The nursing training at the undergraduate: an integrative literature review

Ariane da Silva Pires^I; Norma Valéria Dantas De Oliveira Souza^II; Lúcia Helena Garcia Penna^III; Kelly Fernanda Assis Tavares^IV; Camila Arantes Ferreira Brecht D’oliveira^V; Caroline Muller Almeida^VI

IEnfermeira. Mestranda do Programa de Pós-Graduação em Enfermagem da Universidade do Estado do Rio de Janeiro. Bolsista da Fundação de Amparo a Pesquisa do Rio de Janeiro. Brasil. E-mail: arianepires@oi.com.br
IIEnfermeira. Doutora em Enfermagem, Procientista, Professora Permanente do Programa de Pós-Graduação em Enfermagem da Universidade do Estado do Rio de Janeiro. Brasil. E-mail: norval_souza@yahoo.com.br
IIIEnfermeira. Doutora em Ciências da Saúde. Procientista, Professora Permanente do Programa de Pós-Graduação em Enfermagem da Universidade do Estado do Rio de Janeiro. Brasil. E-mail: luciapenna@terra.com.br
VIEnfermeira. Mestranda do Programa de Pós-Graduação em Enfermagem da Universidade do Estado do Rio de Janeiro. Bolsista da Coordenação de Aperfeiçoamento de Pessoal de Nível Superior. Rio de Janeiro, Brasil. E-mail: kfassis@yahoo.com.br
VInterna do 8º período da Graduação em Enfermagem da Universidade do Estado do Rio de Janeiro. Bolsista de Iniciação Científica do Conselho Nacional de Desenvolvimento Científico e Tecnológico. Rio de Janeiro, Brasil. E-mail: carolinemulleralmeida@hotmail.com
VIInterna do 8º período da Graduação em Enfermagem da Universidade do Estado do Rio de Janeiro. Bolsista de Iniciação Científica. Rio de Janeiro, Brasil. E-mail: camilabrechtuerj@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2014.11206

ABSTRACT: Bibliographical research on integrative literature review mode, descriptive and qualitative approach, whose objective is the training of nurses in graduate considering the fundamentals that underpin the teaching-learning process. The objectives were to characterize the theoretical methodological approaches of scientific literature about the training of nurses and to discuss the pedagogical trends that guide the education of nurses on graduation. Seven studies published from 2008 to 2012 were selected. Data were subjected to thematic content analysis. Based on this analysis, two empirical categories emerged - pedagogical proposals of teaching and the world of work in health and nursing; and training and the profile of the nurse for the Health System: legal aspects. A strong link between the process of nursing education and professional practice in the world of health work was revealed.

Keyword: Nursing Education; curriculum; work; nursing

INTRODUCTION

The object of this study is the nursing training, considering the fundamentals that underpin the teaching-learning process. This object emerged from previous research, submitted to Science Program - Scientific, Technical and Artistic Production of University of Rio de Janeiro¹.

The work of the nurse is not easy to be developed, considering that one has to have specific skills and competencies to cope with the complexity involved in the labor process of health and nursing. Accordingly, nurses need a specific, high standard training, because the nature of this work - human care - requires a critical look at the practice and training, requiring ongoing training to ensure quality care², translated as the satisfaction of user needs, considered the central object of the strategies and measures adopted in the search for quality³.

Thus, it is necessary to allude to the complexity involved in this profession, because in addition to caring for human lives - often in situations of pain, suffering, misery and death - it is also influenced by the configuration of health and nursing service, which are equally complex and fragmented^4,5. So, some challenges must be investigated: the nursing training and how it has contributed to the construction of technical, scientific and ethical competencies, for nurses to care with quality in an often adverse working context⁶.

According to Article 3 of the National Curriculum Guidelines (NCG), the Undergraduate Program in Nursing, in general, should aim at training the generalist, humanist, critical and reflective nurse. From this perspective, it is expected that this professional is able to understand and intervene in problems and situations of health and illness more prevalent in the national epidemiological profile, with emphasis on its region, emphasizing the biopsychosocial dimensions of human life and its determinants⁷. In addition, the nurse to be graduated should be able to act with a sense of social responsibility and commitment to citizenship, as a promoter of comprehensive health human⁸.

This study is relevant as the teaching is understood as a basic tool for the transformation of work processes in health and education, of which nursing is an integral part, implying a reinterpretation of concepts and attitudes to produce a workforce capable to act in accordance with the requirements and purposes of the profession^9,10.

Thus, it is understood that the present study will encourage and foster such a reinterpretation.

In order to grasp the object of study, the following objectives were outlined: to characterize the theoretical and methodological approaches of the scientific production on nurses training; and to analyze the educational trends that guide the Graduate Nursing Programs.

METHODOLOGY

This is a bibliographic research, on integrative literature review mode, therefore it was developed respecting the following phases: construction of the guiding question; search or sampling of literature; data collection; critical analysis of the included studies; discussion of the results; and presentation of the integrative review.

The question that guided the research was: what has been published on educational trends and the process of nurses training?

To answer the guiding question, the research was performed in PubMed, Cochrane Library, Science Direct, Latin American and Caribbean Literature on Health Sciences (LILACS), Scientific Electronic Library Online (SciELO), Database of Nursing (BDENF) and Medical Literature Analysis and Retrieval System Online (MEDLINE), from March to April 2013, with the following descriptors: nursing, education, curriculum and work. Descriptors were used both isolated and combined to two keywords: professional training and work practice.

As a result of searches, 4.616 publications were obtained. 2,578 papers were excluded, because they were repeatedly indexed in the databases mentioned above. Continuing the search, the following inclusion criteria were added: scientific productions in Portuguese, English and Spanish languages, and time frame of 5 years (2008-2012). This frame took into account the introduction of the new National Curriculum Guidelines for Graduate Nursing Programs in 2001, and the formation of the first classes under these standards. After this refinement, 161 productions were found. It was still admitted as inclusion criteria only complete texts that were freely available, thus totaling 52 articles.

To the exclusion criteria, it was used the rejection of theses and dissertations, and the incompatibility of manuscripts with the object of study. From reading the titles of the captured productions and their abstracts, nine publications were selected. When full reading of these articles was performed, the incompatibility of two manuscripts was identified; the first addressed the optics of continuing education in nursing professionals (assistants, nurses and technicians). The second was a publication in an international journal in the English language, which aimed to build a cartographic map of teaching, from the pedagogical changes produced.

However, it did not focus on the chosen object. Thus, these two items were excluded from the corpus analysis.
At the end of refinement, only seven publications (one in Spanish and six in Portuguese) remained for data collection. For this, a distinct instrument was prepared, which was characterized by a questionnaire containing the following information: title of articles; year of publication; authors' names; the study site; title of the journal in which the work was published with the volume and the year; objectives of the studies; applied methodology; results and conclusion.

From the questionnaire, information was condensed in a figure, facilitating on the one hand, the reading and identification of relevant data obtained from the analyzed literature, and, on the other hand, establishing the relation between this information and the object of study. After mapping the works, it was applied the content analysis¹¹ and theme-categorical systematization¹² throughout corpus of scientific literature selected.

Operationally this technique is synthesized in three stages: pre-analysis; material exploration; treatment of results, inference and interpretation^11,12.

Based on this analysis, two empirical categories emerge, which were built from the junction of the themes that had a higher incidence in the analyzed literature and were titled as: pedagogical teaching proposals and the world of work in health and nursing; and training and the profile of the nurse for the Unified Health System (UHS): legal aspects. The data were discussed in light of the literature on the subject^-10,13-30.

RESULTS AND DISCUSSION

From seven texts examined^{6,17,20,22,23,25,30}, it is evident an equal division of articles considering the year, ranging from one to three publications per year, with the exception of 2009, when it was not identified scientific literature in the  investigated databases. See Figure 1.

Regarding the themes, the manuscripts dealt mainly: the importance of critical/reflective education and integrated curriculum, from problem-proposal; the construction of a Political Pedagogical Project (PPP) in line with the Law of Directives and Bases of Education (LDB) and the National Curriculum Guidelines (NCG); and the constant reassessment of the training process, both from the perspective of graduates and training institutions.

And, in relation to the theoretical/methodological framework, the discussions were based on Brazilian educational legislation, making inference on socioeconomic and current health model in the country.

Regarding the methodological approach, we observe the predominance of qualitative, descriptive research, including documentary studies. Referring to the subjects/population, nurses (graduates, teachers and coordinators) and institutional documents (PPP and graduate curriculum) predominated. There were two articles of reflection, which discussed the importance of integrated curriculum in graduate nursing programs and the relationship between the assumptions of popular education, health, work and nursing training. In both articles of reflection, the authors used their empirical knowledge to portray the subjects covered.

1st Category: Pedagogical teaching proposals and the world of work in health and nursing

This category examines two main educational paradigms that underlie the process of nursing education: the traditional teaching practice and the problematizing teaching practice^{6,17,20,22,23,25,30}.

From this perspective, it is important to characterize the traditional model of education, based on "transmission of compartmentalized, absolute knowledge, with teaching and assessment practices that highlight memorization and reproduction of knowledge”^13:490, corroborating an alienating training. Such training makes it difficult for the student to have a vision of wholeness of the human being, society and education itself.

The studies are critical to this teaching proposal, highlighting the incompatibility of this model with the demands of the world of work and the Brazilian health system. It is known that some educational institutions have perpetuated conservative models for the training of health professionals, a biology-centered orientation that focuses on disease education, treatment and actions of a medical nature. However, these actions are insufficient to meet the demands of the public health model and the complexity of the human being, healthy or sick^14,17,30.

With the implementation of UHS, there were changes in the organization of care practices and management of the health system. These changes occurred through the development and expansion of proposed new care models, which eventually involved the diversification of health services, the processes of qualification of workers and the nature of healthcare work. Thus evidencing the need for innovative paradigms that guide training of professionals^15,16.

It is noteworthy that "the teaching-learning process developed at the core of universities plays a social role of utmost importance, for it is through this that changes are determined in the social, political, economic and cultural system of society"^17:315.

Education can differentiate itself from the traditional education when the teacher values the experiences and knowledge of students during classes and in the act of teaching, thus becoming a facilitator of learning18. In other words, the relationship between educator and student should be mediated through dialogue and respect between both: "Nobody educates himself; men educate each other, mediated by the world"^19:39.

The participatory approach, based on the assumptions of Paulo Freire, sets up a walk to consolidate a critical, dialectic education, that is able to make the student an active subject in the teaching-learning process, recognizing its potential, from their characteristics and life history in the socioeconomic and cultural context^{7,19,20,22,23,25,30}. In this perspective, it becomes easier for this professional to transform the reality of working in health¹ and nursing, which are developed in institutions that have labor organizations plastered, fragmented, little rational and very complex.

Institutions that adopt participatory methodology must be guided on the following principles: dialogue with each other; take as the starting point of the educational process people’s previous knowledge, believing that everyone has knowledge from their experiences; give attention and facilitate moments of exchange of experiences and knowledge construction between technical knowledge and popular knowledge, which presupposes that the various knowledges are just different, and not hierarchical, and that the experience is as valuable as the theory^{20,22,23,25,30}.

Other important aspects were the issues of labor and professional training, which, despite being distinct dimensions, are closely linked20,21. "In nursing, we observed that the training was predominantly articulated to the world of work"^22:680.

Thus, in Brazil, since the early 1980s, it has been consolidated an understanding of the health-disease process and the concept of illness linked to biological, socioeconomic and political factors, which crystallized in the Constitution of 1988, which was "encouraged by public health policies and pressed by social needs, adapting to a new profile of health professionals began to be drawn"^23:436.

The university then experiences a moment of effective transformation because training human resources with adequate profile  to social needs is its challenge and implies providing students the ability to learn to learn, which does not match the traditional education or pedagogy of transmission, yet so present in universities²³.

2nd Category: Training and the profile of the nurse for the UHS: legal aspects

This category discusses elements involved in the process of nursing education in Brazilian society: LDB, NCG, PPP and integrated curriculum, as building blocks for sustaining a pedagogical proposal in line with the UHS^{6,17,20,22,23,25,30}.

The LDB No. 9394, of December 20, 1996, establishes guidelines and bases for national education, which set a new paradigm for training. In nursing, more specifically, there are the National Curriculum Guidelines for graduate nursing programs (NCG/Nursing), whose primary goal is the curricular flexibility, in order to allow a solid formation according to the stage of knowledge developed in each area, allowing the graduate to face the rapid changes in health care and its effects in the workplace²⁴.

In professional training, NCG guide nursing education to the needs of the UHS, by recommending that the nurse should be able to know and act on the most prevalent health-disease problems and situations in the national epidemiological profile with a generalist, humanist, critical and reflective profile, with scientific and intellectual rigor, based on ethical principles²⁵.

The analyzed studies show the importance of considering that the NCG/Nursing, approved in 2001, sparked a movement to restructure curricula, seeking to adapt them to new work requirements. In this context, curricular changes occur in universities throughout Brazil^{6,17,20,22,23,25,30}. Moreover, it emerges the "concern with solidarity and citizenship with knowing how to live, with learning to be and learning to live with each other"26:403, as elementary conditions that constitute the essence of humanism and ethics as propellants of human behavior.

Thus the PPP emerged as the main political and technical tool to guide universities, and it should be developed collectively within the institution. This participatory drafting provides the PPP the particularity of guidance to each university as a whole, being unique for each degree course. It features an intentional action that must be defined collectively as consequent collective commitment²⁷.

It is alluded relevant aspects regarding both to the importance of this collective construction and to the difficulties that permeate this building process. In this context, the PPP must express an attempt at communication, interaction of subjective and objective aspects of reflexivity and creativity, whose triggering depends on the initiative and involvement of subjects involved in this process as a collective action. The starting point is thus an interactive, collaborative process based on rationality and integration of knowledge relevant to the analyzed context, which is no simple task^{6,17,20,22,23,25,30}.

However, nor the construction or implementation of this collaborative project are easy, if we understand that "it is the way to training based on professional preparation with competent, transformers, conductors and reflective of reflection-in-action professional elements "^22:681.

There are some ways to train technically competent professionals, capable of meeting the real needs of the population. One of them is through flexible learning projects that take into account the regions, cultural, socioeconomic and political traits and personal and institutional identities¹⁷.

It is mentioned the need for consonance between the PPP and the flexibility of graduate curricula, including prescribed by law. In this new national order, it is no longer recommended the minimum curricula, with model based on disciplines and workload, but it creates the possibility for graduate programs to implement educational projects that may consider new models of society²⁸.

In this same line of thought, the curriculum should be drawn from a sociopolitical vision, which is to understand that it is an essential mechanism for the formation of individual and social identities, in which interfere power relations²⁹.

Relating the characteristics of the contemporary world of work and the establishment of curriculum guidelines that provide the philosophical, conceptual, political, and methodological bases that define a set of skills and expertise from different areas of knowledge, it is presented the opportunity to exceed the limits that separate what was expected of education and what it may indeed hold^{6,17,20,22,23,25,30}.

In this context, an integrated curriculum emerges with an innovative proposal, which implies a new view of students as active, reflective, creative and supportive subjects. Also proposes to promote both a theoretical and practical relation as a more global understanding of the problems, in finding solution for them¹⁷. Thus, it presents itself as a key to the construction of reflective knowledge, being a facilitator of the teaching-learning process.

However, it is essential to monitor the pedagogical proposals and teaching methodologies adopted by assessing, on the one hand, its compatibility with the NCG, and, second, how these pedagogical practices are understood and implemented within institutions that train nurses³⁰. 

CONCLUSION

This review study provides learning a bit more about the aspects involved in the training of nurses and their teaching-learning process. However, it is understood that this "training process" is much greater than the aspects that were explored and discussed in the analyzed scientific literature.

From the analysis of the manuscripts, it can be concluded that there is a strong influence of the training of nurses in their professional practice process in the world of health work, since their knowledge, skills and competences (professional profile) are made from training graduation. The way this process occurs can generate positive or negative consequences, both for professional and for the quality of care delivered by him.

It is also noteworthy the rapid changes occurring in contemporary society, imposing challenges that require greater skills and critical thinking of nursers, with the need to overcome, by the educational institutions, the dichotomy between theory and practice, from a participatory and liberating pedagogical process, providing to the graduated professional a holistic view of human beings and of their society, aiming to intervene in their problems.

It is evident, finally, the need for deeper studies on this issue, as well as research into new objects of study; so it is recommended to study the satisfaction of graduates in relation to the training process. It is also suggested studies in which the educational institutions investigate if the process of formation is consistent as the desired professional profile on NCG and the demands of Brazilian society.

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