RESEARCH ARTICLES

Articulating theory and practice in health education in face of the Unified Health System

Cecília Nogueira Valença^I Raimunda Medeiros Germano^II; Fernanda Aparecida Soares Malveira^III
Lorena Mara Nóbrega de Azevêdo^IV; Aline Galúcio de Oliveira^V

^IPh.D. in Nursing. Assistant Professor I of the Health Sciences School of the Trairí, Santa Cruz, Rio Grande do Norte, Brazil. E-mail: cecilia_valenca@yahoo.com.br.
^IIPh.D. in Education. Assitant Professor of the Nursing Department from the Federal University of Rio Grande do Norte. Natal, Rio Grande do Norte, Brazil. E-mail: rmgermano@yahoo.com.br.
^IIIMaster degree student from the Graduate Program in Nursing from the Federal University of Rio Grande do Norte. Nurse from the family health unit from Parazinho. Rio Grande do Norte, Brazil. E-mail: fernanda_malveira@yahoo.com.br.
^IVMaster degree in Nursing. Nurse from Divino Amor Maternity from Parnamirim city. Teacher from Universitário Facex, Nursing Graduation Course. Natal, Rio Grande do Norte, Brazil. E-mail: lorenanobregaazevedo@yahoo.com.br.
^VMaster degree in Nursing. Nurse from the Hospital Universitário Onofre Lopes. Natal, Rio Grande do Norte, Brazil. E-mail: aline_galucio@yahoo.com.br.
^VIDissertation clipping Hearts and minds solve the unified health system, SUS: visions and experiences of nursing students, defended in the graduate program in nursing from the Federal University of Rio Grande do Norte, 2011.

DOI: http://dx.doi.org/10.12957/reuerj.2014.3104

ABSTRACT: This article aimed at assessing the contributions of a continuing education course entitled Experience and Internship under the Unified Health System in the context of public health for formation in health and nursing. Qualitative research, conducted with 18 nursing students of the Federal University of Rio Grande do Norte, Brazil, who took part in the project from 2006 to 2009. Data were collected in 2010 by means of focus groups and were then submitted to thematic content analysis. One of the major contributions related to changing perceptions or behavior towards the system, as a result of the articulation between its teaching–service-community reach, its interdisciplinary nature, and the participation of students as active learning subjects. Conclusions showed that the project is a viable model to motivate students into the exercise of their professional and political role in the health team in humane, comprehensive, and citizen-wise ways.

Keywords: Nursing; formation; higher education; single health system.

INTRODUCTION

It is possible to formulate a specific health policy for training, as well as to formulate a theory of change in health professions graduation, under the axis of completeness, dialoguing and building from the sectorial management¹.

Completeness, in a larger view of the human being, considers culture, the environment, the aspirations, customs, values and beliefs, inherent in each group of community, caring and respecting their life context, the needs of the individual/collective subjects and their relationships with several determinants².

The commitments with the axis of completeness in the transformation of health degree, will come from the several actors who commit themselves, especially those who are on the interfaces of the training: teachers, educational leaders, students, education managers and managers of the Unified Health System (SUS)¹.

Thus, the National Curriculum Guidelines (NCG) highlight the need of teaching projects incorporating the theoretical of the SUS. They value the ethical postulates, citizenship, the epidemiology and the health/disease/care process, encouraging the early and progressive student insertion in SUS, which will ensure knowledge and commitment with the reality of health of their country and their region³.

The interlocution between the Ministry of Education and the Ministry of Health converge for the implementation of the NCG as a strategy to changes in graduation, seeking to guide the vocational training of needs of the health population and SUS³.

The Brazilian Government has, at this moment, this political-conceptual basis in support of their speeches as a formulator of an education policy for SUS, being directed towards the production of changes in the practices of care and management and health training¹.

With a view to the national scene, a clipping of the project Experiences and Internships in the Reality of the Unified Health System (EIR-SUS) are shown in this study, applied in the context of the Federal University of Rio Grande do Norte (UFRN), where it has developed the EIR-SUS, in the municipality of Santa Cruz/RN.

From this point of view, this research aimed to identify the contributions of EIR-SUS under the public health for training in health/nursing.

LITERATURE REVIEW

The health care student, especially nursing student, must go beyond his technical skills, being necessary for improvement of intra and interpersonal skills, the political commitment to education and society, as well as the historical understanding of the current moment of nursing education in Brazil. In this way, the preparation of these professionals must be based on knowledge, skills, attitudes, ethical sensitivity and moral integrity, equanimity and self-knowledge⁴.

Some authors define that the dialogical perspective of theoretical referential from Freire is shown as a possible path to holistic and humanizing education of health professionals. In this way, he contributes to reorganize the health training with human approach, without distancing from the need to meet the current prerogatives of the health practice based on the unified health system, SUS⁵.

Thus, the extension course EIR-SUS has been shown to be an initiative of the Ministry of Health together with the Student Movement in this area that allows the graduate student deepen the discussion about the challenges of SUS implementation across the country.

The course aims to provide a broad vision of the principles and guidelines of SUS, through interdisciplinary theoretical/practical activities. EIR-SUS is presented as an alternative and complementary to the teaching of graduation.

Thus, the methodology of problematization is a link of this instance of learning, contributing to stimulate students to critique and have a reflection on the different situations presented.

METHODOLOGY

This is a descriptive study with qualitative design. The research was developed with 18 students of the Graduation Course in Nursing from UFRN who participated in EIR-SUS, in the period from 2006 to 2009.

The data collection was through the technique of focal group⁶, in order to generate debate and discussion among students, according to the following guiding questions: For you, does the experience, along the lines of EIR-SUS, contribute to the formation in nursing? How?

In the information collection period, in September 2010, we conducted three focus group meetings, at which two undergraduate research fellows were participating, assisting in the recording and registration of the discussions. The groups were organized according to the availability of the participants, scheduled by phone, each one with six students. The Coordinator of the focal group presented the questions that were discussed widely among participants.

The information collected were subjected to content analysis, in thematic mode⁷, being possible to apprehend two categories: the Proposal of EIR-SUS Santa Cruz/RN and Contributions to health training. The last one includes two subcategories: Theory/Practice Articulation in EIR-SUS and Experience and discuss about other realities.

The technique of thematic content analysis was based on the themes emerging from the reports of the subjects and represented units of meaning able to denote the reference values and models of behavior in the narrative. The analysis comprises three moments: pre-analysis (brief Reading of data took from the recordings); exploration of the material (selection of lines of subjects and organization of categories or thematic cores); and processing of results (interpretation). We conducted empirical material brief reading and the constitution of the text body, which takes place from the validation-completeness, representativeness and relevance criteria⁷.

The study was approved by the Research Ethics Committee of UFRN, upon the opinion paragraph 223/2010 and CAAE 0105.0.051.000-10. All participants signed an informed consent term, after the explanation of the objectives of the study. To maintain the anonymity of the participants, they were designated by names of stars and constellations.

RESULTS AND DISCUSSION

A proposta do VER-SUS Santa Cruz/RN: como o projeto acontece? The proposal of EIR-SUS Santa Cruz/RN: how does the project happen?

The general population needs to know about health as their right and that their participation is allowed, as well as to see themselves as responsible in the construction of better living conditions. However, health professionals, due to have knowledge about SUS, they should share their knowledge with the population so that they can identify their rights and contribute to the development of ways to consolidation of health policies⁸. In this sense, it is essential that healthcare students develop their critical thinking about the social role of SUS.

The Extension Course EIR-SUS was registered in the pro-rectory extension of UFRN, it has multidisciplinary character and happened in the months of January and July as a holiday experience, with a duration of 10 days full-time.

EIR-SUS is composed of four steps: pre-experience, institutional visits, experience in community and group assessment. The pre-experience consists on the moment of integration in the group, time of reflection on the health system and society and theoretical deepening about SUS.

In the institutional visits step, students include three levels of care (primary, secondary and tertiary), for example, basic health units, hospitals and specialty centers, besides important sanitary issues. During the days of visit, discussions on the importance of each service, linking practice and theory are also entered.

In the experience in the community step, students are led to an approximation of the reality of the population of Santa Cruz and neighboring cities. They are divided into pairs and each one goes to a community, whether urban or rural, where they remain for two days, articulating with the community institutions and to the general population.

In the assessment or post-experience, there is the evaluation of the experience in the community and the course as a whole. During the evaluation, students point out their discovery of reality.

The insertion of the student, in this discussion area, encourages their participation in other social movements and contributes to the reaffirmation of their ethical/political commitment in relation to the process of construction/reconstruction of SUS⁹.

In this way, students who participated in the experience are encouraged to integrate the student movements or extension projects in the community. EIR-SUS happens in the municipality of Santa Cruz/RN, together with the University Hospital Ana Bezerra (HUAB) and academic centers of the graduate courses.

The participation of the HUAB is about the teaching support, infrastructure and articulation with local services. The relationship with students through academic centers, as proclaims the proposal of the Ministry of Health for EIR-SUS; the student leadership must be at the heart of this training project.

The choice of students in any graduate program of UFRN aims to promote interdisciplinarity. The student are the participants from the beginning of the course, from the first to the fifth period, because they considered to be easier to awaken the first critical eye and sensitive about the reality, before the students join in supervised practice and internships.

The public health at the school: contributions of EIR-SUS

From this category two subcategories analysed below emerged.

Articulation theory/practice in EIR-SUS

The contributions that the EIR-SUS can bring to public health education in health/nursing training, students pointed out the opportunity to articulate the theory to practice:

As they were presenting the discussions, he showed the practice. At the meeting of the Council we participated, they talked really the problems of the city (Apus).

I think that teaching in public health, education in nursing and in health need to be also guided in practice. This student needs to understand also the part of the process of institutional work, where he is inserted. (Sirius)

There was concern in understanding the student, still in graduation about the destiny of the health courses and the world of contemporary work.

In this Millennium, the market and the neoliberal globalization act to dispel national education projects, particularly on the periphery of the world capitalist system. This leads to reformulation of old questions: rather than ask what country we want, what we world we want and what education we aim to deal with current problems, students are led to another question: what are professionals demanded by the market? That dislocation expressed lack of commitment to the education of the country and its people, constituting the main challenge being faced by the student movement today⁹.

These several plots of national and international relationships, socioeconomic and political, affect not only the labor market of the health professions, but also the design of training and production of health services. About these questions, students reflected:

We see politics and politicking in SUS for real. For example, a health unit has a doctor in a full period, but the other does not have because the Mayor doesn't want to pay the doctor in such a way. Then, we see the politicking acting also on health. (Apus)

The political character of health training appears to have been flamed within the student curiosity. The targeting of facilitators from the student movement is important to develop the critical vision of the reality of health.

In this perspective, students listed the main contributions of EIR-SUS to training in health/nursing and to the understanding of public health during the course:

With respect to the most significant points, I believe it was pre-experience space, where we had exactly the time to uncover, to understand the process of SUS as a whole. And the post-experience, that was the moment that you had the report [...] I also highlight in this pre-experience the moment of some dynamics that we worked, making the process of sensitization. In post-experience I found very significant this return: So, what did you experience there? (Sirius)

Besides this experience, quite significant in the life of the student, by the multiple learning opportunities, EIR-SUS is part of the debate on the political/educational project and implementation of the curriculum guidelines of the graduation courses of the health area⁹.

Students consider significant the contribution of EIR-SUS in vision change or behavior in the system. They need to feel training process subjects and not its objects, so that the student participate in decision-making and questioning about the needs of the population.

The EIR-SUS gives this support to make the comparison, you understand the theory and compare it. You compare and compare, which is very interesting. Another very positive point is that unraveling [...] I think it's very interesting, because in addition to bringing this new point of view, to question, to generate those doubts in our head, it also brings the possibility of improvement. (Apus)

In this way, the student feels a militant in the struggle of SUS construction, believing in its improvement, from possible solutions he can observe. Another point considered significant in EIR-SUS was the dialogue with other courses. This interdisciplinary relationship has enriched the experience.

I think the more significant was the own experience in the community, which I took many lessons from it; the interaction with people, with other professionals, that there were people of all courses, I mean, many courses: medicine, that everyone always has a bit of bias with the medical staff and it was great working with them; with biomedicine; with pharmacy, too; physiotherapy. So, it was great to meet a little [...] of other professionals, because we were all still very much at the beginning, [...], but that everyone will work in health. (Régulus)

In interpersonal relationships, academics tend to enjoy working with colleagues and rely on the support and understanding of the group. This contributes to the good relationship, the satisfaction and the feeling of belongings¹⁰.

From the interdisciplinary work, seeking the integrality of care and resolution of the actions, can interfere on the determining factors and constraints of the health/disease process of the individual or the community, contributing to an improvement in their quality of life¹¹.

From the testimonials, there were concepts of health in public work:

I think EIRSUS shows to broaden the concept of health. Because you're there with people doing engineering, law, and several courses. You have contact with several different people with the same purpose: to meet the SUS. From there, the term health is quite different from the one that other people see. (Scorpius)

It is understandable the interdisciplinary in EIR-SUS as able to connect knowledge and practices from several areas of knowledge in order to contribute to the elaboration of a collective and expanded point of view on the issues and health needs of the population. The contribution of this teaching/learning space for training in health/nursing is discussed:

It is not only form nursing  but it is from health. Of health itself [...] Because when we get in touch with the staff of humanities, we see the breadth of thought, the human right issue. Unlike us, who are very focused, restricted. Sometimes, we will only process the disease. We talk a lot in health/disease process. [...] It is man´s experience as an individual in society, in their day to day, [...], which is not strictly related to health, but rather to the quality of life, [...] When it is not present, the body goes into disharmony [...]. (Órion)

The training provides learning experiences that lead to the formulation of concepts and critical positions about care in primary care, while there is a need to overcome other idealized conceptions about this reality¹². EIR-SUS promoted this critical awakening to the human being in a larger perspective of health.

Experience and discuss other realities

To face challenges and restrictions on professional activities, it is necessary to the improvement of the training and educational strategies for the construction of skills and socio-political attitudes for the professional practice defense and better working conditions¹³.

In the words of those who have already completed the Graduation Course in Nursing about the contributions of EIR-SUS to their professional life, the speeches highlight:

It contributes to that student comes, at least to get out of the institution of higher education knowing that there is a national health policy that guides all the health practices of the country. I think this is one of the major contributions of EIR-SUS in addition to the contributions from the rescue of life itself, of the own memory, which is to see the suffering, pain, to see hunger. (Sirius)

It made me open my eyes to reality [...] To go out of the banks of the University, that you only have the scientific apparatus. But, you have a zero experience, or experience that you have, there are in specific moments during graduation [...] This meant that people could actually experience the difficulties and the importance that SUS has on the lives of people in poor communities that are the focus of local experience, where we stayed. (Arcturus)

In this new logic of nursing education, knowledge of public health is shown as a transversal and structuring of training to SUS.

The implementation of a pedagogical proposal is challenging in the search for public construction and dialogical reality transformer knowledge, from awareness and citizenship of teachers and students¹⁴. Therefore, training should enter into dialogue with other scientific and popular knowledge, arousing the exercise of transforming the reality of current health in the country.

There was a problematization in EIR-SUS, calling for discussion. And it wasn't a loose discussion, which was only to give content and discussed. It was a guided discussion, with facilitators supporting us. And EIR-SUS brings a very different proposal, because this theme of collective health discusses and beyond the problematization of texts [...] Is something like that, we really experience, it's not just theory, [...] the student to theory and practice in a problematical way, it's not just the teacher talking and we listening. (Apus)

For students, the teacher must facilitate the teaching/learning process, stimulating reflection. In this perspective, to overcome the perception of powerlessness in instituting cohesive practices with the theoretical/methodological referential of public health, it is imperative that the teacher guides the student in preparation of summaries in order to form nurses able of interpreting the health/disease as a process and health as a social right and therefore transforming practices based on the hegemonic model¹⁵.

The problematizing methodology builds the educational-reflective process, from the experience of significant experiences of the participants in the reality of health. This methodology in health services, allows the construction of potential areas of renewal, discussion, reflection about doing in health. This allows the use of creativity, spontaneity, the construction and deconstruction of new and old utopias on doing of workers¹⁶.

Even on the fact the student choose to participate in EIR-SUS instead of having to enroll in a subject, students also reflected:

The issue of availability, when you want that. [...]; I want to know that. Because it is something that I don't know. A curiosity to know what's happening, beyond our limits of experience, makes you really absorb this new reality, which is shown today. (Órion)

This burning desire in unraveling of reality facilitates the teaching/learning process. Thus, the problematization leads the student to an approximation of the precepts of SUS, of teamwork and of completeness, as well as an awareness on the problems and social ills, taking the students to realize their knowledge and experiences as a part of the educational process.

CONCLUSION

EIR-SUS brought relevant contributions to training in health/nursing because it incorporates current questions on the formation of human resources for SUS. The category proposal of EIR-SUS Santa Cruz/RN described the model of student experience and its stages.

The category contributions to training in health brought the most significant aspects, from the testimonials of students: the joint teaching/service/community; the union of theory and practice throughout the activities; the use of active methodologies in the teaching/learning process; the problematization of situations and social contexts; awareness on social and health needs of the population; the opportunity to experience the reality of SUS users; critical reflection about reality; the student leadership and encouraging participation of student movements and extension projects.

It is observed that EIR-SUS is no longer being held as extension project, currently at UFRN. It is expected that the principles and values of SUS continue to be experienced in other pedagogical strategies.

Among the limitations of the study, there are the complexity of SUS principles and their application to the reality of Brazilian health and the nature of qualitative research that aims to generalize its findings.

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