Consolidation of new public management in nursing education: repercussions to the Unified Health System

Objectives: to analyze the ways in which neoliberalism has consolidated itself in the public university and in university teaching in nursing; and what interferences it has produced in the pedagogical conceptions and practices of nurse educators. Methods: this is a qualitative research based on Institutional Analysis and conducted in a public university. Results: the data produced with the nursing teachers revealed the consolidation of the New Public Management in the university teaching of the professor-nurse, which is in contradiction with the formative assumptions for the Unified Health System. Final Considerations: it is noticeable how the university and the university teaching in nursing are already impregnated by neoliberal logic. This will possibly have repercussions on the training of professionals for the Unified Health System. by the of 2, of all


INTRODUCTION
The accelerated consolidation of neoliberal ideology in the world in recent decades is undeniable, spreading to the most diverse social sectors and implementing its logic of mercadologization and mercantilization of everything that is possible in human life (1) . In Brazil, the de facto consolidation of neoliberalism is beginning to intensify after the Constitutional Amendment (CA) no. 19, of June 4, 1998(CA 19/1998, made by Minister Bresser-Pereira, in the government of Fernando Henrique Cardoso, through a management device called New Public Management, notably implemented in the country by the managerialist side (2)(3) .
Neoliberalism has as its principles the delivery of all forms and products of human society to the private initiative and, to this end, it encourages the individualism and individualization of society, through various devices that make the individual service providers and these services capable of having their "efficiency" and "excellence" measured by indices and metrics (1,(4)(5) .
The Brazilian State, which had been consolidating itself by the foundations of the 1988 Citizen Constitution, supported mainly by the Declaration of the Universal Rights of the Human Being and by direct deliberative participatory democracy, was institutionalizing itself through a series of devices that the participants in the constituent movements had built up. However, another founding force, CA 19/1998, was established by the Ministry of Federal Administration and State Reform (MARE) (6) . This would be a counter-reform of the State?
To this end, Bresser-Pereira launches to study directly at source -in England -the movements that would culminate with something called New Public Management, bringing this management modality to edit this CA that would give another direction to the consolidation of the Brazilian State -an institute movement to update the Welfare and Rights State to a Neoliberal State, or ultra-liberal as some authors say (2,7) .
The main characteristic addressed by the above-mentioned CA refers to the separation of State activities into exclusive and non-exclusive. The exclusive activities of the State were in charge of high-level employees, directly related to the three powers, who were given massive training to appropriate the perspective of the New Public Management. The non-exclusive activities of the State were defined as those that could be offered not only by the public sector, but also by private initiative, the third sector and financial speculation, among which were education, health, social assistance, public transportation, etc. (2) .
In this context, regarding the education sector, besides the great expansion of higher education institutions financed and moved by speculative capital (education financing), the implementation/stimulation of business logics taking into account the management and structural organization of public universities is also added (8)(9) . It is also believed that one of the devices that also supported the transformation of the logics of operation and the raison d'être of universities was the academic productivism (10) .
Some authors already comment that teaching in higher education in nursing, as well as university teaching in general, has been suffering transformations caused by neoliberalism: in the private sector, the precarization of labor relations; and, in the public sector, academic productivism, which, in a way, also intensifies and precarizes the teaching work and the production of knowledge (8)(9)(11)(12)(13) , precisely because it alters the ultimate purpose of knowledge production and has great potential to profoundly change the objectives and purposes of training health professionals to other logics than the Unified Health System (UHS).
A dilemma is seen in the process of institutionalization of training for health professionals. One can perceive the formation in health in at least two ways. One of them would be one of the supporting devices for the consolidation of UHS, since it is possible to bring professionals closer to health sites during the formative process to learn together their specific and common team assignments (14) , and, with this, it would be possible to develop even more fundamental concepts and practices of the UHS, such as integrality of care and assistance, welcoming, crosssectionality and teamwork, among others. The other way is the one that responds to the neoliberal desires of training workers to achieve a certain type of work that aims to meet the needs of professionals with skills pre-established by the labor market, responding to the demands of financial capital in globalization (15) .
Thus, the knowledge gap presented so far is summarized in the following question: what are the clues that neoliberalism has become institutionalized in the Brazilian public university and what this has caused to the university teaching in nursing?

OBJECTIVES
To analyze the ways in which neoliberalism has consolidated itself in the public university and in university teaching in nursing; and what interferences it has produced in the pedagogical conceptions and practices of nurse educators.

Ethical aspects
This article originates from a doctoral thesis defended in 2018 (16) , on the consolidation of management in university teaching in nursing. To represent the professors and ensure anonymity, the letter P was used for excerpts from interviews, research diary and meetings with nurse educators. This research was approved by the Research Ethics Committee (REC) of the Nursing School of Ribeirão Preto of the University of São Paulo and met the NHC Resolution 466/2012, as well as the precepts of the Declaration of Helsinki.

Theoretical-methodological reference and type of study
The theoretical and methodological framework of this qualitative research was Institutional Socio-Clinical, one of the strands of the French Institutional Analysis (IA) movement. IA is an approach that aims to denaturalize the crystallization of institutions and is based on the idea that it is through the historical-social movement that everything is institutionalized. IA comprises an institution as the one that has its own rules of existence, going beyond the social organization, 'interacting' in the group essence of life, updating the attitudes and behaviors of individuals in constant production of senses and meanings (17)(18)(19) . The institution includes the game of evolutionary contradictions in the field of knowledge and power, mainly (20) .
IA was born in the 1960's in France in the midst of social movements, where René Lourau and Georges Lapassade are the main exponents of social studies concerning the analysis of institutions, being mainly responsible for the production and maintenance of the socio-analytical intervention chain. The Socio-analytical Intervention contemplates less lasting studies with short and brief interventions and was conceived from the articulation of Socio-analysis, proposed by Jacques and Maria van Bockstaele in the 1950's, and Sociology of Intervention, mainly the perspective of Alain Touraine elaborated in the 1960's. Thus, Gilles Monceau proposes Institutional Socio-Clinical, revisiting the principles proposed by René Lourau and indicating eight characteristics to mark the interventions being: attention to the contexts and institutional interferences; analysis of the orders and demands; analysis of the primary and secondary implications; work of the analyzers; analysis of the transformations as the work advances; the realization of refunds; intention of production of knowledge and participation of the subjects in the device (20) .
In this sense, socio-clinic refers to the most lasting interventions, which provoke the institutions, the instituted and which take advantage of the effects produced in this opportunity to produce the institutional analysis (20) .
In this research, the principles and devices of institutional socioclinics helped to provoke analysis, self-analysis in a group of university professors with respect to pedagogical conceptions and practices. These are understood as professional practices, developed from the perspective of the analysis of professional practices that are updated over time based on the dialectics of the institute, institution and institutionalization (universalization, particularization and singularization), and are closely related to professional implications (17) .
Finally, it is worth mentioning that the intervention carried out with this participating group was long-lasting, extending over four years of research.

Methodological procedures
Participants from the study site were initially invited to integrate the research by contacting the institutional e-mail available on the site of the study site. Eighty-four nursing professors were contacted, of which only 22 responded. 14 of these accepted to participate in the survey and eight said they did not have time available. Thus, 62 nurse educators did not respond to the invitation. Other participants were personally invited from their insertion in events in the area of nursing training, selected at random, provided that it contemplated the inclusion criteria, which are: being a university nurse educator, working in a public university (teaching, research and extension) in the training of nurses. Teaching professionals from other fields of knowledge were not included in this study. After acceptance and consent, interviews, observations and refunds were scheduled.

Study scenario
The study scenario was a public establishment of higher education in nursing, but the name of the place studied was purposely omitted to preserve the anonymity of participants.

Data source
The data was obtained from higher education professors in nursing participating in the research, being 18 nurse educators all from public institutions: 13 of these from the same establishment (all PhDs, with an average time of 10 years in the establishmentranging from 2 years to 29 years of teaching), of which 12 lasted in the production of data throughout the research, one ended participation before individual returns and collective meetings due to lack of time; the remaining five participants were nurse educators from other public establishments of higher education in four regions of the country (northeast, north, southeast and south). Official documents from both the studied establishment and research agencies were also the source of data.

Data production and organization
Several analytical devices, understood as everything that helps in the expansion and/or production of analysis and data, including analysis of the devices themselves (21)(22)(23)(24) , were used for the production and restitution of data in this research, among them: interviews, observations, documentary analysis, individual and collective restitution, use of research journal and new interviews to continue producing data, reflections, analysis and interpretations, as well as continuing in the provocation/production of effects. The interviews were conducted, transcribed and analyzed by the doctoral student, as well as the field observations. Analytical narratives were then presented and discussed in a specific private research group meeting with other researchers and graduate students. The research groups that supported the deepening of studies and training for this research were related to qualitative research, institutional socio-clinics, collective health and education. Thus, it was possible to take to the moments of individual and collective restitution a material extensively reflected and analyzed, to be appreciated and discussed with the participants.
Both the interviews and the observations composed the research device as provocative strategies at the same time of pedagogical-formative reflections and capable of making the contradictions of the university nurse educator's pedagogicalthinking appear. The observations occurred in classroom activities, in laboratories, in practical activities in health services and in the immersion itself in the studied site and were understood in this research as movements of "being with" the other in the production of data and information, putting in analysis the contradictions in act, therefore, closely imbricated to the principles of intervention research and institutional analysis. All the provocative strategies used in this research were also crossed by the diversity of types, ways and forms of participation of university nurse educators, who have agendas full of activities. Therefore, participation in this research was understood as something produced throughout the process, flexible, cyclical and directly related to the implications.
Throughout the research, there were also implication analysis meetings, in which the participants and the doctoral student, with the assistance of a researcher-observer, analyzed their implications in relation to the research, putting in analysis the historical-existential, psycho-affective and structural-professional dimensions. The implication analysis helps the participants and the researcher to reveal the institutional interferences along the methodological, analytical and epistemological production, and should be undeniably and immanently carried out within the collective (24) .
Thus, 13 audio recorded interviews were conducted, 104 hours of classroom observations, laboratory activities, internships and immersions, and 63 documents were analyzed (1 document with authorization, 18 granted and 44 available online), including resolutions of the university and the institution studied, lesson plans, subject plans, opinions, pedagogical projects, timetables and one compiled on the institutional evaluation, in addition to a document from the research regulatory agency. In the individual and collective returns, the syntheses, analyses and interpretations produced from the interviews, documentary analysis and immersion in the study scenario were presented and discussed with the participants. A research journal was used in which notes were made that gave continuity to the production of data at all times of this research, containing notes of reflections, descriptions, and other information. The time period for data production and analysis was from January 2014 to September 2018.
For the production of this article the 32 items of COREQ were considered regarding the relevance to this qualitative research based on Institutional Socio-Clinical.

Data analysis
The analysis considered moments of transcription/translation (transcription of interviews; production of observations, analysis of documents); transposition/arrangement ('re'production of data through: individual returns; constant immersion in the scenario; permanent resumption of the notes of the research journal; meetings of collective discussion); and reconstitution/ arrangement (production of a text that seeks to represent the entire process of research, production, analysis and interpretation of data -the thesis) (25) .

RESULTS
From the implication analysis carried out throughout this research, it was possible to highlight that most of the participants shared similar origins and life stories -notably from the working class, showing enthusiasm for the transformation of teaching and the training of nurses in higher education, through critical education. This, in a way, presents from what context the production of data could be woven.
For the production of the results, three analysts of the 'university teaching and the nurse educator' were fundamental: "timemoney relationship", "discussing pedagogical conceptions" and "resistance". The analyzers, based on institutional socio-clinics, are everything that causes institutions to unveil themselves and show their contradictions, influences and updates in process.
The results were presented from the origin of the data production and were organized as follows: "Consolidation of the New Public Management at the university and in the university teaching of the railway professor from documents"; "consolidation of the New Public Management at the university and in the university teaching of the railway professor from observation data"; "consolidation of the New Public Management at the university and in the university teaching of the railway professor from interviews with participants of the study site"; and "consolidation of the New Public Management at the university and in the university teaching of the railway professor from interviews with participants of other training centers".

Consolidation of the New Public Management in the university and in the university teaching of the nurse educator from documents
A change of direction in the management and management of the Brazilian State was identified, in official documents, producing the gaps for the financing of sectors such as Education, mainly, and Health, which are the two focus areas of this research. The following excerpt announces this issue with the word "efficiency" included in Art. 37 of the Federal Constitution (26) : The most recent management reports of the studied university begin to include terminologies and ideologies typical of managerialism (New Public Management), such as "efficiency", "excellence", "productivity", "better use of resources", "cutting costs", "reducing costs", "accountability", "practicality", among others, as presented in the following analysis sections: The university studied began to implement different work regimes and evaluation processes of teaching activities. It also started a process of hiring temporary professors with lower salaries, whose salaries are about two minimum wages in force (refers to the parameter of early 2019), to work 12 hours/week of dedication to teaching, while the effective positions are not replaced according to need. The following excerpts, from which citations and references were omitted for ethical purposes, announce this issue: [ In the case of nursing, the Capes report for the 2017 nursing area already contains predominant or priority quantitative elements such as, as illustrated by the following analytical excerpts:

Consolidation of the New Public Management in the university and in the university teaching of the nurse educator from observation data
This study shows that these measures have affected undergraduate subjects, since they are having to reinvent/adapt to continue to exist, since the number of professors has been reduced, pushing the teaching staff to return to theoretical-expositive models of teaching, as presented in the following analytical excerpt: In an informal meeting with P03, the professor affirms that because of the cuts and not re hiring of professors, her subject will have to rethink its strategies and teaching-learning methods, since they worked in 4 professors for a class of 50 students, being small groups between 10-12 students per professor, according to the requirements of the pedagogical reference used for the formation of critical professionals, and now they will have to work with a larger group per professor, approximately 17 students, or even make two groups of students for each professor, which would greatly increase the teaching load of dedication to undergraduate teaching. (Excerpt of annotation in research journal)

Consolidation of the New Public Management in the university and in the university teaching of the nurse educator from interviews with participants of the place of study
Another important aspect is the way teaching in higher education in nursing has been adapted or co-opted to the productivist logic so that more time is available for dedication to activities that generate products quantifiable by Capes evaluation -the research:

Consolidation of the New Public Management in the university and in the university teaching of the nurse educator from interviews with participants of other training centers
This situation was also confirmed in new interviews with other participants from other universities: […] It is logic of productivism, to produce more of the same more with the intention of punctuating than with the social relevance, many times it does not give a return for the subjects that not

DISCUSSION
The analyzers "time-money relationship", "discuss pedagogical conceptions" and "resistance", associated to the set of data producing analytical devices, produced effects caused by the neoliberal updating that, mainly, the institutions State, University, Teaching in Higher Education and Training have suffered in the last years, which possibly interferes directly in the training of nursing for the work in UHS.
The change of direction in the management and administration of the Brazilian State is identified mainly with CA 19/1998, the reform of the Brazilian State, which is observable through the insertion of terms referring to efficiency, evaluation by performance, setting goals, etc. In addition, public servants were trained by the government at the time in the 1990s to meet the desired changes for the Brazilian State.
In this context, the evaluation processes of teaching activities have a format characterized by the possibility of punishments/ sanctions, such as a change in the work regime if the professor does not reach the productivity parameters pre-established by the teaching evaluation committee and by their peers in the accredited unit.
The Capes report for the 2017 nursing area also provides reflections in this sense, since it carries elements such as: indirect evaluation of university professors through graduate program reports; quantitative evaluation through pre-established quantitative or quantification indicators; scores established from numerical quantities of products (articles, internationalization) and quality assessed through numbers of citations (quantitative).
In this university studied, the impact of these measures was clear. There were subjects that had a greater number of professors to be offered in formats appropriate to the formation of UHS oriented workers, with immersion/internships in the health scenarios (direct contact with social practice as recommended to the formation for UHS) since the beginning of the course, in which professors followed the nursing students (in number of 10 for each professor) to the professional exercise scenarios, seeking alignment to the consolidation of UHS. These disciplines are being forced/induced to change their pedagogical conformations to meet neoliberal ideas.
At the site researched, there is a strong culture of academic productivism, aimed at meeting the demands of productivity according to the criteria of Capes, to consolidate the graduate programs, maintaining or raising their scores. To this end, professors are being "motivated" to produce more "products" of this nature ordered by Capes and reaffirmed through their resolutions and decisions. This has caused a certain reduction in dedication to teaching and extension, or even the assumption of training and extensionist processes with greater practicality to be executed/ managed by professors.
From the results of this study, it is possible to see that both the university studied and the type of teaching work are increasingly aligning with neoliberal ideals. This is mainly due to the measures taken to institutionalize this perspective, updating the State model, which had been constituted with the intention of a Social Welfare and Rights State, for a neoliberal State.
Thus, knowing the power of influence and induction of the State over the end-activities, one can see how the "state-company" has induced the updating of the "university-company" and also a professionalization of teaching management (shaped by the characteristics of the NGP -management side), as discussed by some researchers of this subject (1)(2)(3)7,(9)(10)27) .
Thus, we consider that the institution 'teaching in higher education and the nurse educator' is being updated in a managerial sense, as evidenced by the data presented here. For this reason, a type of university-company has prevailed, based on neoliberal and managerialist assumptions, focused on the process of production of knowledge based on statistics and quantifications, holding individuals accountable through increasing accountability and quantification of their work (9)(10)(28)(29)(30)(31)(32) .
This movement causes reverberated updates in other institutions of human life, including human life itself, in order to think of all things from a managerial point of view, in which everything becomes manageable and quantified in indexes. In this direction, the formations are aligned with the logic of practicality, capable of being transformed into indexes, quantified and easy to account for, like finished products (10,33) , or at least semi-finished products.
There have been movements at the university of transferring learning responsibilities to students, notably with the use of hard technologies at a distance, which converge with the university-company, because actions of this nature make both the work of the professor and learning more practical. This type of university-company has the potential to sharpen pedagogical practices that promote individualism, competition and, in the case of health, the understanding of health as a private good, that is, a commodity, going against the ideals and legal presuppositions of UHS, especially in relation to health as a right of citizenship. In view of these perspectives, it is consistent with the idea that managerialism has great potential to induce curricular definition and training, both in basic and professional areas (8,(34)(35)(36) .
This university perspective is increasingly distant from the health training ordered by UHS for its effective consolidation, which means that it is distant from and not consistent with having UHS as the inducer of health professional training in Brazil. This finding about the crossing of the management in the university teaching in nursing coadunate and walks together with the definancing, disassembly and irresponsibility in the implementation of health as a right as mentioned by researchers of the subject (36) .

Study limitations
The study was carried out at a public university and with university nurse educators. It can be expanded with other investigations that consider other professionals, the private sector, education managers and undergraduate and postgraduate students, for example.

Contributions to the area of Nursing, Health or Public Policy
We consider these limits of the study as relative, because they allow us to reflect on the ways in which the teaching of nurses is intertwined/captured by the neoliberal state design in institutionalization. This signals reflections and future actions to be taken in nursing, health and/or public policies and, notably, for the effective consolidation of UHS.

FINAL CONSIDERATIONS
This study, conducted with university nurse educators, identified how much the logic of neoliberalism expressed by the perspective of the New Public Management / Management has interfered in the university teaching of the nurse educator and, consequently, in training for UHS. This New Public Management at the university has contributed to the production of a strong culture of academic productivism with the purpose of consolidating graduate programs in this logic and, thus, the professors are impelled to produce more quantifiable "products" (such as, for example, articles in this logic). The dedication to undergraduate teaching loses space before research, and the same happens for cultural and extension activities. Therefore, the potential of the New Public Management on the updating of 'education' and 'health' institutions is noted, causing updates on university teaching and this has repercussions on the current curricula and the training of health professionals.
It is also added that the Unified Health System is based on the health perspective as a right of citizenship and duty of the State, and would need more articulated professional education to it, but the logic discussed here leads nurse educators to meet institutional demands aligned to neoliberalism in order to remain in the teaching profession. We consider it a challenge for the Brazilian nursing to question the close relationship between the State designs and the practices of training and care.