Discussion of the environment in undergraduate nursing training


Cinoélia Leal de SouzaI; Cristina Setenta Andrade II; Elaine Santos da SilvaIII.

I Nurse. Professor at the Guanambi College. PHD student in Nursing and health, Universidade Estadual do Sudoeste da Bahia, Jequié, Bahia, Brazil. Email: cinoelia5@hotmail.com
II Nurse. PhD in Public Health from the Universidade de São Paulo. Professor at the State University of Santa Cruz. Ilhéus, Bahia, Brazil. Email: cristina70@uòl.com.br
III Nurse. Guanambi College. Bahia, Brazil. Email: elaine-ss@live.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.16574




Objective: to discuss health and environment in undergraduate nursing education. Method: in this qualitative, descriptive, documentary study, data were collected in 2014 from the programs and syllabi of four courses at universities in Bahia State, and from 21 students, and were analyzed using content analysis. The study was approved by the research ethics committee (Protocol CAAE: 10817013.5.0000.5526). Results: the curricula indicate that nursing courses are approaching environmental issues, especially in collective health disciplines, but students considered the discussion incipient and lacking in depth in the nursing curriculum. Nurses play a leading role in establishing the relationship between health and environment, because they produce and manage infected solid waste, as well as acting in territories with socio-environmental problems. Conclusion: the study evidenced a distant relationship between health and environment, indicating the need to include environment as a transverse theme in nurses' training.

Keywords: Education nursing; Environment; curriculum education; nursing, baccalaureate.




In the current scenario of social, economic and environmental changes, nurses occupy an important role1 for their influence in the health sector because of the number of employees and the interdisciplinary manner of promoting care. So, they need to be in a permanent learning process to accompany the changes that occur constantly in the population health.

It is known that since the early 1970s, the nurse had featured in social movements to change the health care model in Brazil and in the appreciation of the profession, including, above all, discussions about the curricular structure and the professional training1.

The XXXI Brazilian Congress of nursing in 1979, has already signaled concerns and movements for a debate on the conceptual and structural landmarks of Nursing curriculum2. Such concerns were magnified in the early 1980s, strengthening critical thinking in nursing because of the overall understanding of a crisis in the profession.

In 1988, the Brazilian Association of Nursing (ABEN) consolidated the document that formed the basis for other debates that took place mainly in the framework of the Graduate Committees of the Brazilian Congress of Nursing, between 1989 and 1990 that culminate structuring and approving the Inputs to prepare a proposal for a minimum curriculum on Nursing courses2 . And, in 1994, at the first national seminar on guidelines for Nursing Education in Brazil (SENADEn), several principles that should be incorporated into the curricula for vocational training at all levels, particularly in graduation courses, were formulated1,2.

Those movements help to structure the current model of the Nursing curriculum in Brazil, formalized in an official text, which must be understood as a historical creation and determined the current curricular structure based on the National Nursing Curriculum Guidelines (DCN/EN) 3.

It is known that nurses training involves various aspects in which the environment is included as a determinant of health and their practice, since it is directly related to the health standards of the population and the discussion is essential to positively change health levels.

The study of the consequences of environmental changes on health is important to prevent risks, harms and diseases, since these changes interfere in the search of a healthy life and in Nursing working areas. In this perspective, this study aimed to discuss health and environment in nursing graduation courses.



It is obvious that higher education is currently challenged to break paradigms that point in the direction of a training with social relevance and consistent with the National Nursing Curriculum Guidelines and the transforming process of professional training4.

The National Nursing Curriculum Guidelines derive from the nurses' mobilization through the class association, educational entities and sectors of civil society, that defended changes in vocational training, based on the design of health discussed by the Brazilian Health Reform and the Unified Health System (SUS), which occurred with great participation of the nursing field, and from which it was found that it is not possible to consider the health isolated from the environmental conditions that surround the individual and the community5,6.

Talking about health regardless the relationship between man and its social and environmental context means to go back to the time when diseases were a purely biological phenomenon, with no other interference but just the man and their body7.

And this reorganization of thought and actions in health occurs whit a new vision of health practices towards a health professional training that should provide health care with emphasis on the implementation of an integral service, in view of the range of skills required in the process of nursing care and health work, but also of the determinants involved in this process8.

It is important to note that health professionals training was generally built on a content fragmentation and organized around power relations, which gave the specialist professor a central position in the teaching-learning process9. And, to understand the complexity inherent in environmental issues and its relationship with health, we must involve a set of knowledge of the various sciences, focused from a critical approach10.

It is important to think of a curricula more responsive to labor needs and to the specific demands, to develop an ability to listen to curricular practices in the spaces in which they occur, and in other social spaces in which health is learnt, as a source of questions and demands in the training process11.

The scope of action of the Nursing professional is an important device to think about the technicality implicit in health care that sometimes is involved only with the established processes such as protocols, technological knowledge and prescriptive acts that can promote a lack of care and responsibility towards the individual, the family and the community.



It was a qualitative research with descriptive and documentary approach, in which the data were collected in the curriculum, syllabus and subjects' programs of undergraduate nursing courses at the four State Universities in Bahia (UEBA). The study was conducted from January to December 2014.

The universities studied accounted for six nursing courses included in this research. 76 subjects' programs and syllabus were analyzed. After reading these documents, 12 programs and syllabus related to environment were selected, namely: Biology, Human Parasitology, Pharmacobotany, Collective Health, Parasitology, Environmental Health, Nursing Practices in Collective Health, Nursing Management in Public Health Services, Supervised Internship in Nursing, Environment and Health, Health Surveillance and Epidemiology.

Also, we used a semi-structured interview to complete and enrich the data obtained in the documents. 21 students participated in the interviews, defined by convenience sampling, of different semesters of undergraduate nursing courses of UEBA, following a preset script. The script allowed flexibility during the conversations to show the knowledge of students about the environmental approach at graduation. An initial identification of the student and sequential Arabian number was established to describe the students' statements.

To treat the data we used the technique of content analysis in a critical-analytical approach to unveil the meaning cores for systematic procedures to describe the contents of the secondary data sources, which enabled the inference of knowledge related to environmental aspects 12,13. The treatment of this material was divided into three phases: data ordering (documents organization and interviews), data classification (analysis categories built from the documents and the students' answers), and results interpretation. From the analysis of the documents, the following category emerged: health and environment in the curricula.

From the interviews with Nursing students, we could identify, by the statements analysis, the following category: environmental education in the students' perspective, that was divided into two subcategories: environmental education as an educative process and environmental education for sustainable development. And finally, the data was processed and discussed. This process allowed to breakdown the material in units of meaning that generated the category and subcategories.

According to resolution nº466/12, the research was approved by the Research Ethics Committee of the Universidade Estadual de Santa Cruz, under the CAAE Protocol: 10817013.5.0000.5526, and data collection was carried out from May to July 2014 and all participants signed an informed consent form (FICS).



Health and environment in the curricula

This first category emerged from the documentary analysis of the Nursing undergraduate courses curricula examined, which allowed to highlight and relate the National Nursing Curriculum Guidelines and information on health and environment in the reality of these courses.

The list of essential contents of Nursing undergraduate program is divided into three large areas in the National Nursing Curriculum Guidelines: Biological and Health Sciences; Humanities and Social Sciences; and Nursing Sciences. Between these major content areas, the areas of Humanities and Social Sciences and Nursing Sciences include the ecological factors as determinant3:1.

Analyzing the environmental aspects in those programs, it was noted that, in six courses some subjects approached content about environment, distributed in general content subjects, and only one presented a list of specific content about the environment.

There was also a differentiation as to the environmental approach in nurses training, because we noticed a detachment of the interdisciplinary discussion on health and environment, which may be related to the history of nursing that always acted more in hospital services in which the environmental needs and problems experienced by the population assisted is not noticed.

However, it is important to consider that even in the hospital context, in which hospital infection prevention is present, the destination of the infected solid waste is minimally approached which means environmental issues have little relevance.

In the National Nursing Curriculum Guidelines we found subjects that indirectly address environmental issues on health, such as: Biology, Human Parasitology, Pharmacobotany, Collective Health, Parasitology, Nursing Practices in Collective Health, Nursing Management in Public Health Services, Supervised Internship in Nursing, Environment and Health, Health Surveillance and Epidemiology.

However, only one discipline addressed specifically the relation between health and environment and its consequences for the population health: Environmental Health in a Nursing course near the Atlantic forest, in which academics coexist with a green lush, characteristic of cocoa harvests, in the South of Bahia. The topics discussed focused on specific issues of health and environment in the local territory.

It was noticed that the predominant content geared almost exclusively to the parasite-host-environment relationship. These courses focus mainly infect-contagious diseases and lead to the prevention of illnesses, leaving many important aspects as secondary. As an example, we can cite the limited discussion on the areas of vulnerability, the difficulties of access to health due to environmental barriers, or even the superficial discussion about health territory.

It is important to highlight the urgency of opening the students' eyes to a formation of nurses that look after people not only as patients, but as human beings in all their dimensions and, for that, education must not only focus on content and techniques but apply them to their experiences 14.

According to the National Nursing Curriculum Guidelines, the professional profile formed by the nursing courses must act on various aspects of the determinants of health and focusing on the reality of each region to break with the biologicist approach, characteristic of health training courses 3.

The performance of the Nursing professional in health experiences scenarios on communities is found in article 5, paragraph XI of the Curricular Guidelines3, in which the nurse must answer to the regional specificities of health through interventions strategically planned, in the levels of promotion, prevention and rehabilitation of health, giving full attention to the health of individuals, families and communities.

It is known that practical disciplines in the nurses training expanded substantially from the end of the 1990s, where Family Health Units acted, because of the growing need to incorporate nursing and care professional from the needs of the population.

The National Nursing Curriculum Guidelines still points out that the professional qualified to practice the profession, based on the scientific and intellectual rigor, is guided by ethical principles and able to know and interfere in the problems/situations of health-disease that are more prevalent in the national epidemiological profile, with focus on their region and value the biopsychosocial dimensions of their determinants. Once again, the concept territory is approached3.

Another important factor in the relation health/environment/society is culture, which in most cases is directly related to the type of human action on the environment. The cultural aspect is often evoked in the National Nursing Curriculum Guidelines as a focus of attention of the nurse, as evidenced in the topic of nursing science, in which the contents (theoretical and practical) that make up assistance must consider sociocultural, economic and ecological determinants of health-disease process , as well as the ethical, legal and humanistic principles inherent to nursing care3.

Environmental education in the students' perspective

From this, two subcategories emerged that are examined below.

Environmental education as an educative process

A look at the students' understanding of undergraduate courses in nursing on environmental education, made it possible to identify it as the educational processes that aim to understand and preserve the environment.

The preservation of natural resources is one of the biggest concerns of contemporary society, and the depredation of the environment has been a focus of discussions in the world for many years. In that sense, the students' understanding about environmental education focuses primarily on the study/teaching of man versus environment aiming at preservation, as exemplified in some students' speeches:

It is the teaching actions that take care and preserve the environment (E1).

It consists on educational processes that discuss in relation to the process of care for and preserve the environment, besides its importance in the life of the population (E2).

It is still worth mentioning that environmental education was little related to the field of health knowledge and to other knowledge areas such as economics, social sciences, among others, which raise the concern about the absence of the interdisciplinarity in the formation of health care professionals.

Environmental education for sustainable development

Environmental education has always been strongly linked to the concept of sustainable development and sustainability which, despite being from different theoretical approach concepts, are presented as similar by the students, as can be observed in some replies showed below.

Teaching and learning about the environment, sustainability, ecology, among others (E3).

It is the promotion of sustainable development (E4).

It is about sustainability and sustainable development. (E5).

The relationship between environmental education and sustainable development showed that the understanding of some students is based on the principles already discussed in many international events, which aim to establish a harmonious relationship between development and environmental sustainability, currently one of the lines of thought more discussed related to the development of contemporary society and its consequences for the environment.

It is important to remember that the incorporation of a more comprehensive health concept, seen as a result of living conditions, access to health services, as well as individual factors that seek a healthy lifestyle and the relationship with the environment, started to be more discussed from the Federal Constitution of 1988, and later with the Unified Health Service implementation in 1990, which has returned attention to the social determinants of health.

The intersectoral approach and interdisciplinarity are key issues in the discussions about the environment. Thus, health becomes a resulting factor of the everyday practices and the actions facing the environment and dependence on natural resources; so, in nursing, knowledge should be associated to environmental learning15.

The conception of territory incorporated into the collective health was also evidenced in the National Nursing Curriculum Guidelines to consolidate the National Health Service16. Nursing recognizes as territory for health care production, evidenced by indicators of health, individual and collective needs in social contexts, regions that generate demands to build therapeutic and community projects to be developed in practice and nursing education stages.

The identification of health problems in the territory must therefore go beyond the list of prevalent and evident losses, through notifications to address and consider the understanding of vulnerabilities and determinants 17. It's worth pointing out that environment is considered in the Law 8,080 of 1990 as determinant for health, and that health determining factors and conditions are food, housing, basic sanitation, the environment, work, income, education, transportation, recreation and access to goods and essential services, among others18.

Another aspect that calls attention to the National Nursing Curriculum Guidelines is the description of the ecological factors as fundamental contents of nursing graduation courses and nursing professional practice. The inclusion of ecological determinants mentioned in these guidelines is not clear or objective, since the definition of the term is not expressed, neither which ecological aspects would be studied in this education field 3.

The discussion on environmental issues is pertinent, since changes caused by the modern society in the environment are causing new problems. Nevertheless, it must be clear that is not the same as ecology and although they are integrated, environmental problems are only a field of action within ecology19.

Despite the curricular changes in the nurse formation to insert them in the public health services, graduation still focus on non-preventive techniques and practices, like clinical and therapeutic activities in the biomedical area, which show a detachment of strategies and health education and do not appreciate the environmental issue20.

In practice, the courses cannot raise possible associations between diseases and environmental issues. Therefore, there is a need to expand the discussions on this subject, to prevent diseases the population is suffering, as well as the environmental risks they are exposed to 21.

The conceptions of health, environment and territory should be discussed in more depth, from identifying problems and needs, and interdisciplinary practice as a strategy based on environmental education, that can contribute to truly understand the man-health-environment relationship, by observing the field and confronting it with the academic theory 20.

Thinking on the practices in society in a context marked by the ongoing degradation of the environment, involves a necessary liaison with the production of meanings on environmental education, which as stated by policies and legislation should occur with the same importance at all levels of education21.

Despite Brazilian legislation establishes that environmental education should be discussed in all student training means, in all levels of education, there is no reference to environmental education in the National Nursing Curriculum Guidelines. In joint publication of the Ministry of health and the Ministry of education, in order to rethink health education practices, it was also pointed out that training in health, in compliance with the Education National Guidelines, must be attentive to the accelerated pace of knowledge evolution and the changes of the labor process on health, to achieve a balance between technical excellence and social relevance22.

In this perspective, it is indisputable that the experiences in nursing degree courses require the need to incorporate the environment as cross-cutting theme of the contents and disciplinary practices, and that the traditional training that overvalues the specialization to the detriment of the interdisciplinary knowledge has contributed to this lack of discussion on proven relevant topics like the environmental issue, so important to the formation of the nurses.



The incorporation of environmental issues on health policies and the integration of the goals of environmental health are emerging, especially related to the skills and competencies of nurses, who must be provided with knowledge that target their actions with a view to effective practices on the needs imposed by society and the environment. Accordingly, this study discussed how environmental issues have been addressed in the curriculum of the National Nursing Curriculum Guidelines.

Although the Nursing curriculum guidelines address in various contexts the importance of nurses in different territories, which is a key issue in the field of knowledge of health and the environment, they ignore the practical aspect of this relationship, and the students that participated in this research, little can relate the importance of environmental changes on health, specifically, and they show general descriptions towards sustainable development without a relation with people's health.

It is important to highlight that the difficulty of adopting practices that protect the environment makes education an essential tool for people awareness. In this way, university stands out as a pulsating territory of important movements of change to apply these provisions by accumulating knowledge and productions.

The study presents some limitations, as it does not allow to extend the student's opinions to other groups, so it is suggested that other studies try to identify, in different territories, how students and health professionals correlate, in their actions of practice, the health and environment topics, to enable a better compression and intervention in environmental issues.

Discussing the existing relationships in nature and their implications in various kinds of life on Earth with future health professionals, it is important to implement effective policies directed to the environment, but also for the nursing practice, since the medical institutions are big producers of waste and energy consumers, besides they take care of people who live in health and disease-producing territories.



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