Curricular reforms in the transformation of nursing teaching in a federal university

Rev Bras Enferm. 2021;74(4): e20201242 https://doi.org/10.1590/0034-7167-2020-1242 7 of ABSTRACT Objectives: to discuss the curricular reforms adopted for nursing teaching in Brazil, from 1969 to 2019. Methods: historical, qualitative approach using the thematic oral history and document research. 13 interviews were carried out with graduation nursing professors from a federal university in the South of Brazil. The document sources were the political-pedagogical projects of the course and their associated documents. Minayo’s thematic analysis was used. Results: nursing curricula delineates the profile of the professional that must be formed and are reviewed in order to be adapted to social and educational changes, showing the scientific and professional potential of the nurse. Curricular reforms consider the quality of nursing formation. Final Considerations: the structure of the curriculum and the reforms that took place emerged according to the historical, political, epidemiological and social context demanded from the profession, to attend to the demands of society and to the work market. Descriptors: Curriculum; Education, Nursing; Education, Graduate; Higher Education Institutions; Nursing History.


INTRODUCTION
The constitution of modern nursing as a profession started in the second half of the 19th century, with the foundation of the nursing school of the Saint Thomas Hospital, in London, where, through Florence Nightingale and her presuppositions, Modern Nursing came into existence (1) .
The Civil War (1861-1865) in the United States was a driving force for the start of professional nursing in the country, since, up to that point, there had been no nursing organizations. Throughout the conflict, many women left their families and/or husbands to aid in situations that took place in locations previously not seen as "appropriate" for women. Their role during this period changed the public opinion about the work of women in health care, and those who volunteered for this war noticed the importance and the value of a formal education to care for the "sick". Some of them were instrumental for the establishment of the first nursing schools in the United States (2) .
In Latin America, the origins of nursing date back to the pre-Colombian age, with its healers, but only in the 19th century, the field received a sanitary approach, with the support of religious congregations. The first nursing schools were created in Argentina, Cuba, Chile, Mexico, and Uruguay. The professional and discipline of nursing advanced in Latin America, being tied to scientific and technological advances, as well as to economic, social, and political changes experienced by society (3) .
The historic events of the formation of nursing in Brazil started in 1890, through Federal Decree No. 791, from September 27, 1890, with the establishment of the Nursing School of the National Hospital for the Mentally Ill, in Rio de Janeiro, which was directed by physicians (4) . However, it was after the First World War that the professionalization of nursing and Brazilian public health were pushed forward, with the creation of the National Department of Public Health, headed by Carlos Chagas (5) . The systematized official teaching of modern nursing in Brazil was introduced in 1923 by Decree No. 16300/23, in Rio de Janeiro, through the organization of the Nursing Service from the National Department of Public Health, directed by Carlos Chagas and, today, having been renamed Anna Nery Nursing School (6) . Since the beginning of the 20th century, the transformations that permeated the context of education in nursing were instituted through curricular reforms, external processes from the Ministry of Education and Culture that started in 1923, 1949, 1962, 1994, and 2001 (7) .
In the decade of 1980, in consonance with the social movements that were taking place all over the country for the Brazilian society to return to democracy, nursing also started to show the need of reforming its professional practices. With this in mind, the Movimento Participação (MP, the Participation Movement) was a reaction to the posture and directions given by the Brazilian Nursing Association (ABEn), focused on becoming aligned with the Sanitary Reform project, becoming committed to make changes to the context of national politics (8) . The ABEn, since 1990, with the creation of the National Seminars of Directives for Nursing Education (SENADEN) has been trying to implement strategies and follow-ups to carry out nursing policies in its many levels (technical, graduation, and post-graduation), with proposals to enhance the quality of the formation of these professionals (9) .
The ABEn, after a long period of discussions with the participation of schools, health institutions, and organization entities concluded a new curriculum proposal, which came into force in 1994, through decree No. 1721/94. This new curriculum predicts that nurses should be formed in four fields: management, assistance, teaching, and research (7) . The curriculum model for nursing which resulted from these changes in 1994 was incorporated to the sanitary reform, articulating clinical and epidemiological dimensions and showing a preoccupation with the different realities of the country.
In 1996, Law No. 9.394/96, known as the Law of Bases and Guidelines for National Education (LDB), was approved. This Law opens spaces for graduation curricula to become more flexible and for the "minimum curricula" and the "curricular grade" to provide autonomy to higher education teaching institutions in the scientific-didactic field, allowing for the creation of courses, the establishment of curricula of courses and programs, and for the adoption of specific curricular directives for each course (10) . The LDB influences the curricular organization of nursing and, as a result, the entire formative framework of nursing professionals and of nursing auxiliaries and technicians. Therefore, the influences of curricular structures capture, for the formation of the nurse, the political and economic confluence of the Brazilian society of the time.
The National Curricular Guidelines (DCN) for the nursing course in 2001 establish the objectives of the education in the course through competences and abilities that should be considered in higher education institutions. The directives show that "The formation of the Nurse should attend the social needs of health, especially those of the Single Health System (SUS), guaranteeing integral care and a humane and quality attention" (11) .
Curricular reforms are important because they follow up the evolution of education throughout the world, in addition to guiding the organization of the courses to guarantee the quality of their curriculum. Curricular changes are part of political movements brought forth by representative entities, new policies in education and health, teaching institutions, professors, and students. Since this is a historical-social study, we have established a timeline that could encompass the theme, starting in 1969, when a federal university was created in the South of Brazil, and going as far as 2001, when the Curricular Directives for Nursing currently in effect were implemented.

OBJECTIVES
To discuss the curricular reforms adopted for nursing teaching in Brazil, from 1969 to 2019.

Ethical aspects
This research was approved by the Research Ethics. Participants signed the Free and Informed Consent Form before interviews and the concession agreement after the interviews were transcribed and validated.

Type of study
Social-historic qualitative research, using thematic oral history and document research. The thematic oral history used the 7 of Curricular reforms in the transformation of nursing teaching in a federal university Petry S, Padilha MI, Costa R, Mancia JR.
interview as a data collection technique, and a thematic character specific to the selected group was chosen for the study, according to which the researcher attempted to clarify the facts associating the statements of the interviewees to other document sources. The historic research uses the documents as a method to achieve historiographic information and presents procedures for its choice, organization, analysis, and synthesis (12) . This research used the checklist from COREQ (Consolidated Criteria for Reporting Qualitative Research) (13) .

Study setting and sources of data
The setting of the study was a federal university in the South of the country, founded in 1960, who started offering a graduation course in 1969. The oral data sources were 13 professors who participated in the course from its implementation to 2001, when the National Curricular Guidelines which are still in force were put into effect.

Collection and organization of data
13 interviews were carried out with the aid of a digital recorder, from December 2018 to April 2019, with professors and coordinators from the Nursing graduation course of a federal university in the South of Brazil. These professors and coordinators were a part of the historic trajectory of the course, from its beginning to current times.
For data collection, the following inclusion criteria was adopted: professors linked to the university and who participated in the construction of curricula in the course during the period of interest, using the snowball sampling technique (14) . Exclusion criteria were: lecturers whose influence at the time was indirect; and professionals consulted who were not linked to the institution. The number of participants was determined by data saturation.
The interviews lasted for approximately 40 minutes, were recorded and transcribed in their entirety and later validated by the participants via email. All of them were carried out by the main researcher of this study, who was formed in the university being investigated and became theoretically immersed in publications about the theme. The interviews took place in the spaces of the university, in the house of the professors, in cafés, and one was carried out using a video software, since physical presence was impossible.
The participants of the research were identified using the letter C for the course coordinators and the letter P for the professors, followed by a sequential number. Although this is a social-historical study, participants did not need to be nominally identified, since the interest of the researchers was the curricular reforms themselves, and not the characters who were a part of this reform.
The documental part of the study involved selecting the documents in the Main Library of the University, in the personal collection of the professors, in the university catalogues which had information about the Nursing Department, the curricula, in disciplines and in syllabuses, in addition to the political-pedagogical projects of the course.

Data analysis
Data analysis was based on the thematic analysis proposed by Minayo (15) , which takes into account two moments: the first related to the fundamental determinations of the research, mapping the exploratory stage of the investigation; and the second, the interpretative stage. The latter is seen as the ordination and classification of data, final analysis, and report. Tables with the units of record of all interviews were created and distinguished by color, to be later grouped to form categories of analysis.

RESULTS
The results are organized in three categories: Curricular reforms and dynamics to improve teaching; The influence of the curricular structure in the formation of the nurse; The National Curricular Guidelines and the curriculum structure in the formation of nurses.

Curricular reforms and dynamics to improve teaching
The coordinators of the nursing graduation course present similar responses regarding the meaning and importance of curricular reforms. They state that a curricular reform starts based on movements of dissatisfaction with the curricular model of each era, and teaching is based on that. In this category, the starting movements of a curricular reform are presented, as well as the aspects that influence the dynamic of development of a graduation course in the middle of the reform.
Curricular reforms are part of the historic context. The reality, the situation of health, the context in which the course is inserted also evolve historically; therefore, one expects the course, the professional formation, to reflect these changes. (C3) It is the level of dissatisfaction that starts to emerge, regarding professors and students, the evolution of policies, the nonadherence to the practice, to what is being done out of the university, non-adherence meaning agreement, in the sense of knowledge, the way in which nursing assistance is processed, in which it should be processed, and what the university is doing towards that, so these concerns start emerging and a discussion is necessary. (C2) The mobilization of professors towards reforming the curriculum is shown as a preoccupation with the formation of future nurses, when, in the 1970 decade, they attempted to make their students public health specialists. It can be noted that the integration between professors and students is essential for discussions to advance, aimed at implementing proposals of transformation in the curricular structure of a course. 7 of Curricular reforms in the transformation of nursing teaching in a federal university Petry S, Padilha MI, Costa R, Mancia JR.

The influence of curricular structures in the formation of the nurse
The nursing graduation curricula change according to the sanitary reality, the possibilities of employment, and the teaching technologies. Nursing teaching is expressed through the political-pedagogical project (PPP) of each course. The contents to be addressed must be the result of an analysis of local reality and its needs. Nursing, in its trajectory as a profession being formed, adapted itself through time, as public, educational and health policies emerged; therefore, it can be noted that the curriculum itself becomes more adequate to quality teaching and to the needs of the work market. There is a concern towards improving scientific knowledge of nursing, generating effective reflections in care assistance.

The National Curricular Guidelines and the curricular structure in the formation of nurses
The coordinators state that teaching nursing is based on local epidemiology, and that the curriculum of a nurse will be different between the regions of the country. The DCNs outline the profile of nurses, who should have a generalist formation, and only in the 2001 DCNs curricula, based on the change from a hospitalcentric model to a primary-attention-focused one were these themes discussed. The discussions bring forth the formation to act at SUS and the need to consolidate this system.
The specific context of the region must determine this perspective, so that the nurse can attend to the needs of the population/ community in which they are being formed. This is a contradiction, if you think about the national exam of courses. If we want a formation that is related to regional characteristics and attends to the health needs of each region [and we have very different epidemiological frameworks, cultures, and habits in the many Brazilian regions], we must also have an exam that takes these traits in consideration. (C3) The national curricular guidelines, and the pedagogical project of the course, will generate the teaching plans. You deal with professor and university autonomy. University autonomy, hierarchical university management. The professor has relative autonomy, and I say this because the professor can decide about how this teaching is going to happen. The DCN is determinant, since it will define that the teaching has to be guided by the sanitary reality. The epidemiological profile of the place is what should measure the course. The professor makes this analysis so that this lesson can be taught. This is a weakness there is, but it can be a strength, it can, but that depends on the group of professors that structures it, or on the department organs that manage it. (C5) The autonomy of the graduation courses based on the DCNs and the definition of political-pedagogical projects guide nursing in a particular way, tailored to specific regional needs of health work. It stands out that the DCN does not suggest, specifically, which disciplines must be offered by the courses: the curricular guidelines, on themselves, are guides to elaborate teaching towards quality and professional valuing. The statements bring forth the need for guidelines to improve education from multiple perspectives, and not specifically in the scope of knowledge and personal mastery of a professor.

DISCUSSION
Nursing teaching passed through transformations, and, through the years, followed the needs of each era regarding care models and health practices, going from a hospital-centric model to a public health one. The process of constructing nursing knowledge evolved from the execution of basic tasks to a critical, scientific, and systematized human care (16) . Nursing schools had an essential role in this process of directing the practices of thinking and caring (17) .
In the decade of 1940, the number of hospitals started to grow, especially in cities such as Rio de Janeiro and São Paulo, with the medicalization of the body and a larger preoccupation with recovering the workforce, coming from the working class. Hospital institutions associated to medicine universities or created by social security pushed forward the Brazilian biomedical model of health care services, which became even more prevalent during the military dictatorship, as private hospitals started receiving funds from social security. However, this model ends with the sanitary reform, which influenced the teaching of nursing, from the promulgation of Law No. 775/49 to the establishment of a minimum curriculum in 1994 (18) .
With the dynamics of health and production of knowledge, the reforms in higher education were found to evolve from the simple completing of purely educational rules to the presentation of curricula focused on strategies of teaching the citizens. The relation between professors and students is filled with expectations, focused on the nursing education for public health work. This becomes evident in the discourse of the participants of this study. 7 of Curricular reforms in the transformation of nursing teaching in a federal university Petry S, Padilha MI, Costa R, Mancia JR.
In this regard, a study about the formation of nurses in Latin America and the Caribbean highlights, by looking at the curricula, how heterogeneous the education is, focusing on hospital health care. The teaching values the use of active methodologies and transformative education above all else, based on evidences and critical and reflective thought (19) .
Every historical-social process opens the door for anxiety in those involved -from this perspective, education in health and for health. In the field of nursing knowledge, the focus is improving the quality of education for proficiency, seeking expertise in nursing care. This dynamic of constructing and deconstructing the curriculum is shown in this study.
There is a rhetoric of breaking hierarchical control, which, therefore, instigates different ways of thinking and developing the educational work. This can be made clear by the drive of the group of teachers towards finding the theoretical resources that should be applied to the practice of nursing care (20) . These aspects can be noticed in the development of regular workshops for discussing the curriculum and its operationalization, aiming at a course that adheres better to the reality of each time, guaranteeing a richer teaching-learning process and answering to regional needs.
There is a challenge to the formation of the nurse with regard to integrating the disciplines of the basic and professional cycles. Throughout history, higher education institutions have been organized in isolated disciplines, disconnected from the professional practice and targeted at either a technical or a specialized formation (21) . This fragmented curricular formation; the articulation between the content of the different disciplines and the application of knowledge eventually become hardly viable (22) . When one evaluates how to build a quality curriculum, the challenge of creating one that is integrated, from the first to the last semester, and articulated in an interdisciplinary way, is constant, especially for nursing, both in the basic cycle and in the professional one.
Breaking with the biological model of health education is a great challenge, focused on the disease and on clinical-medical guidance. Therefore, the idea to broaden the context of health is formed, encompassing health promotion, prevention, treatment, and rehabilitation, while articulating with the development of post-graduation (23) .
The DCNs fomented changes in the pedagogical projects of the courses with regard to the ways to teach and care for nursing, as well as in the different profiles of professionals who focus on the effectiveness of the SUS. Brazilian nursing schools, based on the LDB changes, started to implant a new curriculum, which demands measures related to the organization of academic/administrative structures and a program of professor training to transform the model of nurse formation (24) . The LDB, together with Decree No. 2207/97 provides that professors from higher education institutions must be at least post-graduates, up to PhDs (10,25) .
Health professionals are important subjects in the historic process for the implementation of SUS, whose construction and consolidation recognizes the role of the nurse. This professional has many attributions and competences within the system, and have participated in the trajectory of public health policy implementation (26) .
The nurse profile which emerges from the description of the DCN resulted from discussions that started in the 1980 decade, aiming to oppose early specialization, to associate theoretical and social practice knowledge, and to problematize the many realities. DCNs do not indicate, exactly, the content and the disciplines that should make up the curriculum of a nurse; therefore, the institutions, in their needs, reformulate themselves according to their beliefs or according to the guidance of the subjects involved. These changes happen because of the dissatisfaction of professors and students with regard to the current curriculum. The way in which the guidelines are comprehended must be monitored, as well as the way in which they are implemented in the pedagogical proposals of the nursing graduation courses, and the way in which institutions are guaranteeing a formation that is connected to humanized health care, as prescribed by SUS.
In this setting, advances can be noticed in the policy of nurse formation, relative to the articulation of educational and health policies. In Brazil, these recent modulations of nursing graduation courses become closer to the proposals of the DCNs, whose principles are connected to the public health system. However, this proposal is in the same space as formation tendencies guided by the market and by competition (24) .
In this context, the challenges are even greater, when competition strengthens the construction of professor autonomy in courses that seek to produce innovative and creative curricula, capable of developing professional aptitudes, autonomy, expertise; all that as part of a set of measures to empower nursing professionals. Organizational entities, such as the Brazilian Nursing Association and the National Council of Nursing reiterated the need of empowering through the organization of converging curricula and the regulation of professional exercise.
The curricula encompass the structure of a course, highlighting its subjects, workload, syllabuses, among other aspects. The understanding of their effectiveness is verified by the resourcefulness of professors and students. The change in the structure of curricula comes from both sides, since both show themselves as flawed for the formation of future nurses. The evaluation of the evolution of curricular changes seeks to understand learning experiences, the development of competences, the relation between professors and students regarding the classes, and the obstacles inherent to these changes (27) .
The content and the disciplines themselves end up being taught and conduced by the professors, who have the knowledge needed about a certain theme, and, as such, are taken as experts in a certain field. This is positive as long as it does not lead to immobilizing or fossilizing knowledge, preventing renovations. The autonomy of university and professors is highlighted, and each teaching institution has, in its political-pedagogical projects, a way to carry out teaching, which, often, is guided by the professors and their respective fields of knowledge.
The process of reflection about the planning of teaching by the professors of each discipline opens spaces to highlight the lines of subjectivity and the processes of individualization of the professors (28) . Our understanding is that the formative processes must ponder on the advances of knowledge, the changes in the working process, the transformations, and the social needs for each demographic and epidemiological profile of the population (29) . 7 of Curricular reforms in the transformation of nursing teaching in a federal university Petry S, Padilha MI, Costa R, Mancia JR.
In a curriculum, the process of changes is surrounded by contradictions regarding what is proposed and prescribed by public policies, what is known by its actors, and the issues posed by the institutional context (22) . The role of professor and the student is part of a challenge associated with teaching and learning effectively: each one has a prerogative when it comes to teaching. The professor is responsible for promoting activities and creating situations for a critical and reflective learning, while the student should take a position regarding the content -for example, taking responsibility for the construction of their own knowledge and being capable of developing competences that improve their performance (30) .
University professors must go beyond the specific knowledge of the field in which they were formed; the university demands that they, with the aid of their knowledge from experience and from scientific production, act on the pedagogical foundations of the teaching-learning process. Therefore, in higher education, the professor holds responsibility over the formation of the professionals and is committed to the formation of people who will work in society (31) . The setting of the classroom is a space where knowledge is constructed and mediated, reality is contextualized and problematized, and there is a mutual exchange.
In its trajectory and history, nursing teaching attempts to adapt itself to the demands of society and to the policies of health and teaching. As the profession advances, universities and their graduation courses adapt as teaching institutions, to form professionals using the most modern tools so they can act in their local realities. The content and the subjects taught emerge from the social and epidemiological needs of the region and are expressed in their curricula by professors skilled and trained to teach every topic.

Study limitations
The limitation of this study was the small number of institutional documents. Furthermore, it would be necessary to establish discussions relating a macro level (national and/or international) to a micro level (that of the institution being studied) so we can reach a more profound dialog, for instance, within the Latin American setting.

Contributions to the Field of Nursing
This study made it possible to reflect on the importance of DCNs in the curricular reforms of the courses, for a more adequate implementation, more in line with regional needs in a country with continental dimensions such as Brazil. In addition, it can give support to other studies as it can instrumentalize an academic practice based on principles that strengthen the commitment of the body of professors with the quality of the curriculum. Historic studies allow us to learn from the rights and wrongs of the past, aiming to prevent the repetition of problems and future curriculum reformulations, and to improve the quality of nursing teaching and guarantee that market demands are attended.

FINAL CONSIDERATIONS
In the period investigated, it was possible to show that there were transformations, through the DCNs, in the materialization of the curriculum of the institution. This represents an advance in the teaching of Brazilian nursing, which can be seen as little due to the high expectations, but which was as good as possible for the time.
Some challenges were overcome institutionally, considering, especially, the materialization of the curriculum, since the nursing course could start to be conducted by reflecting (self-evaluating) the social body.
Finally, the impact of the application of the curriculum should be investigated, since, here, only one side of the issue was listened to, and, to reach complete understanding, we need to listen to the students. This implies another challenge to be investigated, which can lead to the possibility of new intellectual productions or even further studies that, in fact, may provide a broader view of the discourses towards the advances in the quality of institutional teaching.