RESEARCH ARTICLES
Nursing education for prevention of cervical cancer
Magda Rogéria Pereira VianaI; Maria Eliete Batista MouraII; Benevina Maria Vilar Teixeira NunesIII; Claudete Ferreira de Sousa MonteirIV; Eliana CampeloLagoV
IMaster in Family Health from Uninovafapi University Center, Professor of Graduate Nursing at Santo Agostinho School, Study Group on Family Health, Teresina, Piauí, Brazil, Email: magdarogeria@hotmail.com
IIPost-Doctorate by the Open University of Lisbon - Portugal, PhD in Nursing from the Anna Nery School of Nursing, Federal University of Rio de Janeiro, Program Coordinator Professional Masters in Family Health University Center Uninovafapi, Professor, Department of Nursing, Federal University of Piauí, Study Group on Family Health, Teresina, Piauí, Brazil, Email:mestradosaudedafamilia@uninovafapi.edu.br
IIIPhD in Nursing from the Anna Nery School of Nursing, Federal University of Rio de Janeiro, Coordinator of Undergraduate Nursing Course, Federal University of Piauí, Teresina, Piauí, Brazil, Email: benevina@ufpi.edu.br
IVPhD in Nursing from the Federal University of Rio de Janeiro, Professor of the Nursing Department at the Federal University of Piauí, Collaborator in the Professional Master’s Degree Program in Family Health Center UniversitárioUninovafapiTeresina, Piauí, Brazil, Email: claudete@uninovafapi.edu.br
VPhD in Biotechnology, Federal University of Piauí, Professor in the Professional Master’s Degree Program in Family Health Center UniversitárioUninovafapiTeresina, Piauí, Brazil, Email:elianalago@ig.com.br
VI Text extracted from the Master's Thesis entitled: Training of nurses for the prevention of cervical cancer in the context of the Family Health Strategy, defended at the Post-Graduation Program Professional Master's in Family Health University Center Uninovafapi, in the year 2013.
ABSTRACT: This study aimed at analyzing the training of nurses for prevention of cervical cancer in the context of family health strategy. A qualitative study with 30 nurses in Teresina, Piauí, Brazil, 2013. Data were generated through interviews, processed on Alceste 4.8, and lexically analyzed by descending hierarchical classification. Results were presented in three semantic classes: nursing care in the prevention of cervical cancer; continuing education of nurses for prevention of cervical cancer; and nursing education at the undergraduate and expertise levels for prevention of cervical cancer. Nurses are trained for prevention of cervical cancer in the family health strategy, through undergraduation, specialization, and continuing education. However, such training must be based on meaningful learning so that professional practice can change around organization of health services.
Keywords: Nurse; prevention; uterine cervical neoplasms; family health strategy.
INTRODUCTION
Cancer of the cervix is the second most common type among women in the world and represents a serious public health problem in Brazil. Prevention is important for the early detection of cancer-initiating cells and determines the possibility of a cure in the primary care.
In Brazil, cervical cancer is the third most common malignant neoplasm and the fourth leading cause of cancer death among women, even with the possible prevention and early diagnosis in this pathology1.
The early detection of cervical cancer becomes a more effective action and is done by the implementation of the preventive examination, for tracking of the disease in its initial phase, which provides the woman the opportunity to treat and cure offered by primary health care in the Family Health Strategy (FHS). Thus, professionals must feel prepared to provide assistance that will bring positive results to reduce the deaths resulting from this pathology.
Women represent the prevention of cervical cancer and ways to prevent the disease as well as the possibility of early detection through Pap smears.Recognize the importance of the exam for health maintenance when incorporating it as a duty to be fulfilled with periodicity2.
In health, training should be different from the reproduction of conservative teaching models, focusing on pathophysiology in support diagnosis and therapeutic equipment and limited learning to university hospitals, providing safety to professionals in the care which they perform3.
The quality of health services and the degree of satisfaction of users are affected by professional education. In this sense, a low quality training provides a service lack professionals with skills, knowledge and skills needed to perform in the public health system (SUS). Therefore, nursing, through specific actions need to reorganize themselves according to the principles of SUS and take new approach on the actions, taking responsibility for solving problems, breaking theold ways of working and dealing with health -disease in the society4.
In this professional education, the highlight is the nurse who, by having specific duties to perform work in a humane and integral must be able to identify the health needs of the population, a capacity that must be acquired throughout their student day and offered by the institution in which they graduated5.
Faced With this problem, this study aimed to analyze the training of nurses for the prevention of cervical cancer, in the context of the family health strategy, and discuss the aspects that interfere in the nurse's educational process.
THEORETIC REFERENTIAL
Typically, the training of a professional to meet the profile, which labor market demands, could be related to the method adopted in the educational course.
The nurse training process was regulated by resolution no. 03 of 07/11/2001, and points to the nurse with a critical-reflexive education to intervene in the health care problems for the population6.
The ways to teach are based on two components: a banking education and problem-based education. The banking education is based on the experience of the teacher and in the transmission of knowledge, configuring it as the more traditional method of education in which the student is a passive agent, a mere receiver of what is transmitted by the professor. There is a concern in developing the critical sense of the student. This type of education is purely technical and skill enhancing the student and is very dependent on the teacher7.
In the problem-based education, professors and students actively participate in the teaching-learning process. The student is a critical agent, participant and constructor of knowledge in which the teacher is the facilitator of the learning.
The adoption of problem-based education in teaching is defended by various scholars. A precursor of this type of education was a pedagogue, who spoke about the knowledge necessary for educational practice citing events that were part of the teaching experience, discussing the question of the formation of this side of the reflection on progressive-educational practice in favor the autonomy of the being of the students8.
In this sense, nurses with training based in this education are able to develop actions from the problems that arise. Therefore, in the prevention of cervical cancer it is necessary to seek alternative in order to resolve the barriers surrounding this issue. Therefore, this presents a professional approach grounded a permanent reflection process making them able to develop quality care, holistically according to the individual need of each patient.
METHODOLOGY:
This is a qualitative study, developed in the family health strategy of the central northern region, which works in public hospitals and municipal health centers of Teresina, Piauí, in the period of June to September 2012.
The subjects were 30 nurses, identified in the study as E1, E2, E3..., which carry out activities for the prevention of cervical cancer in the family health strategy, excluding the trainees and professionals engaged in volunteer activities.
The data collection was carried out after signing the free and informed consent by the subjects and approval of the research ethics committee of the university center UNINOVAFAPI - CAAE: 0485.0.043.000-11.
For the data production, interview technique were used, by means of a semi-structured questionnaire, which, in addition to characterize the subjects by means of fixed variables, also raised issues such as: training for the prevention of cervical cancer, contribution of training for prevention of cervical cancer, aspects that interfere in training for prevention of cervical cancer.
The data were processed in the software ALCESTE 4.8, (analysedêslexèmescooc currents danslêsenoncés d’ um texte) and a lexical analysis done by means of descending hierarchical classification, which uses the concordance of words in propositions which constitute the text, in order to organize and summarize information considered most relevant, and has as a reference in its methodological basis, the conceptual approach and logic of lexical worlds9,10.
ALCESTE segmenting the material responses from interviews of subjects in large units called units of initial contexts (UIC) and in segments units called elementary contexts units (ECU).
RESULTS AND DISCUSSION
Through the descending hierarchical classification, the training of nurses for prevention of cervical cancer, it was revealed in 3 semantic classes, as shown in Figure 1:
INSERT FIGURE 1 HERE
Nursing care for the prevention of cervical cancer
Class 1, directly associated to classes 2 and 3, consisting of 46 ECUs, concentrates 55.42% of UCE classified. Here, the words (nurse, professional, patient and work), were selected by frequency and by values of x² higher in class, as shown in Figure 1.
The nurses from the study revealed that there are aspects, which interfere with the training for the implementation of quality care to women in the prevention of cervical cancer. It is what can be observed in the following UCEs:
I know how important it is for me as a professional to give assistance in which the patient will be able to understand all my orientations [...] (E3)
Many feel unable to carry out the collection, perhaps due to the lack of constant training [...] (E4)
Missing a performance protocol of the nurse.(E30)
In the earlier UCEs if they observe the concern to provide a good service to patients, however, the nurses feel insecure on the completion of the examination, by the lack of training or a protocol that route and facilitate actions to be provided.
The nurse's field is complex and requires the development of skills, translated into knowledge, attitudes and skills that provide their role in health promotion. Such skills were defined in the national curricular guidelines in an undergraduate nursing course (DCN/ENF), in a democratic manner and with social participation6.
Defining the expectedcompetencies of a professional provides advantages that can be described as, the chance to even think about the nature of their work as part of a broader framework of what has been done; establish that members of a profession are entitled to do and what the public can expect from them, set more clear than those that exist for education institutions and programs of continuing education, make it clear to the student what is expected to achieve as a recent graduate or someone seeking a more advanced skill11.
The DCN/ENF, in item I of its Art. 3º, describe that the course should prepare the professional for the exercise of nursing, based on scientific rigor and intellectual, for that he is capable of knowing and speaking about the problems/health-disease situations and be able to work.With a sense of social responsibility and commitment to corporate citizenship, as a promoter of the integral health of the human being, i.e., equip the professional knowledge required to carry out general and specific competencies and abilities6.
Correspondingly, the law of professional practice, by Law 7498 of 25/06/1986, states that it is up to the nurse to exercise privately, and nursing consultation, planning, organization, coordination, implementation and evaluation of nursing services12.
The nurse is the professional most active in pursuit of uterine cancer screening in the multidisciplinary team, because, at the time of the examination is he who provides information to the woman, is who creates reception spaces and privacy in the nursing consultation13.
In this context, they must be enabled to plan assistance, healthcare methodology based on nursing care systematization of(NCS).Which according to the resolution of the Federal Council of Nursing (COFEN) 358/2009, is a private activity of nurses, and uses the scientific method to the identification of the health / disease, basing actions of nursing care, which may contribute to the prevention, promotion, recovery and rehabilitation of the individual, family and community. This activity promotes effective quality care, contributing to professional autonomy, improving communication, preventing errors and omissions14.
The Ministry of Health recommends the adoption of a care protocol for women in the prevention of cervical cancer to serve as guidance in the implementation of the gynecological exam, thus, this protocol can be followed with the aim of improving the nurse's skills female care.
Continuing Education of nurses for the prevention of cervical cancer
In this class, the contents of the 17 UCE's (which corresponds to 20.48% of the total corpus), directly associated with the class 3.
The words (cancer, training, cervix, prevention, uterine, update) grouped, which are shown in Figure 1 and associated elements to greater prominence in ECUs, strengthen the training of nurses in providing quality care and greater security in the exam. These professionals recognize that strengthening of knowledge to guide and identify possible cases, preventing disease progression, is what can be evidenced in the following ECUs:
I went through training and update courses for prevention of cervical cancer [...] I had the opportunity of doing training through the Municipal Healthcare Foundation, specifically for cancer prevention. (E27)
It was observed in these UCEs that professionals studied skills for care to women in relation to the prevention of cervical cancer. It is striking that the knowledge and experiences acquired in courses have proved to be as facilitators for improvement in quality of care and safety in carrying out the examination.
In accordance with the national policy of continuing education15, in training, even though in some cases, to achieve individual learning, they do not always, translate into organizational learning.Considering the focus of this policy, which represents a change in the design and in the practices of empowerment of service workers and incorporates the teaching and learning the daily life of organizations and labor practices and social, within the actual context in which they occur.
Changes in the training of healthcare professionals were requested from the idea of organizing a healthcare network, having the primary attention as port of entry and established on the basis of attention to family, because these are the basis for the feasibility and implementation of actions and projects directed to the proposals by SUS. Thus, the qualification of healthcare workers contributes decisively to the realization of the national health policy, which directs to an assistance in adequacy to doctrinal principles of SUS16.
The nurse FHS plan your care differently and has a need to enhance their knowledge through continuing education for better serve the population, therefore, the lack of adequate and specific qualification can lead to difficulties in carrying out a targeted assistance and directly affect the quality of this care.
Nursing education at the undergraduate and specialization level for the prevention of cervical cancer
Class 3, directly associated with class 2, consisting of 20 ECUs, grouped the words (specialization, family, graduation, health, training, prevention, cancer, cervix), shown in Figure 1.
It became evident that there are nurses who recognize training for the prevention of cervical cancer was contemplated in the undergraduate program. Although not enough to ensure a secure assistance for women who seek the basic care and, in spite of having carried out graduate courses, must seek additional information in books, articles and manuals of the Ministry of Health, this is revealed in the following ECUs:
I didn't do a specialization, in undergrad \and had little contact with the subject, the practice was not enough [...] The undergraduate education was quite a failure and contributes little to the safety procedures for the prevention of cervical cancer. (E25)
Revealed from these UCEs, is a dichotomy between the learning and doing and superficiality or insufficiency in academic training for a better support for the activities in basic care, which makes impossible the subjects to carry out actions with safety.
It was observed that respects diverse, independentnature; interfere with the performance of technical and scientific skills necessary for the prevention of cervical cancer and point out deficiencies related to training, work processes and management within the primary care unit (UBS) and family health program (FHP).
In this direction, we consider the theoretical and practical essential for professional practice, as well as general education advocated by the DCN / NFE6.
The resolution CNE/ESC no. 3/01 recommends that the professional training meets the social needs of health by ensuring humanized care, integral and of quality, so that offers a critical-reflexive training, humanist and generalist, enhancing the profile of a qualified professional for the exercise of the profession and guided by ethical principles with emphasis on SUS17.
Thus, the higher education institutions are responsible for the training of scientific and social learners, which should play a relevant role as the subject of this action, for a satisfactory skill in carrying out the prevention of cervical cancer, which requires a differentiated know-how16.
The completion of a graduate course in the family health area is important for the nurse who works in this area, when they do not acquire sufficient knowledge in graduation for an adequate actuation, which favors great contribution to professional practice18.
When observing the distancing between academia and the provision of assistance in the health services and with a focus on the training of critical-reflective subjects committed to health. Through inter-ministerial ordinance MS/MEC no. 2.101, dated November 03, 2005, the national program of reorientation of professional training in health - Pró-Saúde - for undergraduate courses in medicine, dentistry and nursing.With the objective of bringing the formation of graduate at Country the demands of basic attention, that if conducted in Brazil by the family health strategy (FHS) and as main goal contribute to the replacement of the traditional model of organization of health care through the integration between teaching and service19.
In accordance withpró-saúdeand the newly created, the educationprogram through work for health (Pet-Saúde). This is regulated by Inter-ministerial Ordinance no. 421, of March 03, 2010. This proposes to develop tutorial learning groups training as a way of developing activities directed towards strategic areas of the Unified Health System (SUS).In order tostrengthen the integration between teaching, service and community, as well as the implementation of DCN in undergraduate courses in the area of health, characterizing it as an instrument for qualification in the service of healthcare professionals20.
With this reorientation training of health professionals, there is a challenge for IES in relation to education policy, which is to overcome the traditional pedagogical practices. It starts with the belief that students should have greater participation in the teaching-learning process, and teachers for the challenge becomes creating educational practices that foster more meaningful participation of the student in their own professional education.
Nurses need to direct their actions to seek coherence to operate and develop critical-reflexive construction of their own work process. It is from the reality of this that builds the knowledge and the necessary changes to situations experienced in everyday life are achieved21,22.
In the UCEs below, the nurses agree that training in undergraduate and specialization contributes positively, thus improving the performance in the completion of the preventive examination of cervical cancer, as follows:
In the undergraduate program and the specialization in family health, this training contributes greatly, because it has been studied theoretically and put into practice actions for the prevention of cervical cancer [...](E6)
The training interferes positively in the cervical cancer prevention activities [...] (E22)
There have been many internships that have made me face this reality [...] (25)
Theinternship practice in women's health and for the specialization, gave opportunity to conduct cervical cancer prevention in the community. (E29)
It is important to reflect that the education in healthcare is a dynamic and permanent process, which goes beyond graduation, ex tending throughout one's whole career. Thus, the professional education should incorporate strategies that integrate theoretical and practical teaching and service to develop critical and reflective attitude from the context in which the professional is inserted.
Study on critical education of Nurses, with the objective of discussing the areas of knowledge, issues and political pedagogical principles disclosed in scientific publications done by faculty of a nursing program, revealed that the subjects are among others related to women's health23.
It is perceived that the woman's health was one of the areas of knowledge cited in publications for teachers. Therefore, the training institutions need to worry about training professionals who will be able to perform their role in their reality for the promotion of quality in care and achieving the goals of health care services to women, especially in the prevention of cervical cancer.
As the design of problem-posing education9, the student must be structured from the questioning of the work process and explore its ability to host and care to the various dimensions and health needs of individuals, collectives and individuals.
With this foundation, it is possible to offer a humanized, of high quality, considering the reality of the individual and performing environment.
CONCLUSION
The study showed that in the nurse's performance is important to the development and implementation of the policy of permanent education aiming to meaningful learning and the possibility of transforming the professional practices.
The nurses recognize that skills to the care of women and the knowledge acquired in the courses, has contributed to the improvement of quality of care and safety in performing gynecological exams.
It is necessary to implement a policy of continuing education well defined to provide security to nurses in the development of activities restricted to it, aimed at health promotion, disease prevention, especially in relation to the scope of this study is that of women's health.
In this sense,the incentive for managers of health institutions is necessary for continuing education through the implementation of educational programs with strategies that allow nurses to acquire an efficientposture for the development practices that ensure safe service and good results in these actions.
This study has limitations, in the sense of not allowing the analysis of actions following the educational intervention for nurses related to the prevention of cervical cancer in the health services.
Thus, it is expected that this study can contribute to the debate on the training of nurses and collaborate to overcome the difficulties experienced by them, encouraging them to adopt a critical and reflective posture, and arouse interest in other studies, so that a better quality of care can be achieved.
REFERENCES
1. Ministério da Saúde (Br). Instituto Nacional do Câncer. Estimativa da incidência e mortalidade por câncer no Brasil. Rio de Janeiro: INCA; 2011.
2. Nascimento L C, Nery IS, Silva AO. Conhecimento cotidiano de mulheressobre a prevenção do câncer de Colo do útero. Revenferm UERJ.2012; 20:476-80.
3. Ministério da Educação (Br). Comissão Nacional de Avaliação da Educação Superior. Orientações gerais para o roteiro de auto-avaliação das instituições. Brasília (DF): Instituto Nacional de Ensino e Pesquisa Anísio Teixeira; 2004.
4. Ministério da Educação e Cultura (Br). Programa Nacional de Reorientação da Formação em Saúde – Pró-Saúde: objetivos, implantação e desenvolvimento potencial. Brasília(DF): Ministério da Saúde; 2007.
5. Bicca LH, Tavares KO. A atuação da Enfermeira no Programa Saúde da Família: uma breve análise da sua prática assistencial. Revista Nursing. 2006; 92:632-7.
6. Ministério da Educação (Br). Conselho Nacional de Educação. Câmara da Educação Superior. Resolução nº 3, de 07 de novembro de 2001. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Enfermagem. Brasília (DF): Ministério da Educação e Cultura; 2001.
7. Bordenave JD, Pereira AM. Estratégias de ensino-aprendizagem. 28ª ed. Petrópolis (RJ): Vozes; 2007.
8. Freire P. Pedagogia da autonomia: saberes necessários à prática educativa. 37ª ed. São Paulo: Paz e Terra; 2008.
9. Reinert M. Alceste: une méthodologie d'analysedesdonnéestextuelles et une application: Bulletin de MéthodologieSociologique; 1990.
10. Ribeiro ASM. Análise quantitativa de dados textuais- manual. Brasília (DF): Instituto de Psicologia-Universidade de Brasília; 2004.
11. Jorge AAF. A formação do enfermeiro e os conteúdos curriculares necessários para aquisição de competências e habilidades para o planejamento e a gestão em saúde.Revista Eletrônica Gestão & Saúde 2012; 03:1013-30.
12. Conselho Federal de Enfermagem (Br). Lei do exercício profissional n° 7.498, de junho de 1986. Rio de Janeiro: Gráfica COFEN; 1986.
13. Cruz LMB, Loureiro RB. A comunicação na abordagem preventiva do câncer do colo do útero: importância das influências histórico-culturais e da sexualidade feminina na adesão às campanhas. Saúdesoc 2008;17:120-31.
14. Conselho Federal de Enfermagem (Br). Resolução 358 de 23 de outubro de 2009. Rio de Janeiro: Gráfica COFEN; 2009.
15. Ministério da Saúde (Br). Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação em Saúde. Política Nacional de Educação Permanente em Saúde / Ministério da Saúde, Secretaria de Gestão do Trabalho e da Educação na Saúde, Departamento de Gestão da Educação em Saúde. Brasília (DF): Ministério da Saúde; 2009.
16. Montenegro LC, Brito MJM. Aspectos que facilitam ou dificultam a formação de enfermeiro em atendimento primário de saúde. Investeducenferm2011; 29:238-47.
17. Ministério da Educação(Br). Secretaria de Educação Superior. Diretrizes Curriculares para os cursos de Graduação. Resolução CNE/CES 3, de 07 de Novembro e 2001. Brasília (DF): Ministério da Saúde; 2001.
18. Rocha JBB, Zeitoune RCG. Perfil dos enfermeiros do programa saúde da família: uma necessidade para discutir a prática profissional. Revenferm UERJ.2007; 15:46-52.
19. Ministério da Educação(Br).Portaria Interministerial n.º 2.101, de 3 de novembro de 2005. Institui o Programa Nacional de Reorientação da Formação Profissional em Saúde - Pró-Saúde para os cursos de graduação em Medicina, Enfermagem e Odontologia. Diário Oficial da União, n. 212, Seção I, p. 111, de 04 de novembro de 2005. Brasília (DF): Ministério da Educação; 2005.
20. Ministério da Educação (Br).Portaria Interministerial nº 421, de 03 de março de 2010. Institui o Programa de Educação pelo Trabalho para a Saúde (PET Saúde) e dá outras providências. Brasília (DF): Ministério da Educação; 2010.
21. Reibnitz KS, Prado ML. Inovação e educação em enfermagem. Florianópolis (SC): CidadeFutura; 2006.
22. Wall ML, Prado ML,Carraro TE. A experiência de realizar um Estágio Docência aplicando metodologias ativas. Acta paul. enferm., [Online]. 2008 [citadoem 25 fev 2013];21(3). Available at: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0103-21002008000300022&lng=pt&nrm=iso>.
23. Pimentel MRAR, David HMSL.Formação crítica de enfermeiros: repercussões na Universidade do Estado do Rio de Janeiro.Revenferm UERJ.2013; 21:247-53.