The research and association between teaching and care in the consolidation of the Brazilian National Health System

Abstracts

Esse texto se constitui de reflexões teóricas e vivenciais das autoras acerca da articulação entre pesquisa, ensino e serviços de saúde para a consolidação do Sistema Único de Saúde. As pesquisas de enfermagem na saúde coletiva possuem como desafio romper com as formas tradicionais em que se separa quem pesquisa, aprende, ensina e cuida. É da produção investigativa e reflexiva que se processa o movimento de transformação do processo de cuidar e de ensinar. Assim, as pesquisas para a consolidação do Sistema Único de Saúde clamam por uma intensa articulação entre o ensino-serviço e a produção de conhecimento. Desafia-nos a constituir projetos de pesquisa junto com os trabalhadores e isso implica em avançar da coleta de dados para a produção de dados, do levar estudantes para atividades e estágio para parceria e co-responsabilização pelas ações. Propomos assunção do não saber para criarmos práticas instituintes.

Enfermagem em saúde comunitária; Educação em enfermagem; Pesquisa em enfermagem; Sistema Único de Saúde

ORIGINAL ARTICLE

The research and association between teaching and care in the consolidation of the Brazilian National Health System

Cinira Magali Fortuna^I; Silvana Martins Mishima^II; Silvia Matumoto^III; Maria José Bistafa Pereira^IV; Marcia Niituma Ogata^V

^INurse. Ph.D. in Nursing, Professor at the Ribeirão Preto Nursing School of the University of São Paulo, Ribeirão Preto, SP, Brazil. [e-mail]

^IINurse. Ph.D. in Nursing, Professor at the Ribeirão Preto Nursing School of the University of São Paulo, Ribeirão Preto, SP, Brazil. [e-mail]

^IIINurse. Ph.D. in Nursing, Professor at the Ribeirão Preto Nursing School of the University of São Paulo, Ribeirão Preto, SP, Brazil. [e-mail]

^IVNurse. Ph.D. in Nursing, Associate Professor at the Ribeirão Preto Nursing School of the University of São Paulo, Ribeirão Preto, SP, Brazil. [e-mail]

^VNurse. Ph.D. in Fundamental Nursing, Associate Professor in the Department of Nursing at the Center for Biological Sciences and Health of the Federal University of São Carlos, São Carlos, SP, Brazil. [e-mail]

ABSTRACT

This article comprises the authors' reflections about theory and experiences about the connection between research, teaching and health care services for the consolidation of the Brazilian National Health System (SUS - Sistema Único de Saúde). The research in collective health nursing face the challenge of breaking with the traditional forms that separate those who research, teach, learn and provide care. The movement for changing the process of caring and teaching occurs through an investigative and reflexive production. Therefore, the studies for the consolidation of the SUS call for an intense connection between teaching-service and knowledge production. It challenges us to create research projects together with the workers, which implies advancing the data collection to data production, and taking students to the activities and internship for the alliance and co-responsibilization of actions. We propose assuming the lack of knowledge to create instituting practices.

Descriptors: Community health nursing; Education, nursing; Nursing research; Unified Health System

RESUMEN

Este texto se constituye de reflexiones teóricas y vivenciales de las autoras acerca de la articulación entre investigación, enseñanza y servicios de salud para la consolidación del Sistema Único de Salud. Las investigaciones de enfermería en salud colectiva tienen como desafío romper con las formas tradicionales de separar investigación, aprendizaje, enseñanza y cuidados. La transformación del proceso de cuidar y enseñar se procesa a partir de la producción investigativa y reflexiva. Así, las investigaciones para la consolidación del Sistema Único de Salud claman por una intensa articulación entre enseñanza-servicio y la producción cognoscitiva. Nos desafía a instituir proyectos de investigación conjuntamente con los trabajadores, lo que implica avanzar de la recolección de datos hacia su producción, del llevar estudiantes para actividades y pasantías a la asociación y co-responsabilización por las acciones. Proponemos asumir el desconocimiento para crear prácticas instituyentes.

Descriptores: Enfermería en salud comunitária; Educación en enfermería; Investigación en enfermería; Sistema Único de Salud

INTRODUCTION

We begin with a statement to situate our problem⁽¹⁾: the health crisis moves through practices that no longer explain, cure, or solve.

The individual-biological paradigm and preventative care speak of life, disease, and death subsidized by knowledge. And this knowledge ignores the culture of the family, of the suburbs, of the slums, and its own interactions with the human beings who move through the health system. Knowledge no longer explains, welcomes, consoles, nor encourages a fight for life.

Therefore, it is in the crisis of health services, educational institutions, scientific production, the global society of control⁽²⁾, and integrated world capitalism⁽³⁾ that we find the daily challenge of remaining inventive in a space where reproduction, the repetition of the already-instituted, and exclusion predominate.

Day in and day out in the health system, workers create sparks of life, caring actions, and partnering connections which are responsible for many avoided deaths⁽⁴⁾. On the other hand, they can also produce neglect, carelessness, and a lack of accountability for their actions. This situation points out the contradiction we experience in every aspect of the health care system and the training of its personnel.

In the institutions which train health workers, professors and students alike reach beyond technique alone and strive to teach and learn aspects such as caring, and placing oneself in another's position.

Following suit, research initiatives born from the desire to address human suffering and misery are captured by the logic of capital gains, profit, individual authorship, and power, and produce something different than originally desired. They create competition for a robust lattes curriculum, for lucrative patents, funding, and international citations.

These are instituting movements^(5-6), potent in their production of powerful new ways of research-teaching-learning-caring, which are captured by the instituted logic.

Out of this struggle between instituted and instituting forces emerges the challenge of making other bets, investing in other logics. We consider this to be the challenge facing research in public health, of which Nursing constitutes an important labor force⁽⁷⁾. And thus we ask: How can we conduct research that includes an effective modification of care settings? How can we produce partnerships between actors and services that really articulate training and research? More than this, how can we connect knowledge with practices for the production of life and inclusion of workers and users? These are some of the challenges ahead for the implementation of Brazil's Unified Health System (SUS), which we support: this paper aims to reflect on some aspects of this problem.

THE EMERGING RESEARCH ON THE SERVICE-LEARNING ENCOUNTER

In general, research begins with needs selected by researchers who are linked to the study and/or by educators who have their own areas of research and courses in graduate programs. Also apparent is the influence of more generalized research that defines research priorities and funding policies⁽⁸⁾.

What we thus find is that research and studies in the academy are shaped at a considerable distance from the practice and reality of the SUS. Despite some initiatives, such as the Research Program for the SUS (PPSUS)⁽⁸⁾, a question has emerged in the field of Public Health and the consolidation of SUS, namely: How can we connect the knowledge, and the processes of building knowledge, produced by the university and the health system with health practices? It seems that a gap exists that must be bridged.

What stands out is that we do not question the separation of the different fields that constitute and construct society: what demarcates the social needs for the health of our population, the research objects defined by the researchers, and the body of knowledge taught in the training of health workers. Our scope is too limited to delve into these aspects, but they certainly are there for us to think about instituting logics of research, education, and care.

Today, much of our research builds projects in which the health services and their workers, as well as their users, are invited to play the role of research subjects. From this statement, a question arises: aren't these subjects being treated more like objects?

Armed with knowledge and positions of power, we conduct interviews and apply questionnaires, collect data, and analyze and publish it with the supposed idea that we are somehow returning knowledge to the community.

As we seek to listen more to what health care workers say, we find dissatisfaction with this form of knowledge production. We identify feelings of strangeness and embarrassment on their part about being the object of research, which is not always explicitly present, but often becomes present in times not set for the interviews, in days when appointments are made and cancelled, in spaces which are off-limits for observation, in records that are restricted to the health service. A type of relationship becomes established, one of use, of polarization between those who understand and know and those who don't, between the researcher and the subject to be analyzed.

If we take as a starting point the understanding that reality is multiple and shifting, which is produced, and produces itself, through encounters and separations, and that it is not external to us, we have already accepted the inadequacy/failure of this form of research that divides subject and object, research and reality⁽⁹⁾.

It is through forming links with the institutions that train health workers, and which still view themselves as the primary research centers, that health services may seek to improve and modify their practices in teaching/research and care. This precise connection should emerge from a common labor, of being united in health and training services: students, teachers, workers, and users^(10-12).

This may already occur in some places, but in general researchers, teachers, and students attend health services as visitors, viewers in need of some cases to illustrate their theories, practice their skills, or collect materials for research.

Despite several years of debate about the implementation of the National Curriculum Guidelines for health courses, which require coordination between training and work experience⁽¹⁰⁾, time and again we are surprised by proposals to re-issue health education services. These are supposed to teach, research, and properly service (but usually with pre-selected users) teams with adequate diversity and quantity of workers, and unknown unmet demand; conditions very different from most SUS health care. How can we conduct research that includes the effective modification of care settings and teaching?

It seems that a clue, an indication, lies in the vehement need to refuse the already established place of knowledge, since we do not know. Academic knowledge, technical and scientific, no longer explains; instead, couldn't we reject the established roles, those of academia bringing solutions, workers seeking responses, passive users and students breeding practices?

If we do not know—and in assuming this not knowing we break with the supposed division between those who teach, those who learn, those who study, and those who care—wouldn't these be actions of interface between all subjects at the liaison between teaching and service? This series of specific actions that are performed by specific individuals (teacher teaches, researcher researches, workers care, users are cared for, student learns), does it not require the mainstreaming of institutions in a move to be triggered, invented, given agency?

It seems to us that research needs to be based upon a sensitive listening to what is occurring in health care services, of the students and users involved. Sensitive listening, because it indicates the importance of the analysis of supply and demand.

If we ask a collective of workers what they perceive as problems in their daily lives requiring research, an avalanche of difficulties will be identified, all sorts of problems will be raised, including issues already addressed from investigative point of view.

This brings us the co-responsibility to think together about the issues presented, which undoubtedly requires investments of all kinds: libidinal, structural, material, outreach strategies, and dissemination of research results, among others.

The demand for a given research topic must be analyzed collectively, and in general it requires breaks, analyses in its broadest sense to see the emergence of another problem. Our lodestar for this discussion is the care and lives of workers and users.

Demand is modulated by supply⁽⁹⁾; researchers by their presence and their questions offer something beyond the explicit, so they must to reflect on what to offer.

The research emerging from the collective meeting will question authorship: whose idea is that one? Born at the meeting, born out of a combined reflection. Analysis and interpretation are also tasks of the collective that actively ponders the issue of research. This ends up deterritorializing the notion of data collection, because they were not there to be picked a priori, but rather are produced in exchanges at the time of the research.

The investigator, the reality, and the subjects are also in production in this way of thinking of research, insofar as the research is intervention⁽⁹⁾, is not neutral, does not reproduce itself, and is creation. Intervention-research ⁽⁹⁾ is a mode of investigation affiliated with the institutionalist movement⁽⁵⁾, and which views the transformation of reality as necessary to knowing it. In this process, the social experience is followed-up using and manufacturing conceptual and operational tools for a collective analysis aimed at transforming institutions and their instituted and instituting forces that are underway.

In our experience in the field of public health we bet on the possibility of progress through research that is effected by linking research with service-learning.

From 2001 to 2003 we conducted an intervention research^(13-14) with workers from a Basic Health Unit (UBS) that had a family health team. The team itself asked for assistance in understanding their difficulties with the connection between the new action proposed for the family health team and the traditional action of the UBS.

We conducted weekly groups for two years, one in the morning and one in the afternoon, so that all staff could participate. During this period, the movements of the team in their connections and disconnections for the care of families were followed, and new meanings and work arrangements were produced for the workers.

In another of our studies, we offered a research intervention on collective care, a theme we chose because of our experience that, although it was a family health team, their collective care actions were secondary in relation to individual clinical actions.

The set of workers chose to work with educational groups throughout one year, in 26 meetings of around two hours each, where the actions taken were analyzed; the workers served as a laboratory for instrumentation on management with the groups. In this process, the unit management, technical and social division of labor, biopower, and the relationship between universities and service were also under review.

Another type of experience has been the production of workshops offering reflection on the research carried out in the basic health network of the city, the basis of teaching performance. We conducted four workshops in 2011, holding discussions with nurses with the following structure: a presentation by a guest on the topic of research, and a brief presentation of the results of the survey conducted, followed by discussion.

There was discussion about educational activities, the clinical practice of nurses, and the skills of nurses in primary care. In these workshops, held in conjunction with the Head of the Division of Nursing of the Municipal Health Secretariat, it was possible to produce meetings that drew out concerns about the themes.

CONCLUSION

Forging links between research and service-learning on more creative and innovative bases is certainly challenging and complex, but has greatly contributed toward the consolidation of the SUS. How can we connect these instances, given differences such as work processes developed for different purposes, but which may offer connections that empower tasks and responsibilities?

We present a clue to the necessity of refusing the established forms with which we are familiar enough, which separate those who research, what or who is researched, and those who learn, teach, and care. We propose the assumption of not-knowing.

To produce joint investigations and other modes of cooperation we need to question how we produce and respond to the academic and institutional issues of science and technology in the country, which are aligned with the capitalist logic of production. We face the riddle of the Sphinx: Decipher me or I'll devour you.

It seemed to us that another clue that we could offer as a possible starting point would be in the form of a challenge: How can we provoke workers in the health services and education to exercise self-assessment of their work processes in action, and from this perspective follow the connections that empower life with joy?

The time for collective and reflective production is of a different order; it seems that we still cannot decipher the riddle of the Sphinx in order to develop strategies through which we research the giving of care while caring about teaching and researching. With that we question the timeframes that do not coincide: those of the collective production, and the chronological and productivist pace of academia.

REFERENCES

• 1. Bichuetti J. PSF e sociedade mundial de controle: por uma prática de inclusão, cidadania e solidariedade. Uberaba: Instituto Félix Guattari; 2003.
• 2. Hardt M. A sociedade mundial de controle. In: Alliez É. Gilles Deleuze: uma vida filosófica. São Paulo: Ed. 34; 2000.
• 3. Guattari F. Revolução molecular: pulsações políticas do desejo. 3Ş ed. São Paulo: Brasiliense; 1987.
• 4. Merhy EE. Saúde: a cartografia do trabalho vivo. São Paulo: Hucitec; 2002.
• 5. Baremblitt G. Compêndio de análise institucional e outras correntes: teoria e prática. 5a ed. Belo Horizonte: Instituto Felix Guattari; 2002.
• 6. Baremblitt G. Introdução à esquizoanálise: coleçãoe esquizoanálise e esquizodrama. 3a ed. Belo Horizonte: Instituto Felix Guattari; 2010.
• 7. Almeida MCP, Rocha SMM. O trabalho de enfermagem. São Paulo: Cortez; 1997.
• 8. Brasil. Ministério da Saúde; Secretaria de Ciência Tecnologia e Insumos Estratégicos; Departamento de Ciência e Tecnologia. Seleção de prioridades de pesquisa em saúde: guia PPSUS. Brasília; 2008.
• 9. Passos E, Kastrup V, Escóssia L. Pistas do método da cartografia: pesquisa intervenção e produção de subjetividade. Porto Alegre: Sulina; 2009.
• 10. Feuerwerker L. Estratégias de mudança da formação dos profissionais. Olho Mágico. 2002;9(1):16-8.
• 11. Oliveira MAC, Veríssimo MDLOR, Püschel VA, Riesco MLG. Desafios da formação em enfermagem no Brasil: proposta curricular da EEUSP para o bacharelado em enfermagem. Rev Esc Enferm USP. 2007;41(n.esp):820-5.
• 12. Pereira WR, Tavares CMM. Pedagogical practices in nursing teaching: a study from the perspective of institutional analysis. Rev Esc Enferm USP [Internet]. 2010 [cited 2011 Oct 20];44(4):1077-84. Avaible from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342010000400032&lng=en  http://dx.doi.org/10.1590/S0080-62342010000400032.
• 13. Fortuna CM. Cuidando de quem cuida: notas cartográficas de uma intervenção institucional na montagem de uma equipe de saúde como engenhoca-mutante para produção de vida [dissertação]. Ribeirão Preto: Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo; 2003.
• 14. Matumoto S. Encontros e desencontros entre trabalhadores e usuários na saúde em transformação: um ensaio cartográfico do acolhimento [tese doutorado]. Ribeirão Preto: Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo; 2003.

^*

La investigación y la articulación enseñanza-servicio en la consolidación del Sistema Único de Salud

Correspondence addressed to

Publication Dates

• Publication in this collection
  04 May 2012
• Date of issue
  Dec 2011

History

• Received
  28 Oct 2011
• Accepted
  16 Nov 2011