Analysis of Service-learning activities adopted in health courses of Federal University of Bahia

Análisis de las actividades de integración enseñanza-servicio desarrolladas en los cursos de salud de la Universidade Federal de Bahia

Abstracts

is study aimed to raise and discuss the data about the integration of health courses teaching and service activities o ered at the Federal University of Bahia (UFBA), pre- senting scenarios practices and major di culties existing in the relationship between the university and the services of health. is was a qualitative study of descriptive explo- ratory character, using a questionnaire as a research tool applied to the coordinators of selected health courses. e selection was by reading the political pedagogical project, the following courses were selected: nursing, physical therapy, speech therapy, medicine, nu- trition, dentistry and public health. e results indicated eight types of teaching-service integration activities, 57 scenarios of practice and the main di culties. It was concluded that these courses are sticking to changes in academic training in health, in view of the large number of basic health units in the teaching service process. us, it emphasizes that the UFBA includes activities in health care that enable the integration-education in the higher education process, although there are some di culties in this relationship indicated by the coordinators.

University; Health; Health Education

Este estudio tuvo como objetivo plantear y discutir los datos sobre la integración de las actividades de salud cursos de enseñanza y de servicios que se ofrecen en la Universidad Federal de Bahía (UFBA), la presentación de las prácticas de los escenarios y las principales di cultades que existen en la relación entre la universidad y los servicios salud. Este fue un estudio cualitativo de carácter exploratorio descriptivo, mediante un cuestionario como herramienta de investigación aplicada a los coordinadores de los cursos de salud seleccionados. La selección fue leyendo el proyecto político pedagógico, se seleccionaron los siguientes cursos: enfermería, terapia física, terapia del habla, la medicina, nutrición, odontología y salud pública. Los resultados indicaron ocho tipos de actividades de integración docencia-servicio, 57 escenarios de práctica y las principales di cultades. Se concluyó que estos cursos están pegando a los cambios en la formación académica en la salud, en vista del gran número de unidades básicas de salud en el proceso de servicio de la enseñanza. Por lo tanto, se hace hincapié en que la UFBA incluye actividades en la atención de salud que permiten la integración en la educación en el proceso de la educación superior, aunque hay algunas di cultades en esta relación indicada por los coordinadores.

Universidad; Salud; Educación en Salud

Esse estudo teve como objetivo levantar e discutir os dados acerca das atividades de integração ensino-serviço de cursos de saúde oferecidos na Universidade Federal da Bahia (UFBA), apresentando os cenários de práticas e as principais di culdades existentes na relação entre a uni- versidadeeosserviçosdesaúde.Tratou-sedeumapesquisaqualitativa,decaráterdescritivoexploratório,utilizando-seumquestionáriocomo instrumento de investigação aplicado aos coordenadores dos cursos de saúde selecionados. A seleção foi mediante a leitura do projeto político pedagógico, sendo selecionados os seguintes cursos: enfermagem, sioterapia, fonoaudiologia, medicina, nutrição, odontologia e saúde coletiva. Os resultados indicaram 8 tipos de atividades de integração ensino-serviço, 57 cenários de prática e as principais di culdades. Concluiu-se que esses cursos estão aderindo às mudanças na formação acadêmica em saúde, tendo em vista o grande número de unidades básicas de saúde que integram o processo de ensino serviço. Dessa forma, ressalta-se que a UFBA contempla atividades na área de saúde que viabilizam a integração-ensino no processo de formação superior, embora existam algumas di culdades nesta relação apontadas pelos coordenadores.

Universidade; Saúde; Educação em Saúde

Introduction

The teaching-learning process established from the integration between university and service, through the integration of health service faculty, can lead to new ways of organizing health care work, thereby promoting better preparation for the health services. In addition, the knowledge exchange relationship formed between students, faculty, clinical professionals and users can contribute to the formation of a new profile of professionals committed to health care quality, which meets the actual needs of the population(¹).

Over the past years, aided by the Brazilian health reform, there have been changes in care practices and training of health professionals, who sought and contributed to changing this scenario, e.g., the implementation of integrated curricula, teaching-service linkages, the construction of the National Curricular Guidelines (NCG), the UNI projects, movements coordinated by the United Network, and the student movement(²).

Thus, according to the Ministry of Health(³), the changes in care practices also require changes in the training of professionals; in order to improve the way to care for, treat and monitor health, it is necessary to change the methods of teaching and learning, and to review educational practices and their effects on the actions and services(⁴).

The Ministry of Health considers teaching-service integration to be an important strategy for training professionals, which also meets the principles and guidelines of the Unified Health System (SUS). This integration can be can be understood as a collective work, by making a pact between students/faculty and staff members who comprise the health service teams, which aims toward an individual and collective quality of health care, a quality of vocational training and development and satisfaction of health care staff members(¹,⁵).

It is therefore one of the axes that seeks to solidify the curricular proposal through various actions in the teaching-service interface(⁶). Its regulation has been addressed by the World Health Organization (WHO), regarding innovative actions in training human resources for health, in order to promote favorable conditions for the qualification of current and future health teams(⁷).

Therefore, the following are considered activities promoting teaching-service integration: supervised practice internship, Work Educational Program for Health (PET-Health), National Reorientation Program for Professional Training in Health (Pro-Health) and extension programs(⁴,⁸-¹²). Thus, it is necessary to know in which practice settings these activities are developed by linking the educational institutions and health services, as the pedagogical space goes beyond the classroom, consisting of real work scenarios where experiences and responsibilities are processed and shared among faculty, students, service professionals, managers and the community (¹³,¹⁴).

In view of the need to change this scenario, and seeking to improve the quality of higher education in Brazil and in Bahia, this article aims to map the combined teaching-service integration activities in the higher education process of disciplines at UFBA, by presenting the practice settings and major difficulties in the relationship between the university and the health services.

Method

This was a descriptive, exploratory, qualitative study conducted at the Federal University of Bahia (UFBA) from August to September of 2014, in the Canela neighborhood campus, in the city of Salvador/BA with the nursing, physical therapy, speech therapy, medicine, nutrition, dentistry and public health disciplines.

Initially, a literature review was performed, which sought to identify aspects related to the teaching-service integration and higher education in health. The search for bibliographic materials was performed in databases such as Lilacs, Medline, institutional collections of theses, books, and full-text databases, namely SciELO, CAPES Periodicals, Virtual Health Library, among others. The descriptors used were: education, higher; health human resource training; teaching-health care integration. All of them were available in the Descriptors in Health Sciences (DECS - http://decs.bvs.br).

A total of 675 national scientific journal articles were identified: 126 articles were found in education, higher; 463 in health human resource training; and 86 in teaching care integration services. Of these, all duplicates, publications in foreign languages, those without abstracts, and studies with other themes were excluded. Thus, 20 articles were selected. Text books and masters’ theses from 1999 to 2014 were also used. The extensive time period was used due to the relevance of data on the theme that were addressed by some of the older journal articles.

Thereafter, documentary analysis was performed of the educational projects of the 14 health disciplines offered by UFBA, with seven disciplines selected by comparing them with regard to their aims and the similarity of some common guiding elements of the projects, such as: an integrated curriculum, link between theory/practice, and diversification of learning settings. This analysis enabled identification of the curricular change proposals indicated by the disciplines to contribute to the training of future professionals, committed to the political, social, educational, health and cultural problems, aimed at the health needs of the population.

Later, a five-question instrument was administered in person to the course coordinators, as an evaluation tool. The analytical categories were based on the responses of the coordinators, and were divided into three axes: teaching-service integration activities, practice scenarios, and difficulties related to the implementation of these activities.

After completion of the field activities, content analysis was performed, as proposed by Bardin(¹⁵). According to this author, content analysis comprises a set of techniques for communication analysis, with a very diverse scope that includes any kind of communication. It proposes three phases inherent to the content analysis procedure. The first phase comprises the “analytical description”, when the characteristics resulting from the choice of “communication fragmentation categories” are listed. The elements that make up these categories become objects of the second stage, called inferential, when the logical deductions are performed. Finally, the third step is the interpretation effort for the meaning of the categories/characteristics.

Results

The analysis of the results, along with the theoretical framework and document analysis, evidenced connections that fostered the development of programs, and projects implemented to strengthen teaching-service integration in the researched disciplines. Thus, the analysis categories allowed for the identification of the constituent elements of teaching-service integration at UFBA, such as activities performed, practice settings, and difficulties, as shown below:

Table 1
Analysis categories

Discussions about the training of human resources for the public health sector have existed in the political scenario since the SUS was first considered. This theme was included in the propositions of the Health Reform movement, presented at the Eighth National Health Conference and the First National Conference on Human Resources for Health in 1986, signaling the need for changes in undergraduate courses and the importance of teaching-service integration.

Prior to these conferences, in 1981, the Faculty-Care Integration Program (IDA) was created by the Ministry of Education, with the proposal of integrating students into primary care units, favoring linkages between academia and health services(¹⁶). After these initiatives, projects supported by the creation of SUS, were implemented, such as: the National Program of Incentives for Curricular Changes in Medical Courses (PROMED), to stimulate the supply of internships in university hospitals and primary health care; the Experiences and Internships in the Reality of the Unified Health System Project Program(¹⁷), which recognized the health system as a teaching and learning space; Aprender SUS in 2004, encouraging the integrality of health care as a changing axis of training(¹⁸).

These projects and actions began to drive curricular changes of health disciplines, aimed at strengthening the teaching-service integration at UFBA. Therefore, the results of this study can contribute to the reflection about what is being developed at UFBA regarding this integration, pointing to changing paths.

PERFORMED ACTIVITIES

The Statute and General Regulations of the Federal University of Bahia(¹⁹) has an objective of providing training, continuing education and qualification in different fields of knowledge and work, in order to exercise professional activities and participate in the development of society. This objective is in line with the DCN Health(²⁰) in the nursing, physical therapy, speech therapy, medicine, nutrition and dentistry disciplines, which encourages the training of autonomous, insightful professionals to ensure that comprehensive, quality and humanized care is provided to individuals, families and communities.

In order to meet the objectives of this study, based on the questionnaire administered to the coordinators of the analyzed disciplines, the activities identified as strategic for the teaching-service integration were grouped into subcategories, and are discussed below.

Curricular internship

An obligatory, supervised, internship was a curricular component in the seven health disciplines, which included the goals of the educational program and was integrated into the teaching-service integration activities. It was considered essential to the training of students and those integrating teaching-service in their disciplines. Experience in the curricular internship favored curricular development, enabled the improvement of students’ skills, and strengthened relationships between the partners in the training institution, professionals, managers and users, expanding the possibilities of teaching-service integration(⁴,¹⁰).

Alves and colleagues(¹⁰) investigated the experience of a supervised internship for students in the ninth semester of Dentistry at the Federal University of Paraíba (UFPB), in a Family Health Unit (USF) in the city of João Pessoa. They concluded that the internship favored the curricular development and the approach of higher education institutions, in addition to encouraging a space for critical reflection to seek solutions to actual health problems.

Extension and research activities

Extension activities were highlighted by all the coordinators as supporting the teaching-service integration process.

The UFBA was a pioneer in developing extension activities in Brazil. Since its first years of creation, it began extension practices for care: providing cultural services, courses, conferences and lectures. However, only in 1971, when the General Extension Coordination - the organ responsible for structuring extension projects - was created, were these practices reconsidered and took on another characteristic: the axis of linking teaching and research functions, expanding and enabling the relationship between the University and society(²¹).

In 1997, the UFBA program was created, which in 2000 changed names to the Curricular Activity in the Community (ACC), constituting a permanent program of effective integration between teaching/research and society. Currently it is called Curricular Action in Community and Society (ACCS), and it is integrated into the curricula of most health disciplines.

A study performed with UFBA students, in a setting in Salvador that helps the homeless, demonstrated the importance of student involvement in ACCS for professional training. By coexisting and dialoguing, students started to have a broader view of social problems, leading to reflections and promoting the development of essential practices for growth as future professionals and individuals participating in various segments of society(²¹).

The ACCS were also indicated as integrating teaching-service in public health and medicine disciplines. Another research study performed at UFBA demonstrated the importance of student involvement in ACCS for professional training(²²).

On the other hand, research was performed with consideration of the teaching-service integration only within the nursing, dentistry and public health disciplines.

In Brazil, the study began soon after the arrival of the university, in the first half of the twentieth century, aiming to meet the demands of the industrial period. Here in Brazil, teaching and research were performed separately and far away from one another, with a lack of communication among activities. In addition, nowadays a greater emphasis is observed in research rather than extension activities(²³).

Thus, this study emphasizes that, even though research has played a prominent role since the creation of the first universities in Brazil, unlike extension, this was not one of the activities identified by most coordinators as integrating teaching and service.

Programs for reorientation and vocational training

Based on the accumulated experience in the area of health and education, a 2005 partnership between the Ministries of Health and Education led to the creation of Pro-Health, initially contemplating the nursing, medicine and dentistry areas. The objectives included the establishment of mechanisms for technical cooperation between SUS administrators and academic institutions, and the extension of the duration of educational practice in the SUS services, among others. It was expected that this program would replace the hospital-centered model with health promotion and disease prevention actions, due to the close connection with the public health system(²²).

Thus, since 2005, UFBA has actions of Pro-Health, which enabled the reorganization of the medicine, nursing, pharmacy, speech therapy, nutrition, dentistry and psychology disciplines.

All coordinators of the analyzed disciplines (except for public health) indicated that the Pro-Health and PET-Health programs represented teaching-service integration activities.

Implementation of Pro-Health and PET-Health programs focused on teaching-service integration, with a view toward using the health service settings as clinical practice settings for academia. These programs aim for the approximation of the academic world with the reality of the public health system. These initiatives call for centrality in primary care, with the concept of integrality in health as a reorienting axis of practice in the training process for the SUS(²³).

PRACTICE SETTINGS

Settings for practice or learning are constituted as privileged places in the world of work, intersecting with the world of education. In health care, daily practices can be remodeled and transformed to an extent that drives the development of a relational and interactive process between teachers, students, healthcare professionals and patients(²²).

Consequently, 57 practice settings that provided care, predominantly for SUS, were found, where students were placed to develop and apply the theories learned in the classroom, distributed among: basic health units, hospitals, obstetrics, emergency care units, emergency medical service (EMS), ambulatory, psychosocial care centers, public schools, elder care facilities, community associations, community centers, care centers, centers for prevention and rehabilitation, specialized centers, the Bahia Legislative Assembly, TV Bahia, and the Municipal Health Secretariat of the Bahia State Health Department. For better discussion, these practical scenarios were grouped into categories according to their nature: care, prevention, and management.

Assistential

An intervention is sought within the training process, so that degree programs replace the axis of training focused on individual care provided in hospitals with a more contextualized and committed educational process, considering the social, economic and cultural dimensions of the population.

There is a clear influence of the report developed by Abraham Flexner, in 1908, on the Brazilian model of education in health configured on curative practices and, in particular, within hospitals. Due to this report, scientific and institutional criteria for regulation of academic and professional background in health were introduced(²⁴). Thus, among other things, hospitals were considered from the perspective of their contribution to the education of health professionals.

The data of this study indicate that the hospital setting is the main practice area offered to students of the investigated disciplines. Of the 57 places listed by the discipline coordinators, 23 corresponded to hospitals. Outpatient clinics were also included in this category; discipline coordinators identified eight outpatient clinics.

There is an intense debate, in Brazil, regarding the participation of the teaching hospitals in the education of health professionals, as almost all of the professionals have, in hospitals, prioritized the field of academic education(²⁵), which match the results of this study. The most important polarization might be the debate between the deinstitutionalization of education as opposed to a hospital-centered model.

Preventive

The educational process for health personnel is primarily organized from the labor market, especially by strengthening research, innovation, teaching and care given to the establishment of the hospital-centered model. Specialties began to organize both university health care departments and disciplines in teaching hospitals and clinics. Therefore, little attention was given to primary care practice settings(²⁶).

However, UFBA is already reconsidering its curricular framework for health disciplines. Within nursing, speech therapy, medicine and nutrition, there are 13 practice settings corresponding to the basic health units that integrate teaching and service. In addition, the dentistry discipline, although not indicated in basic health units, is mentioned within social centers, which fall within the primary care model of health.

Management

The public health discipline only provided training in the management area. This discipline, created in 2009, from the Support Program for the Restructuring and Expansion of Federal Universities (Reestruturação e Expansão das Universidades Federais - REUNI), developed its curriculum to include the following skills: analysis and monitoring of health status; planning, programming, management and assessment of health systems and services; health promotion, risk prevention and health problems; management of collective work processes in health; ethics in public health. Thus, the practical scenarios offered in this discipline, within the Municipal and State Secretary of Health, ensure the inclusion of students in political and management levels. Thus, these future professionals may be responsible for policy-making practices, planning, programming, coordination, monitoring and assessment of health care systems, as well as contributing to the strengthening of health promotion and environmental, sanitary and epidemiological surveillance(²⁷).

DIFFICULTIES

Integration between teaching and service depends on various supports so that in fact it occurs in the perfect condition, operating in perfect harmony. However, it is known that difficulties remain in the implementation, despite the activities of the disciplines having been met. Based on the answers of the discipline coordinators, 15 were related to difficulties in teaching and service integration. The primary concern regarded the receptivity of the students to the service and the professionals linked to it. Neither the health units nor the working professionals are structured or empowered to receive students, either due to the lack of investment or their own disinterest, lack of financial, cultural and scientific encouragement of the institution and/or service of the employee, and because of the belief that students will cause difficulties with their work routine.

In this scenario, a difference in process is observed in the practice areas between public and private universities, in which public institutions are disadvantaged, because private schools have strategically established a paid scholarship for the preceptorship, in order to ensure acceptance of these students by health professionals.

Furthermore, a lack of clinical placement sites was identified in public and state organizations, due to the number of private courses being offered. The lack of adequate primary care unit infrastructure to receive students and teachers, and the shortage of professionals in some health teams is noted, preventing multidisciplinary work aimed at the provision of quality health service: a recruitment strategy to fully staff integrated teams is required. The coordinators of speech therapy, nutrition and physiotherapy disciplines provided these data. Thus, there must be a physical structure containing all relevant subjects integrated in the practice scenario, along with materials and technologies available for improved care. All findings of this study corroborate with results of research on the difficulties in developing activities in teaching-service integration (⁹,²⁸)-²⁹.

Conclusion

The health education model was broadly discussed in regard to practical curriculum, plans and educational content. According to university and health reforms, another type of professional profile was necessary, which was active in different fields of practice, more qualified, and able to change to meet the actual needs of the population. Thus, linking the university and the health service, whose students must be integrated into diversified practice settings, impacts professional training and qualification. Therefore, it is clear that universities tend to be linked with health services in order to provide better professional training.

The UFBA followed this path, and also incorporated the changes, since it interacted with health services so that its students could be in practice settings to implement the lessons learned in the classroom, becoming more skilled workers. The supervised curricular internship, extension and research activities, and reorientation and training programs were described as teaching-service integration activities that were present in seven health disciplines studied.

The supervised curricular internship, found in the seven disciplines studied, and in accordance with the objectives of the pedagogical project, is essential for the professional formation of students.

The extension and research activities were also present in the seven disciplines, so it may be inferred that these are critical in the formation process.

Guidance and vocational training programs were also considered essential in health education, although the public health course did not address these programs.

Thus, the activities identified as collaborators for the higher education process are instituted in the educational projects, derived from changes that begin to consider the diversification of practice settings, and the early integration of the student in health settings (mostly SUS) and social support networks.

However, despite the efforts to make changes, difficulties were encountered, mainly related to the organization of the mediation between the university and the health services, which question, analyze and redefine this integration.

Therefore, the integration between the university, the Municipal Secretary of Health, and health facilities where services are provided, should be facilitated and effective in order to benefit both parties, as each institution needs the other. The university needs settings for its students to come into contact with the social reality and to practice what is learned in the classroom, in order to improve the training and professional qualifications through lived experience, and consequently improve health care. And, the health services require the sharing of experience and knowledge among teachers, students and health care professionals, because it establishes an ongoing teaching-learning process among them, favoring the progress of the service.

Considering that the study did not address the facilities for the development of teaching-service integration activities, the lack of this category is presented as a limitation of this research. Research about the facilities that contribute to the relationship between higher education and the health services is indicated as a possibility for further studies.

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Publication Dates

• Publication in this collection
  June 2016

History

• Received
  26 Mar 2015
• Accepted
  14 Nov 2015