Problematization methodology in primary healthcare teaching

Metodología de la problematización en la enseñanza de atención primaria de salud

ABSTRACT

Objective:

To identify the contribution of the problematization methodology in primary healthcare teaching in a nursing undergraduate course.

Method:

Documentary, descriptive and qualitative study, carried out with undergraduate students from the Ribeirão Preto College of Nursing at the University of São Paulo. Data were collected through analysis documents which consisted of 21 evaluation forms filled out by first-year undergraduate students in the 2013 school year taking the subject Comprehensive Health Care I, whose theoretical framework was focused on primary health care.

Results:

It was found that the subject met the intended goals, allowed coordination between theory and practice, and enabled the contact of undergraduate students with the profession and work environment in the beginning of the course.

Final considerations:

Analysis of the evaluation forms for the subject Comprehensive Health Care I evidenced that the use of the problematization methodology favored primary healthcare teaching.

Descriptors:
Nursing Students; Nursing Education; Primary Health Care; Higher Education; Learning

RESUMEN

Objetivo:

Identificar contribuciones de la metodología de la problematización en la enseñanza de atención primaria de salud, en un curso de enfermería.

Método:

Estudio documental, abordaje cualitativo, realizado con el Curso de Bachillerato y Licenciatura en Enfermería de la Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. Fueron analizadas 21 fichas evaluativas completadas por estudiantes del primer año de 2013, cursantes de la disciplina Cuidado Integral en Salud I, cuyo abordaje teórico era atención primaria de salud.

Resultados:

La disciplina alcanzó los objetivos propuestos, permitió la articulación entre teoría y práctica, e hizo propicio el contacto del estudiante con la profesión y con el mundo del trabajo ya hacia el inicio del curso.

Consideraciones finales:

El análisis de las fichas evaluativas de la disciplina Cuidado Integral en Salud I permitió considerar que el uso de la metodología de la problematización favoreció la enseñanza de atención primaria de salud.

Descriptores:
Estudiantes de Enfermería; Educación en Enfermería; Atención Primaria de Salud; Educación Superior; Aprendizaje

RESUMO

Objetivo:

Identificar a contribuição da metodologia da problematização no ensino de atenção primária à saúde em um curso de enfermagem.

Método:

Estudo documental, descritivo, de abordagem qualitativa, realizado junto ao curso de Bacharelado e Licenciatura em Enfermagem da Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. Foram documentos de análise, 21 fichas de avaliação preenchidas por estudantes do primeiro ano letivo de 2013, que cursaram a disciplina Cuidado Integral em Saúde I, cuja abordagem teórica, era atenção primária a saúde.

Resultados:

Identificou-se que a disciplina atingiu os objetivos propostos; propiciou a articulação entre teoria e prática; e proporcionou o contato do estudante com a profissão, e com o mundo do trabalho já no início do curso.

Considerações Finais:

A análise das fichas de avaliação da disciplina Cuidado Integral em Saúde I permitiu considerar, que o uso da metodologia da problematização favoreceu o ensino de atenção primária a saúde.

Descritores:
Estudantes de Enfermagem; Educação em Enfermagem; Atenção Primária à Saúde; Educação Superior; Aprendizagem

INTRODUCTION

The Unified Health System (SUS, as per its acronym in Portuguese), the public health system in force for the past 25 years in Brazil, is still in organization and implementation process. The network was designed to favor the strengthening of primary health care (PHC), a branch of medical care which aims to meet the health needs of assisted populations according to local realities.

To meet the requirements of the professional work process at the SUS context, the Brazilian Ministry of Education institutionalized the National Curricular Guidelines for higher education courses in 2001, aiming to propose changes in the training of healthcare professionals. The National Curricular Guidelines for nursing courses point to the qualification of nurses in consonance with a professional profile including a sense of social responsibility and of promoting comprehensive health to human beings. To achieve this target, nursing schools have to include skills such as decision-making, communication, leadership and management and education in the health field in their curriculum and active learning methodologies (ALM) in their teaching strategies⁽¹⁾.

Active learning methodologies were designed to disrupt traditional teaching and learning methods and advocate that knowledge must be built by people themselves instead of reproduced mechanically and uncritically⁽²⁾. Methodologies used as an alternative teaching method are grouped in a category named problematization methodology (PM). In this case, the contents built by students must be adapted to their previous cognitive structure, so they can find relationships, laws or concepts necessary for their learning^(3-4).

The undergraduate course of the Ribeirão Preto College of Nursing at the University of São Paulo has aimed to apply the PM perspective in some of its subjects since 2006. The pedagogical project of this course is grounded in the National Curricular Guidelines for nursing courses and in frameworks which involve dialogic skills, an integrated curriculum, PM and PHC⁽⁵⁾.

The subject Comprehensive Health Care I (CHC I) stands out among the subjects of the curriculum which were developed from the perspective of the PM.

Fifty positions for this subject are offered annually in the first year of the course. The main objective of CHC I is to introduce students to PHC teaching. It must allow the development of knowledge, skills and attitudes present in the health-disease process, and the delivery of comprehensive health and nursing care to SUS users. The comprehensive care provided to users by nursing students must obey ethical principles from the identification of individual and collective health needs, in biological, psychological and sociocultural dimensions.

The CHC I program builds upon the PM teaching method, and the strategy that encompasses this subject is called pedagogical cycle, which was inspired by the specialization course in Activation of Change Processes in Higher Education for Healthcare Professionals, promoted by the Escola Nacional de Saúde Pública e Rede Unida (National Public Health School and United Network, in Portuguese) of the Ministry of Health in 2005 and 2006⁽⁶⁾, carried out by professors who belong to the Ribeirão Preto College of Nursing faculty team.

To fulfill the pedagogical cycle, students enrolled in the CHC I subject are divided into subsets, with 12 or 13 members on average, every year. Each subgroup in supervised by a professor or mediator, and the activities are performed in periodic meetings, with a weekly workload of six hours per class. These meetings take place in class or in Family Health Strategy (FHS) units.

The pedagogical cycle is made up of five stages: 1. Immersion: Nursing students are inserted in an FHS unit and get to know family realities of the community by performing home visits; 2. Temporary synthesis: Students discuss the problems found during the home visits, under the supervision of a professor or mediator; 3. Qualified search: Students carry out a bibliographic survey to obtain scientific knowledge, aiming to answer a learning question (LQ); 4. New synthesis: Students share knowledge and build a collective answer to the LQ; 5. Evaluation: Students are submitted to self-evaluation, evaluation by the professor or mediator and group evaluation.

At the end of each school year, there is a descriptive evaluation of the CHC I subject, through the filling of forms by students who complete it.

To identify aspects which involve the pedagogical process of the CHC I subject and formulate future innovation proposals for the pedagogical cycle, in 2014 the group of professors in charge of the subject planned to determine the contribution of this method to PHC teaching. The present study was carried out from this perspective, guided by the following research question: How has the use of the PM in the CHC I subject in the nursing course at the Ribeirão Preto College of Nursing added to PHC teaching?

OBJECTIVE

To identify the contribution of the problematization methodology to primary healthcare teaching in a nursing undergraduate course.

METHODS

Ethical aspects

The investigation was performed after approval of the proposal by the Research Ethics Committee of the Ribeirão Preto College of Nursing at the University of São Paulo, in accordance with Resolution 466/2012 by the Brazilian Health Council.

Theoretical-methodological framework

The study was grounded in the work of experts on the PM^(7-9) and analysis of results was organized according to the proposal by Laurence Bardin⁽¹⁰⁾.

Study type

Documentary, descriptive, qualitative study^(11-12).

Methodological procedures

Study setting

The study was developed with students from the undergraduate nursing course from the Ribeirão Preto College of Nursing at the University of São Paulo.

Data source

Documents for analysis consisted of 33 forms to evaluate the CHC I subject, filled out by nursing students on December 2^nd, the last school day of 2013.

These forms had questions which involved the achievement of the objectives of the subject, the contributions of the pedagogical cycle teaching strategy to PHC learning, learning settings and the reflective portfolio as an evaluation method.

Data collection and organization

The professors in charge of the CHC I subject met at a private place to examine the 33 evaluation forms and select those which suited as analysis documents for the present study. By reading the evaluation forms carefully, the professors chose those that were filled out properly and excluded the ones that contained information not pertinent to the study object. Consequently, 21 evaluation forms with opinions about the CHC I subject were considered as analysis documents.

Data analysis

The CHC I evaluation forms were examined by content analysis, in a process with the following phases (BARDIN (2011)): 1. Reading of the material: The authors read the information in each form thoroughly; 2. Exploration of the material: The relevant information in the forms was compiled by splitting the texts into units and classifying them into categories; 3. Data treatment: The information was summarized and compared to the existing knowledge to validate data provided by students and generalize results.

The predominant information on the forms allowed to create three analysis categories: PHC learning through PM, PHC teaching and learning settings, and use of the reflective portfolio as an evaluation method in PHC teaching.

Each evaluation form was identified with the initials EF followed by a number.

RESULTS

Primary healthcare learning through the problematization methodology

In 80.9% of the EFs there was information which pointed to the students’ recognition of acquisition of new knowledge, skills and attitudes during the execution of comprehensive nursing primary care with SUS users.

[...] By taking this subject I could understand the role of nurses in PHC. (EF 11)

[...] In addition to fundamental theoretical contents, we had the opportunity to have practical experiences by assisting SUS users. (EF 12)

[...] The subject inserted us into the job market, addressing the topics we were supposed to master at the end of the course. (EF 7)

[...] I could not imagine that this subject would be so relevant to our curriculum. It allowed me to learn how important it is to have contact with the reality of our future profession. (EF 20)

[...] The subject helped to widen our thinking, improved our knowledge, made us critical and reflective of the facts that we experienced in each theoretical class. (EF 21)

The data in the EFs evidenced the valorization by students of the immersion phase of the pedagogical cycle. The reports in 80.9% of the EFs revealed that the subject enabled the contact with the work environment and the profession in the first year of the course, and 76.1% of the participants identified that this method contributed to the teaching/learning process, given that it made a practice mediated by theory possible.

[...] The topics worked on during the pedagogical cycle contributed to my intellectual growth and had a fundamental importance. (EF 4)

[...] The proposed pedagogical cycle was excellent, because we had immersions with families according to what we learned in theoretical classes. (EF 18)

[...] During the immersion phase we were able to put what we learned in class into practice, that is, the relationship with families allowed us to identify their health needs. (EF 17)

[...] What we did in practice, in health units, was extensively discussed in class. (EF 5)

[...] The immersions contributed to enrich my knowledge and experiences, and helped me to prepare for the challenges ahead. (EF 19)

Nevertheless, 19% of the EFs contained information which revealed difficulties in the use of the teaching strategy among students.

[...] I had difficulty integrating the bibliographic search to the LQ. (EF 8)

[...] The most difficult aspect of the subject was to answer the LQ. (EF 1)

[...] The workload is a little tiring. (EF 10)

[...] The proposed method is good, but sometimes it becomes very arduous. (EF 17)

[...] Sometimes the arrangement of activities in the pedagogical cycle was not very productive. Some discussions became repetitive. (EF 15)

Primary healthcare teaching and learning settings

In 76.1% of the EFs, students indicated that the practice settings were a basis for reality problematization and formulation of proposals of activities in professional practice. The analysis of these forms exposed students’ recognition of the importance and impact that the practical activities developed in PHC teaching at the FHS units provide to nurses’ training.

[...] We knew PHC through immersion practices and could discuss in group the needs found so there were significant interventions. (EF 1)

[...] In the PHC setting, I spent time with the user of the family that I assisted, but it was essential to know him away from the FHS unit. (EF 4)

[...] To know the health service already in the first year of the course was very important to me. I could understand the role of nurses in PHC. (EF 14)

In 71.4% of the EFs there was information demonstrating that the practices at FHS units contributed to clarifying scientific expressions used in PHC teaching.

[...] Following and assisting patients observing the social context in which they are inserted helped me understand the concepts of comprehensiveness and equity. (EF 13)

[...] I understood the concept of equity and universality when I began to assist a family that presented many health risks and lived marginalized and in deplorable conditions of social inequality. (EF 6)

[...] I think the activities of this first year contributed a lot to understand the concepts involving SUS principles. (EF 8)

Use of the reflective portfolio as an evaluation method in Primary healthcare teaching

The records in EFs uncovered divergent opinions regarding the use of the reflective portfolio as an evaluation method in PHC teaching: 76.1% of the EFs revealed acceptance and valorization of the method, and 23.8% of the EFs indicated difficulties and resistance by students.

[...] The portfolio is an instrument which helped me perceive my evolution regarding the learning in this subject over the year. (EF 18)

[...] The portfolio allows students to show their potential. (EF 11)

[...] The portfolio demands time, and we do not have much time to dedicate to this type of evaluation. (EF 20)

[...] The portfolio encompasses everything. We have a general reflection about what we learned successfully and what we are struggling to learn. (EF 16)

[...] Taking into account that it is hard work, it would be better to be evaluated by tests and seminars. (EF 8)

DISCUSSION

The present study enabled to identify that the teaching method involving the PM in the pedagogical cycle strategy used by professors at the CHC I subject in 2013 at the undergraduate nursing course of the Ribeirão Preto College of Nursing favored PHC teaching.

Although the EFs, used as a source of documentary data in the present investigation, showed descriptions which revealed difficulties regarding the pedagogical cycle teaching strategy by students, there was a predominance of information about the benefits offered by the subject and the achievement of the intended objectives in the teaching procedure.

This finding was especially relevant, taking into account the importance of the role of nurses in the development of work in PHC.

The function of healthcare professionals who work in the PHC field encompasses providing care to a population aiming to meet health needs. People have to be assisted according to their specificities, complexity, comprehensiveness and the sociocultural context in which they are inserted⁽¹³⁾. Notably, nurses are the basis to make it possible to implement actions and projects from the PHC perspective⁽¹⁴⁾.

It is important to stress that the profile of nurses to be trained, fit for working from the PHC perspective, is a recommendation to undergraduate nursing courses consolidated by the state by means of the Brazilian Curricular Guidelines established in 2001, which requires a pedagogical proposal that favors a participative and reflective teaching/learning process⁽¹⁵⁾.

The path to match this profile includes insertion of contents compatible with the sociopolitical reality, with teaching methods which favor coherence between theory and practice, enabling students to learn nursing skills, solve problems and develop critical thinking through a reflective practice. These strategies would provide students with a significant learning^(15-17).

Contrarily to mechanical learning, which does not establish relationships between new and previously learned information, significant learning is structured in a complex movement of continuity and rupture. The movement of continuity is that in which students are able to relate the apprehended content to previous knowledge, and the rupture one is set from the emergence of new challenges, which can lead students to transcend their experiences and previous concepts and syntheses⁽¹⁸⁾.

To achieve that, professors must be committed with and involved in the training process⁽¹⁹⁾, because in addition to being responsible for professional training, professors should also offer a political background to students, raising awareness of their responsibilities toward society.

In this way, the authors believe that the PM teaching method, implemented through the pedagogical cycle strategy and used in the CHC I subject, provided significant learning.

It is noteworthy that students’ reports revealed a valorization of the immersion phase of the pedagogical cycle. In this step, the teaching activities encompass the movement of practice mediated by theory, that is, they involve the development of nursing care actions related to the work of nurses in PHC. In this way, students take the leading role in the teaching/learning process, from the observation and definition of a study problem until the execution of some level of intervention.

The problematization methodology involves the appropriation of socially produced theoretical-practical instruments, necessary for equating the problems posed in social practice, and the possibility to expand the understanding of this practice as an integral part⁽⁷⁾. This methodology also entails the valorization of experiences of students and views of professors as enablers of the teaching/learning process⁽⁸⁾. It is worth emphasizing that the use of the PM as a teaching strategy can make students promote their own development⁽¹⁸⁾.

Additionally, the results indicate that the pedagogical cycle teaching strategy allowed students who took the subject to have the perception that they are able to build knowledge and change realities.

In the CHC I subject, professional practice is the starting point and results in nursing students being inserted in the work environment and PHC context.

The settings chosen for PHC practice should enable students to use reality immersion strategies to experience situations which will be registered as acquired knowledge and think about them⁽²⁰⁾. These settings are expected to favor the training of professionals toward a greater awareness of their social role and encourage measures that can change reality toward more comprehensive health actions. Most importantly, it is necessary to assure the alignment of training with the needs found in PHC settings⁽¹⁶⁾.

The FHS initiative can make this scenario available, because its directive is comprehensive and continuous health, grounded on equity, resolution and practice humanization. In the FHS, actions have a collective nature. They are characterized by the identification of a community’s health needs, health promotion, monitoring and evaluation of the health care and working process, local management, and community participation in the development of projects of interest to it⁽²¹⁾.

Taking into account these characteristics, practice is continuously built and rebuilt, based on cognitive, emotional and procedural knowledge. It is important that students be instigated to reflect on the situations experienced in the context of health care to develop comprehensive care skills oriented to individual and collective needs, guided by actions focused on the fulfillment of organization and care management centered in PHC⁽²⁰⁾. Notably, this integration has to be encouraged by professors⁽⁶⁾.

In the PM, reality is perceived as a social construct and has to be understood in its problems and analyzed within theoretical frameworks that enable a solid knowledge acquisition and committed work in real settings⁽⁹⁾.

The study showed that the settings chosen to teach PHC in Ribeirão Preto, state of São Paulo, among which there were four FHS units, contributed to the training of nurses. It is worth stressing that students emphasized the fact that the PM allowed them to understand the nurses’ role in the PHC context.

In the CHC I subject, the evaluation of each student has the performance obtained during PHC practice as a reference, especially when it comes to their work in the large group and the subgroup and in the practice setting, which occurs through a reflective portfolio, a tool that was perceived differently by students.

The use of reflective portfolio as an evaluation method enables students to build their own knowledge from reflections, questioning, and relationships that they establish during their practice⁽²²⁾. It is the identification and construction of record, analysis, selection, and reflection of the most significant productions or the identification of the biggest challenges, in addition to one of the forms to overcome difficulties⁽²³⁾.

As a consequence, students will not be attached to the rigid structures of subjects that do not coordinate. Instead, they will find the necessary theoretical aspects as they experience professional practice, and will formulate inquiries for reflection with the support of professors who participate in this process⁽²²⁾.

The differences of opinion among students regarding the use of the reflective portfolio as an evaluation method for the pedagogical cycle evaluation strategy, expressed in the EFs, may be related to the fact that this method brings students closer to the perception of their values, competences and specific skills. It is assumed that these aspects influence their self-confidence and safety regarding the learning process.

This analysis permitted the PM to be construed as a tool in the development of the teaching/learning process during the training of nurses oriented to PHC teaching. It is noteworthy that in Brazil undergraduate nursing courses are still ruled by the traditional paradigm, in which innovative strategies are infrequent^(24-29).

Study limitations

The authors recognize as a limitation the fact that the 33 EFs of the CHC I subject were not properly filled out with information pertinent to the object of the present study, which resulted in the exclusion of 33.3% of the forms and may have compromised the accuracy of the findings.

Contributions to the nursing, health or public policy fields

The results of the present investigation, which revealed an innovative pedagogical proposal that contributes positively to PHC teaching in the mentioned nursing course, point to the possibility of reflection by professors and may encourage them to apply this type of teaching approach.

FINAL CONSIDERATIONS

Analysis of 21 EFs, used as a data source in the present documentary study, showed that the CHC I subject, offered in the undergraduate nursing course of the Ribeirão Preto College of Nursing, with the PM as the teaching method and the pedagogical cycle as the teaching strategy, met the intended goals: it enabled coordination between theory and practice, made the contact of nursing students with the work environment and the profession possible already in the first year of the course, and contemplated significant learning. The latter characteristic is considered a determining proposal in the training of Brazilian nurses.

It is possible to state that the use of the PM in the CHC I subject favored PHC teaching. The pedagogical cycle teaching strategy should be kept in the subject, given the importance to train nurses from the PHC perspective. Its application as an innovative approach to nursing teaching is recommended.

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Publication Dates

• Publication in this collection
  2018

History

• Received
  23 Mar 2017
• Accepted
  27 Jan 2018