REVIEW ARTICLE

Paulo Freire's theoretical and methodological framework: contributions in the field of nursing

Bárbara Bertolossi Marta de Araújo^I; Antônia da Conceição Cilindro Machado^II; Cassiana Silva Rossi^III; Sandra Teixeira de Araújo^IV; Benedita Maria Rêgo Deusdará Rodrigues^V

^INurse. P.hD. Assistant Professor, Universidade do Estado do Rio de Janeiro. Brazil. E-mail: betabertolossi@gmail.com
^IINurse. P.hD. Assistant Professor of the Nursing Course of Universidade do Grande Rio. Hospital Universitário Pedro Ernesto. Brazil. E-mail: haccmachado@oi.com
^IIINurse. M.Sc. Hospital Universitário Pedro Ernesto. Hospital Federal de Bonsucesso. Brazil.E-mail: cassiana.rossi2@gmail.com
^IVNurse. Ph.D. Assistant Professor, Universidade do Estado do Rio de Janeiro. Brazil. E-mail: stapacheco@yahoo.com.br
^VNurse. B.Phil. P.hD. Full Professor, Universidade do Estado do Rio de Janeiro. Brazil. E-mail: benedeusdara@gmail.com

DOI: https://doi.org/10.12957/reuerj.2018.27310

ABSTRACT

Objective: to review studies that address Paulo Freire's theoretical and methodological framework and his contributions to nursing. Method: from April to June 2016, an integrative review of Brazilian scientific production published from 2011 to 2015 was conducted in online databases. Results: 19 articles were identified, revealing two analytical categories: Applicability of Freire's Theory to nursing care; Freire's Theory and training for nursing professionals. Conclusion: Freire's theoretical and methodological framework is important in the field of nursing, in that it regards dialogue as the moment when people meet to reflect on their reality as they make and remake it. It is, therefore, a necessary political and philosophical attitude to the world and to existence, in that human beings change on the basis of their critical thinking about their reality.

Descriptors: Nursing; Health education; health.

INTRODUCTION

Paulo Freire, precursor of critical pedagogy, influenced education with his works. Recognized internationally, he left a legacy for education, in which he believed that the individual would apprehend their subject of study through a dialectical practice with reality¹.

Freire's education proposal goes beyond the theoretical limits, since it is related to the way of understanding and reflecting the world and thus to be able to consciously change it. In his works, Freire proposes an ethical, multicultural, liberating and transformative education, directed towards a society that has behaviors, thoughts and ways of seeing the world differently^1,2.

In this regard, Freire's educational practice is based on dialogue and respect toward the learner, thus encouraging a critical reflection on reality and its transformation. In this way, he considers the educational context as a humanizing process, and through dialogue he enables the problematization and critical understanding of social practice in the social, cultural and historical relations in which man is inserted^3,4.

The education proposed by Freire is a dialogical, reciprocal practice in which the articulation of knowledge, experience, community, and the environment is collectively encouraged. This view of reality is present in interdisciplinarity, proposing a pedagogy based on praxis, arousing the desire to transform reality through a policy of hope and struggle⁵.

From this perspective, we aimed to review studies that address Paulo Freire's theoretical-methodological reference and his contributions to nursing.

This study is justified by the need to produce a deeper reflection on the influence of Freire's Theory for nursing, understanding that the nurse is an educating and transforming being.

Although multidisciplinarity in health care is recognized, nursing – and more specifically the nurse – is considered to be of vital importance in promoting the patient's and their family's health. Such assumption is based on the nurse's practice of care in a direct manner and close to the patient. In addition to being one of the main professionals involved in care, the nurse remains for a longer period with the patient and their family within the hospital context, basic health unit or even in the family and community environment⁶.

Thus, this study intends to contribute to care, in order to update the nursing team regarding the strategies based on Freire's theories employed in the practice of such profession, and thus to support the existing practices.

This study also intends to contribute to education, allowing the undergraduate and graduate students to critically reflect on the educational strategies used by nursing. In addition, it aims to provide elements for further research in nursing.

METHOD

This is an integrative review, a research method that has been used in the nursing literature since 1980, which enables the synthesis of knowledge and the incorporation of the applicability of results of significant studies in practice⁷.

In order to systematize the study, we have used the six methodological stages indicated by Ganong: choosing a question to perform the review; establishment of criteria for sample selection; presentation of the characteristics of the primary research; data analysis; interpretation of the results and, lastly, presentation of the review data⁸.

For this study, we have determined the following research question: In what way has Paulo Freire's theoretical and methodological reference been used in the last five years in the field of nursing?

The bibliographic survey took place from April to June 2016, from the website of the Regional Library of Medicine (BIREME), indexed in the following databases: Literature in the Health Sciences in Latin America and the Caribbean (LILACS), Nursing Database (BDENF), MEDlars Online International Literature (MEDLINE), Spanish Bibliographic Index on Health Sciences (IBECS) and Coleciona SUS (COLECIONASUS).

The following Portuguese words were used: Enfermagem (Nursing) and Paulo Freire. Firstly, 157 works were found. The inclusion criteria for such works were: to be available in full text in Portuguese, Spanish and English languages; to be related to the subject of study and published in the time frame from 2011 to 2015 (last 5 years). Thus, 48 works were selected. Secondly, all review and reflection articles were excluded, as well as those that were not related to the subject of study, repeated books and articles in the databases. After a thorough reading of the abstracts and application of the exclusion criteria, 19 works were indicated^9-27 for making up this study, which were distributed as follows: 17 available in LILACS and two in MEDLINE.

In order to catalog the articles, two data collection tools were created. The first one listed the titles, the authors, the periodicals (year, volume, number, pages) and abstract, helping the authors characterize the articles that used Freire's reference.

The second tool showed the following data: purpose(s) of the study, nursing area, scenario and study participants, how Freire's method was used.

The textual analysis was carried out by interpreting the information from both data collection tools and by reading the articles in their entirety. This analysis made it possible to answer the question underlying the study, in order to identify Freire's contribution to the field of nursing.

RESULTS AND DISCUSSION

The analysis of the selected articles made it possible to draw an overview of the production developed on such theme, on the national journals indexed in the main BIREME databases.

Based on such analysis, it was possible to show that studies published in 2011 and 2012 prevailed over the others, six in each year, followed by five publications in 2014 and only one study in the years 2013 and 2015, according to Figure 1.

FIGURE 1: Presentation of the articles assessed. Brazil, 2011-2015.

The appropriation of Freire's theory in the nursing routine is a fact that has been occurring in several fields of practice of such class. The understanding of the need for the application of critical methodologies that reinforce the building of a community knowledge has been increasing in nursing. Of the studies surveyed, only one was an activity report and the others were field research. All the works identified were national, with the south region standing out with the highest number of works (10), followed by the southeast region, with nine studies.

The scenarios of application of Freire's method are in the locus of the basic care units (Municipal health center, basic health units and units of the family health strategy) with seven (7) studies; followed by higher education and technical institutions (5); and, thirdly, the hospital units (3). As for the other loci (4), they refer to schools and specialized care centers.

Among the participants with higher prevalence are the teachers (4), adolescents (3), nurses and health providers (2), respectively. Diabetic patients (2) also appeared among the prevailing study participants. Regarding the other participants, there are nursing assistants and students, cardiac and stoma patients; women, family members, users of basic health units and elderly caregivers.

As regards the manner of approaching Paulo Freire's^1-5 reference, it took place through the use of problematizing methodologies (14), with an emphasis on the use of culture circles (9), as shown in Figure 1.

Based on the analysis of the studies surveyed, two categories could be created: 1. Applicability of Freire's Theory in nursing care; 2. Freire's Theory and the training of the nursing professional.

Category 1- Applicability of Freire's Theory in nursing care

The works analyzed in this category resulted from qualitative research conducted, mostly in basic health units and in the hospital environment^{9,12-15,17-19,21,23,25-27}. The themes developed and the subjects of the studies allowed the use of Paulo Freire as a theoretical-methodological reference^1-5. Among the application of the different methodologies, the culture circle stands out as being the most used^{9,12,14,15,17,18,25-27}.

The culture circle is characterized by the meeting between people or groups who dedicate themselves to a didactic-pedagogical work or to other cultural and educational experiences, considering a teaching and learning process, no matter where that happens. This is possible because reality is constituted from the material conditions of existence and can be apprehended as a process that happens in each historical moment, which makes it complex, dynamic, contradictory and unfinished²⁸.

The use of this method brings back the appreciation of the cultural and historical sources of the individuals, which are unveiled in the culture circle. The individuals meet in the education process to investigate subjects of interest to the group itself²⁸. The presentation of a problematic situation arising from reality occurs, causing them to reflect on it and then decoding it and recognizing it⁹.

The production scenarios of these studies were mostly basic care, particularly the family health units. The articles dealt with the applicability of Paulo Freire's^1-5 Method in carrying out the health education practices developed by the nurses. The studies were conducted based on the application of the theory of problematization, causing the individuals to reflect by doing, making possible the apprehension of the method. Their objectives were directed beyond the analysis and application of Paulo Freire's method^1-5, as well as to the systematization of (re)construction of health education actions by relying on necessary skills that would enable a reflective and critical educational practice^9,17.

Then, in the different scenarios, Freire's methodology allowed the participants to be closer to each other and the researchers through dialogue about the situations and themes raised. The group process as an alternative to care, both in the basic health units and in other scenarios, proved to be a strategy that favored health education practices. In this regard, the use de Freire's^1-5 theoretical-methodological reference was the distinguishing factor for carrying out the studies.

Such practices, addressed under the reflective perspective held by Freire on problematizing education, enable obtaining answers sought by the individual – with consequent transformation of their history –, allowing the empowerment of the latter, from the liberating point of view^1-5. This type of education breaks with its traditional models, as it values the dialogical interaction between individuals and groups and leads the individual to transformation and autonomy. That is, it provides a transition from naive consciousness to critical conscience and the building of new knowledge, new practices and new individuals^17,18.

In the scope of basic health units, the studies pointed to a reorientation of health services and the development of skills and abilities of the teams. However, this reorientation is attributed to the need to comply with the rules that govern the health care model recommended in the basic network. For a true understanding of reality, it is necessary that the teams focus on the conceptualization of health promotion, as the process in which individuals and communities are enabled to work on the improvement of their quality of life and health, actively participating in such process^{9,15,21,25,26}

The use of the problematization methodology is an opportunity that allows subjects to attribute meanings to their experiences, leading to self-knowledge, as well as to the socialization of other knowledge. The strengthening of this educational practice leads the individual to possibilities of discovering answers to the questions that concern them, as well as the transformation of their reality, building a new history based on their autonomy. Such transformation takes place from the moment in which the individual begins to have critical awareness, which is able to identify their needs and the actions that are indispensable to change their reality^12,14,26.

Thus, as a mediator in the execution of health education practices, nurses need to be aware of the use of educational practices, whose theme addressed is in line with the individual's experiences and has as challenge the construction and appreciation of the culture of their knowledge, through the exchange of information. Thus, through emancipative educational actions to promote health, which are guided by Freire's ideology, it will be possible to build new knowledge and new practices^9,13,19,21.

Category 2 - Freire's Theory and the training of the nursing professional

This category emerged from the analysis of selected articles, when it was observed that, of the 19 studies, seven used the Freirean Theory, regarding the training of nursing professionals, as well as in the activities of permanent education, according to Figure 1.

This finding refers to the implementation of Law no. 9394/96, which establishes the guidelines and basis for national education, and is an instrument that reinforces the establishment of an education concerned with the training of critical and reflective individuals. This fact is reflected in the nursing curricula and is strengthened by CNE/CES Resolution no. 3 of November 2001 – National Curricular Guidelines for Nursing Courses –, which emphasizes the implementation of a curriculum that integrates theory and practice, as well as interrelationship among teaching, service and community with a view to transforming reality^{10,11,16,20,22,24}.

For Freire, critical reflection on practice is fundamental in the teaching-learning process, being expressed as a requirement for the theory-practice relationship. The lack of such reflection can generate a theory characterized by the mere conveyance of knowledge and, in practice, in activism³.

Education should be directly linked to the real-life context^4,5. In health education, university training should focus on full health care, considering the recognition of the historical-socio-political-economic-demographic-epidemiological context of the population. This conception, which is already inserted in the undergraduate courses, makes possible the problematization of reality, generating a better resolution. This way of conducting education meets the precepts of the Unified Health System – completeness, equity and universality –, thus reinforcing the establishment of theoretical and practical training within the health policies in force in the country.

The studies analyzed allowed also to identify the adherence of the practices of permanent education to the concepts of the Freirean Theory^10,20,22. The aforementioned works are in line with the 2009 National Policy on Permanent Education in Health, which sets forth the incorporation of teaching and learning into the daily routine of labor organizations; considers educational strategies as sources of knowledge and problem solving through the problematization of doing itself; and places professionals as reflective and knowledge-building people. It also highlights the team and the group as members of a structure that interacts by avoiding disciplinary fragmentation^29,30.

Regarding the training of the nursing professional, the studies were based on the use of Paulo Freire's methodological reference^1-5, including the culture circle. In this method, participants are placed in a circle, which allows dialogicality in the process of building collective, shared and contextualized knowledge. Such fact reinforces the possibility of the method to give rise, in the practical training of the nurse, a movement of individual reflection and building of shared knowledge, based on the exchange of experiences²⁸.

CONCLUSION

In the different scenarios of praxis, the nurse, through the use of a problematizing methodology, prepares the individual for facing the world – which is increasingly complex and constantly changing –, so that they can think of themselves and their relationship in this context in which they are inserted, thus contributing as transforming agents.

It can be seen, in the first category, that the applicability of the Freirean Theory in nursing care enables the participants to get closer to each other and the researchers, through dialogue and group strategies, favoring health education practices.

In the second category, it was observed that the articles reveal the use of the Freirean Theory in the training of nursing professionals – as well as in the activities of permanent education – , enabling the problematization of reality and generating a better resolution.

Health education is inserted in the context of nursing practice as the path that can lead to the establishment of a dialogical-reflective relationship between nurse and customer. This is the path through which the individual's awareness of their health-disease situation is sought and the perception of themselves as agents who can change their own lives. The nurse is considered an educator by nature, highlighting their importance in a profession with social engagement, showing concern for problems and human rights, and as a science that proposes new methodologies and interventions.

By turning not only to illness and systematizing and individualizing care, they can influence people's lifestyles – encouraging them to take on the role of subjects of their own decisions and mobilizing society for the implementation of healthy public policies – avoiding the archaic conception of education in which the teacher is the main actor, vested with the authority that the possession of knowledge confers upon him. Such knowledge is passed on to the student and the student simply has to absorb it. This type of education, in which the teacher is still a superior being who teaches the ignorant, is a misconception of education based on the deposit of information in the students and becomes an obstacle to transformation.

It should be emphasized that such methodology should constitute the training of nurses from undergraduate education, in which the student will get used to construct their professional development in a critical and reflective way, throughout the activities of permanent and continuous education.

It is concluded that Paulo Freire's theoretical-methodological reference presents itself as an important path in the field of nursing, insofar as it understands dialogue as the moment when humans meet to reflect on their reality, such as they make an remake it. It is more than the adoption of a methodology, it is a necessary political-philosophical stance in the face of the world and existence, considering that human beings are increasingly becoming critically communicative beings.

REFERENCES

1.Freire P. Conscientização: teoria e prática da libertação. São Paulo: Centauro; 2013.

2.Freire P. Pedagogia do Oprimido. Rio de Janeiro: Paz e Terra; 2014.

3.Freire P. Pedagogia da Autonomia: saberes necessários à prática educativa. Rio de Janeiro: Paz e Terra; 2014.

4.Freire P. Pedagogia da Esperança: um reencontro com a pedagogia do oprimido. São Paulo: Paz e Terra; 2011.

5.Freire P. Educação e Mudança. São Paulo: Paz e Terra; 2011.

6.Araújo BBM, Rodrigues BMRD, Pacheco STA. A promoção do cuidado materno ao neonato prematuro: a perspectiva da educação problematizadora em saúde. Rev. enferm. UERJ. 2015; 23(1):128-31.

7.Meira MDD, Kurcgant P. Educação em enfermagem: avaliação da formação por egressos, empregadores e docentes. Rev. bras. enferm[Online]. 2016 [cited 2017 Jul 17]; 69(1):16-22. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-71672016000100016&lng=en . http://dx.doi.org/10.1590/0034-7167.2016690102i .

8.Ganong LH. Integrative reviews of nursing research. Res. Nurs. Health. 1987; 10(1): 1-11.

9.Schülter IT, Heidemann B, Wosny AM, Boehs AE. Promoção da saúde de mães adolescentes: investigação temática de freire na saúde da família. Rev. Rene. 2011; 12(3):582-8.

10.Leite MTS, Ohara CVS, Kakehashi TY, Ribeiro CA. Theory-practice unit in an integrated curriculum praxis: Nursing teachers' perception in children and teenagers' health Rev. bras. Enferm. [Online]. 2011 [cited 2018 Jul 18]; 64(4):717-24. Avaiable from: http://www.repositorio.unifesp.br/handle/11600/6558

11.Souza DF. Educação em saúde na enfermagem: da palestra ao encontro dialógico [doctoral degree thesis]. Rio de Janeiro: Federal University of Rio de Janeiro; 2011.

12.Xavier MLF. Compartilhando saberes e práticas de acompanhantes de idosos com os
da enfermeira sobre a prevenção de complicações respiratórias
pós-cirúrgicas [master thesis]. Rio de Janeiro. Federal University of Rio de Janeiro; 2011.

13.Mendes LR. Dialogando com adolescentes sobre o consumo de álcool: um cuidado
educativo de enfermagem [master thesis]. Rio de Janeiro. Federal University of Rio de Janeiro; 2011.

14.Leite NSL, Cunha SR. Empowerment das famílias de
crianças dependentes de tecnologia: desafios conceituais e a educação
crítico-reflexiva freireana. Rev. enferm. UERJ. 2011; 19(1):152-6.

15.Alves, LHS, Bohes AE, Heidemann ITSB A percepção dos profissionais e usuários da estratégia de saúde da família sobre os grupos de promoção da saúde. Texto-contexto enferm. 2012; 21(2):401-8.

16.Prado RA, Prado ML, Reibnitz KR. Desvelando o significado da avaliação no ensino por competência para enfermeiros educadores. Rev. eletrônica. Enferm[Online]. 2012 [cited 2017 April 12]; 14(1):112-21. Available from: http://www.fen.ufg.br/revista/v14/n1/v14n1a13.htm

17.Gastaldi AB, Polak YNS. Grupos de convivência como estratégia no cuidado do cardiopata. Cienc. Cuid. Saúde; 2012; 11(suplem.):226-34.

18.Ferreira AGN, Silva KL, Sousa PRM, Gubert FA, Vieira NFC, Pinheiro PNC. Cultura masculina e religiosidade na prevenção das dst/hiv/aids em adolescentes. REME rev. min. enferm. 2012;16(4):572-8.

19.Cunha RR, Backes VMS, Heidemann ITSB. Desvelamento crítico da pessoa estomizada: em ação o programa de educação permanente em saúde. Acta Paul. Enferm. 2012; 25(2):296-301.

20.Santos MS, Gomes FDL, Santana N. Abordagens da educação popular na graduação em enfermagem: uma realidade? Rev. baiana enferm. 2012; 26(1):363-73.

21.Durand MK, Heidemann ITSB. Promoção da autonomia da mulher na consulta de enfermagem em saúde da família. Rev. Esc. Enferm. USP. 2013; 47(2):288-95.

22.Almeir EC, Bueno SMV, Denardi V, Baldissera A. A abordagem dialógica para a formação ética do enfermeiro no processo de doação de órgãos. Arq. ciências saúde UNIPAR. 2014;18(1):19-22.

23.Lima AS, Silva SM. Como pessoas com diabetes avaliam a participação familiar em
seu processo de cuidado à saúde? Invest. Educ. Enferm. 2014; 32(2):260-9.

24.Malavazi PF, Barbosa Andrade VB, Silva VJR. A experiência da educação
permanente como estratégia de gestão com os auxiliares de enfermagem. REME rev. min. enferm. 2014; 18(1):228-35.

25.Heidemann ITS, Wosny AM, Boehs AE. Promoção da saúde na atenção básica: estudo baseado no método de Paulo Freire. Ciênc saúde coletiva. 2014; 19(8):3553-9.

26.Costa DVP. Empoderamento na educação em grupo de diabetes na atenção primária à saúde. (Online); 2014 [cited 2017 April 12]; Available from: http://www.bibliotecadigital.ufmg.br/dspace/handle/1843/ANDO-9M3KPA

27.Massaroli R, Martini JG, Massaroli A, Lazzari DD, Oliveira SN, Canever BP. Trabalho de enfermagem em unidade de terapia intensiva e sua interface com a sistematização da assistência. Esc. Anna Nery Rev. Enferm. 2015; 19(2):252-8.

28.Freire P. Educação como prática de liberdade. 26ª ed. Rio de Janeiro: Paz e Terra; 2002.

29.Fagundes NC, Rangel AGC, Carneiro TM, Castro LMC, Gomes BDS. Continuing professional development in health for working nurses. Rev. enferm. UERJ [Online]. 2016 [cited 2017 July 17]; 24(1):e11349. Available from: http://www.facenf.uerj.br/v24n1/v24n1a03.pdf

30.Reis INC, Silva ILR, Un JAW. Public space in primary health care: popular education and health promotion at brazilian health-school centers. Interface (Botucatu). 2014; 18(Supl 2):1161-74.