. It should be highlighted that management is the current substitute for administration, indicating ''a strategy used by a group of people who aim to reach a goal or common objectives by joining efforts''.³ It is affirmed that, despite its contributions to the organization of work,⁴ the classical management model has not adequately attended to contemporary needs,⁵ especially regarding health work. Considering health services' organizational structure, it is presupposed that administrative models are used that look for the best results, including new management conceptions that rapidly respond to clients and workers' needs.⁴ As the main workforce in health, Nursing is part of this management context and directly works with patients, clients or users. Therefore, it needs models that attend to this new demand.

It is affirmed that, in nursing, the management function, whether in hospital institutions or primary health care, represents a complex and often polemic activity, at the convergence between managers' organizational and ideological anxieties. This demands nursing competencies that go beyond the technique and involve attitudinal and cognitive aspects, with a view to adequate strategies for current contemporaneous administrative trends. These include, among others, the use of transformational leadership and teamwork, within the logic of shared decision making. It should be highlighted that, in Brazil, the legitimacy of management actions in the nursing team is exclusively granted to nurses,⁶ who are responsible for leading nursing entities in public and private health institutions and for heading the nursing service and unit, including the organization and management of nursing services and their technical and auxiliary activities, as well as the planning, organization, coordination, execution and assessment of Nursing care services.² On the occasion of the academy-service relation, however - which routinely happens in the practice of educational and health institutions - new management configurations are established, driven by the changes in worldviews that take place in subjects' interaction, departing from an idealistic and moving towards a realistic practice, in a permanently contextualized manner², but not free from conflicts though.

It is exactly in this encounter between theory and practice that teachers need to reflect on nursing management teaching. As appointed, this competence and task is expected from nurses, but lacks new approaches with a view to undergraduate students' learning. In generally, education ''is attached to the ideological, philosophical, theoretical world, without granting students actual learning experiences''.² In this teaching-learning configuration, management does not arouse the same interest as technical education, which is currently dense in heavy technology, reinforcing disease-centered care. The result of this teaching approach has regrettably manifested itself through the existence of nurses in the job market who possess excellent technical skills and competences, especially in nursing procedures, but are unprepared for management and, also, submitted to organizational standards and traditional models.^7,8 In fact, the lack of practical experiences, in combination with the absence of scientific knowledge in a given area, drives professionals to simply reproduce and comply with standards coming from hierarchically superior levels.

Therefore, the true appropriation of management knowledge and actions permits autonomous, free and creative practice as, in fact, each manager can decide on his/her strategy, reach diagnoses, dimension resources, plan their application and solve problems.⁹ It is emphasized that no sole management form exists, as the institutional context, associated with management competency, is what will define the model to be used, with the help of administrative theories which, in general, include six basic management variables: competitiveness, people, technology, environment, structure, tasks.¹⁰ It should be considered that, to develop administrative and management competences, a set of knowledge is essential, involving planning, decision making, interacting with and managing people.¹¹

Thus, we defend that management teaching-learning takes place at the intersection between theory and practice, within the activity area itself, through the use of a planning method that permits contextualized learning. Thus, we considered the MAPP as a valuable instrument that is able to link teaching with practice. It is at the same time a method and a teaching strategy, as it allows students to understand the management context and its multiple branches in the elaboration of an action plan. Based on situational strategic planning, defended by Matus,¹² the situational flowchart is used, in which the identification of problems, their description and analysis take place through the systematization of information, theories and hypotheses. The real situation is the key to this planning and is acknowledged through the set of problems, including the analysis of the care model, which the stakeholders explain in function of its characteristics.¹²

Teaching-service integration and the MAPP

In Latin America, the first initiatives that used teaching-service integration referred to Teacher-Care Integration (IDA), which defended a new teaching-learning process, through practical experiences of the reality in health services, involving students and teachers.¹³ The results of this and other experiences drove the elaboration of a teaching-service integration program in the 1990's, structured based on a theoretical-methodological conception that considered ''three components: university, health services and community; was aimed at producing changes in health professionals' education, in health service organization and functioning and in the community's participation in decisions that interfered in their quality of life''.¹⁴

Based on this historical framework, teaching-care integration proposals have evolved and, although many consider them utopic, specifically considering their implementation in daily health service practice, especially in the hospital context, this represents a challenging and motivating strategy to transform reality, marking the inseparability of teaching and care.¹⁵ Precisely opposed to the teaching-service dichotomy that is usually experienced in the world, the Brazilian Ministry of Health reinforces the need to support education based on the work process, so that its objectives center on the transformation of professional practices and work organization itself, based on the problematization of health service - which simultaneously constitute learning scenarios and a professional activity location.¹⁶

Therefore, there is an urgent need to define a theoretical-methodological concept that can cover the teaching-service articulation duly and effectively, reaching its goals without losing institutional and educational needs out of sight. In the attempt to reach this articulation, the premises of planning can strongly collaborate, as it is affirmed that the organization process is closely linked with the planning process,¹⁷ justifying the problematization of health services and work organization.

Among various planning possibilities in the hospital and primary care contexts, based on a theoretical reference framework, we defend the use of the MAPP. This model is selected for local planning, particularly in highly decentralized contexts like hospital units and primary health care units. It is simple and creative, elaborated to make action plans feasible in a contextualized manner, as it compulsorily inserts the different actors in its formulation process.¹⁸ Thus, it enhances the commitment of the nursing workforce (technicians and, in this case, teachers and students) to management actions, based on problem analysis and coping, as opposed to the simplistic and punctual attitude of generating demands and solutions.

Therefore, the MAPP is cited as a problem-solving strategy that presupposes the participation of different stakeholders in the operation and elaboration of an action plan. As a starting point, it acknowledges each stakeholder's own or singular view on nursing problems in his/her activity locus. It attempts to create and strengthen commitment among the stakeholders who analyze the problems, proposing solutions and assessing the results. As a teaching-learning strategy during the interdisciplinary training, as part of the Nursing Program at Universidade Estadual de Maringá, Paraná State -Brazil, MAPP has been used with satisfactory results in teaching-service integration, because it articulates the stakeholders in care and management, culminating in better teamwork and professional education of future nurses. This experience is developed in the final year of the undergraduate nursing program and takes approximately 40 days.

Putting the MAPP in practice involves the following steps: Problem Selection, Problem Description, Problem Explanation (explanatory tree), Formulation of Target Situation, Selection of Attack Fronts, Design of Operations and Demands,12 as follows:

It should be highlighted, however, if the operations proposed during the training can be put in practice and monitored, the assessment is executed in the ''accountability'' step.¹⁸ For the services, it is highlighted that the use of the MAPP also determines the concretization of some other relevant results, like the listing of problems that can constitute objects for future works, creative solutions to old problems, better acceptance of the team regarding the execution of the proposals and the possibility of incorporating these proposals into the service's practice.

Construction of action lines based on the MAPP: experience-based reflections

As results of its use, we can highlight the student's involvement and greater interaction with the health team, as the adopted planning strategy presupposed the team's participation in the solution of the problems the students had initially highlighted. In this step, the interlocution with the clinical professionals at the health unit enhanced experience exchanges and knowledge updates. The administrative and management tools started to emerge as a result of this interaction.

What happened is that the strategies used to solve problems at a given health units underwent reformulations or new ways of reaching already existing objectives at the services were added. This set of activities starts with the innovation process not only of techniques, but also of attitudes towards existing problems. Some activities can be highlighted that were developed and continued as service routines at the end of the training period. One example is the welcoming in health that was developed with families of colostomy patients. In hospitalization, the perspective of including the families in care and education activities did not exist. In this specific case, after the intervention and interaction with the health team, the trainee listed different problems at the hospitalization unit. This problem was highlighted by the team and feasible for intervention, expressed by the difficulties hospitalized patients' relatives experienced to deliver home care to the colostomy after hospital discharge.

Another meaningful and permanent planning situation was the elaboration and adoption of a medication preparation and administration control board to facilitate the nursing team's work at an emergency care unit. In that case, based on the discussions between the trainee and the local team, the problem was identified, which took the form of duplicated medication preparation or absence of others, because of the lack of a visual device at the nursing station. The board facilitated notes on prepared and administered medication, serving as a means for communication among team members.

In primary health care, successful experiences included the elaboration of educative activities for pregnant women, which the women, the trainee and the team developed together. These provoked sustainable changes in collective educative planning and served to transform local professional practice and academic education. In these processes, and in several others, we experienced that the developed planning steps constituted the link between teaching, the service and the community, highlighting that, in all problem solving steps, service workers, users/families and, finally, students participated. The latter applied the planning steps to solve the problem, taking into account the reality that existed at the service. In this process, the student seems to perceive that health unit management goes beyond the technical-administrative barrier.

We envisage a new activity dimension in care, in which the students learned that unit management should involve the interaction and influence of all stakeholders in daily service reality. Students in training considered the participation of service workers, not only as mere executors of predetermined tasks in daily routines, but as a fundamental part of care. They not only committed the professionals to a punctual task that should be performed during that work period, but also valued empirical knowledge, which the academy often neglects. They sought solutions to the problem and used creativity to reach their objectives. The students also developed alternative scripts for cases that were hard to solve. They were able to obtain feedback from the team and users and to assess new intervention proposals for the same problem, perceiving the flexibility inherent in planning. In this sense, as a result of the services' permanent incorporation of the proposals, we support the idea that the MAPP is capable of modifying the work process itself¹⁹ by incorporating new concepts, innovative actions and, mainly, by driving the stakeholders to rethink and recreate their practice.

Final considerations

As a teaching strategy, the MAPP is able to involve theory, practice and integrate the nursing team with the students and teachers, approaching these actors and consolidating the academy-service partnership. It is an instrument that can be used continuously and constitutes a fundamental planning tool for students who are concluding their education process, enhancing the theoretical-practice experience that can later be reproduced in their professional reality, in hospital and primary health unit management as well as when putting in practice popular participation in health.

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