Ensinar sistematização da assistência de enfermagem em nível técnico : percepção de docentes Systematization of teaching nursing care at a technical level : perception of professors

Objective: The aim was to describe the perception of professors on approaching systematization of teaching nursing care at the technical level. Methods: Descriptive study of a mixed approach. Seven professors of the Technical Nursing Course of a public university in northeastern Brazil participated in a focus group. The textual content was organized by using the free software “Interface of R for multi-dimensional text and questionnaire analysis”, and data analysis was performed based on the theoretical framework of Alfred Schutz. Results: The technical nursing course professors indicated the importance of integrating the nursing technician into the systematization of care, and emphasized the need to include this theme in technical level training. Conclusion: Professors identify doubts and fears about not knowing how and when to teach the systematization of nursing care at the technical level, but ponder the possibilities and needs to consolidate this theme. Descritores Processos de enfermagem; Docentes de enfermagem; Educação técnica em enfermagem; Auxiliares de enfermagem


Introduction
The systematization of nursing care (SNC) is recognized as a methodology aimed to assist the organization of nursing work, to benefit care, to plan the context regarding the provision of care, to document professional practice, and to improve visibility and professional recognition. (1)owever, despite the obligation of its accomplishment established by the Federal Council of Brazilian Nursing, (2) SNC consolidation is still inconsistent in the practice reality, an aspect that occurs unevenly in Brazil, where despite federal units in which SNC has been implemented for decades, there are states where SNC remains only a theoretical discussion.
In this context, we recognize that a chance to support the effective implementation of SNC occurs in the formative aspect of the nursing team.Therefore, we apprehend that the education of health workers is closely related to the quality of care provided; moreover, the training of health professionals, both for technical and academic degrees, is understood as a potential to impact understanding and redesign of the health services reality. (1,3,4)he role of the university as a change agent is highlighted in terms of the reality of health services, and specifically for the consolidation of SNC through the education of nurses -professional nurses and nursing technicians -qualified to deliver care based on this working method, and therefore having the ability to modify those realities in which SNC is still not consolidated.
It is noteworthy that the abovementioned category (nursing technician) is often neglected when discussing SNC, so that the theoretical discussion of this methodology is often exclusive of professional nurses, which can provide a fragmentation in the care process, in addition to being another obstacle to the effective implementation of the SNC. (5,6)n addition to representing the majority class in quantitative terms, (7) we emphasize that nursing technicians are those professionals involved directly with patient care, therefore, they hold an unquestionable potential to contribute both to the implementation of SNC and to the continuous evaluation of the method and specific nursing responsibilities. (6,8)us, we justified the relevance of discussing SNC within the technical level education, since "the quality of education in nursing can directly impact health actions, which mostly depend on nursing technicians." (4)Thus, the phenomenon to be studied is presented: professors' typification of teaching SNC at a technical level.
Therefore, we used the theoretical framework of Alfred Schutz, known as a social phenomenologist and considered one of the most important philosophers of social science in the twentieth century. (9)he typification or the ideal type stands out in the Schutzian approach, configuring the way individuals interpret their attitudes and those of others, according to their stories and relevance. (10)he aspect that enables the researcher to understand a social phenomenon is therefore the systematization of its typical features, (9) which have motivations that also need to be investigated.
The reasons-for are essentially subjective, representing the goals to be achieved within a future time frame and composing a subjective category of action, i.e. they are the reasons that are closely related to the action and to the subject´s consciousness.They are related to the specific purpose, the project to be performed, and the will to do so. (10)he reasons-why are characterized by objectivity, delineated in the events that already had been concluded, with a temporal direction to the past and which are understood retrospectively, i.e., they are unconscious during the action. (10)e sought to answer the following research question: what is the perception of professors about teaching SNC to nursing technicians?From the Schutzian framework, we aimed to analyze the perception of professors from the unveiling of its typification, which means, to learn the way that research subjects understand a phenomenon -in this case, how the professors understand the teaching of SNC to nursing technicians.Therefore, the researcher should investigate the typical features in their statements, which will be unveiled from their reasons-for and their reasons-why.
This classification integrates a process of developing a tool that will subsidize the teaching of SNC to nursing technicians, as part of the Theory and Con-struction theoretical framework.The purpose is therefore to describe the perception of professors about teaching SNC at the level of technical education.

Methods
This is a descriptive study of mixed approach.Seven professors of the Technical Course in Nursing of a public university in northeastern Brazil participated in the study.Data collection occurred from February to March of 2015, using the focus group technique. (11)Two focus group sessions were held: the first lasted 104 minutes, and the second lasted 94 minutes.The research team was composed of a mediator, a rapporteur, and two contributors.
The inclusion criteria were the following: to be working within a professor position, and, a minimum of six months working as a professor in the Technical Course in Nursing.Moreover, we followed the recommendation stated by the literature that focus groups should have the participation of 6 to 15 people, in order to ensure the effectiveness of the focus groups. (11)mong the 14 professors that met the study inclusion criteria and were invited to participate in the study, a total of seven attended and composed the research sample.Their statements were identified by the letter P -professor, followed by a number in sequential order (P1, P2, P3, up to P7), to preserve the identity of the participants.
Based on the principle that the use of projective techniques contributes to an investigation of unconscious content, fosters dialogue, and creates a favorable environment to investigate the subjective aspects not disclosed during verbalization, (12) we used the theory of Experiential Humanescent Pedagogy (EHP) (13) to facilitate the expression of subjectivity of the participants.The EHP is understood as an approach to stimulate the expression of the participants using the following guiding questions: 1) to build a scenario; 2) to describe the scenario, and to draft a text with this description.This report, in written form, was conducted using a research instrument that contributed to the analysis of the subjects' statements; and 3) to express verbally their representations, sharing ideas and opinions. (13) is noteworthy to mention that, in this manuscript, we analyzed only the textual data resulting from this research process.The scenario constructed, therefore, was not included in this analysis.
The room for data collection was as follows: the place for the scenario was in the center with a carpet of 5.00 x 3.00 meters of beige non-woven fabric (NWF) and a brown center circle.In this place, one could find the boards for the construction of the scenario, the modeling clays and miniatures (figures of people, animals, flowers, furniture and various other objects).Behind the abovementioned semicircle there were no chairs, so that participants first attended the presentation of research, followed by signing the Terms of Free and Informed Consent, and then completing the questionnaire on characteristics; and, across from these spaces, there was the chair where the rapporteur would describe the details as seen during the meeting.
With professors sitting in the chairs, the mediator explained how the focus group would be conducted, clarifying the purpose of the meeting, and explaining the proposed construction of scenarios based on the EHP theory, with the question designed during the sessions: "What do you think about teaching SNC to nursing technicians?".It was also explained that, as they were finishing the construction of the scenario, researchers were going to provide an instrument for them to describe that process.
Participants consolidated the initial proposal of discernment to reflect on the theme.We highlight the agility with which the professors built their scenarios, since within 20 minutes all the participants were completing the instruments.The description of scenarios, however, occurred carefully, and in detail.Participants observed the constructed scenario and the questions designed, and resumed writing, complementing and detailing their description.
Finalizing the records, participants were invited first to contemplate their colleagues' scenario and then sit in front of their own product and start sharing their experiences.After contemplating all scenarios, the professors and the mediator sat in a circle around the products.
At this moment, all participants explained their views, described their scenarios, and contemplated the theme that was initially proposed.In the process, the mediator led the dialogue, merely to allow the participation of every subject and mediation of the dialogue.The rapporteur described the meeting, and the audio was recorded with previous consent of the participants.
The statements were transcribed and textual content resulting from the interviews was submitted to lexicographical analysis, with the support of a free software for analysis of textual data "interface of R for multi-dimensional text and questionnaire analysis" -Interface de R pour Analyses Multidimensionnelles de Textes et de Questionneires (IRAMUTEQ).
We used the descending hierarchical classification and the similarity analysis as data processing methods.Each text (n =7) was characterized by the variables of interest "length of experience teaching "and "length of experience in technical level education".A frequency greater than twice the average of occurrences in the corpus, and the association with the class determined by a chisquared value below 3.84 and a significance level of 95%, were followed as criteria for inclusion of elements in their respective class, as suggested by the software tutorial. (14)e emphasize that the software used is a data processing tool.Thus, it performs a lexical analysis of textual content, which identifies fragments and classes that reveal the categories of analysis evident in the subjects' statements.
Despite this fact, the analysis of such data constitutes a part of the researcher's work, which in this study was performed based on the theoretical framework of the comprehensive social phenomenology of Alfred Schutz, (10) whereby each division and each class was analyzed to disclose the characteristics of the research subjects, based on the proposal of methodological principles of phenomenological research. (9)he study was registered in Brazil under the Platform Presentation of Certificate number for Ethics Assessment (CAAE) 39640914.8.0000.5537.

Results
The focus group was composed of seven professors of the Technical Course in Nursing.The majority were female, with a master's degree as minimal level of formation, experienced in teaching, but with a biographical situation in which the teaching of SNC to nursing technicians had not been experienced (Table 1).
The analysis of the corpus from the focus group sessions with professors of the Technical Nursing Course denoted 7,325 occurrences of words, distributed among 1,240 forms, with an average of occurrence of six words for each form -criterion used as the cutoff point for including the elements in the dendrogram and in the similarity analysis (twice the average frequency, therefore, 12).
Through the hierarchical descending classification, we analyzed 213 segments of text that retained 70.42% of the corpus, for the construction of the five classes resulting from the content partitions (Chart 1).
The first distribution of content, which includes classes 1 and 2, allowed the contextualization of the typification of SNC teaching conducted by the professors.On one hand, we identified experiences and possibilities that affirmed the need to include this issue in technical level education and, on the other  hand, there were doubts and fears about the right time to approach this matter, influenced mainly by the biographical situation of professors that referenced the failure in teaching SNC in NT education.
The typical vocabulary from class 1, which integrated 16.0% of the analyzed content, highlights the "Experiences and possibilities of including SNC in NT education", which also presented as meaningful words (p <0.0005): to know, to need, to study, experience and team.Therefore, they pointed to the need for new experiences to consolidate the SNC education at the technical level.
While professors emphasized the importance of including SNC in NT education -the technician needs to know what SNC is, he/she needs to know that there are theories, that there are steps, that there are some steps in which they will have more participation and others in which they are less involved.(P3) -Professors indicated concern about the experience of students in relation to the content taught, as SNC is not effectively consolidated as reality in our world, as evidenced in the statement of P2: We need the whole health team to be integrated and that relation-

ship between theory and practice to be exactly what happens, he does not only have to know the content, he needs experience, he needs to live, he must know, he needs to get involved. (P2).
This concern is highlighted in the class 2, "Doubts and fears: the right time to teach SNC to NT" (16.0%), in which the professors analyzed that the immaturity in their biographical situation regarding the teaching of the SNC to NT ultimately contributes to many fears about what is the right time to carry out this process, mainly due to a healthcare reality in which the SNC is unconsolidated and the lack of theoretical preparation of students to understand the content, which can be seen in the statements of professors: In contrast to such fears, highlighted in the typification made by professors, the second division of content, which integrated classes 3 and 4, was significantly related to those professors with less than ten years of experience in technical education and denoted the reasons-why to teach SNC in NT training, i.e., it justifies why the phenomenon of teaching SNC in technical level should be achieved.It was highlighted that professors must face the fears related to the search for alternatives to allow the consolidation of SNC teaching at the technical level, an aspect supported by the role of the university in changing nursing practice and addressing the fragmentation between doing and thinking in nursing practice.

[...] If it [SNC content] is approached at the beginning [of the technical course] it will not be well understood, because there is no maturity to perceive what care it is and in which moment
Thus, Class 3, "The role of the university in changing practices", added 24.0% of text segments analyzed from the vocabulary: practices, knowledge, experience, to believe, and to happen (p <0.0001).Professors reported that SNC education at the technical level could begin to encourage healthcare environments to change, optimizing the consolidation of SNC through health professionals who are trained and empowered to accomplish it:

[...] I believe it is not because it does not happen in practice that we should not teach it [...] we teach because we believe that this technique is validated, this technique is ideal to be used. So, I think that the university should influence some issues and bring the best practice into the service. (P4)
Other finding adds more reasons-why to teach SNC to NT, as highlighted in class 4, "Overcoming of the fragmentation between doing and thinking" (29.33%), which were composed of the words: to do, ways, to think, to achieve, to accomplish, to consolidate, to want, to build, and to unite (p <0.0001).
Professors discussed the need for more contributions in overcoming of the vision of technicians as executors of procedures, from the understanding of the relevance of such professionals in care planning, and therefore in the SNC.Therefore, this division must already be demystified during the training environment, where students should be encouraged not only to learn to do, but also to think about what is done: We must create alternatives [...] to build it; one would have to teach the student how to think to be able to do, because to do by doing, the technique by the technique, this would not be the proposal.(P7) [...] Sometimes we want to force SNC down their throats and sometimes it does not include these professionals in the process, it is important for them to feel part of this process, they also must learn and contribute, and there is the importance of training.(P5) Finally, the third division of content enabled the understanding of the reasons-for teaching SNC for NT, which shed light on the consequences of the consolidation of the investigated phenomenon, that is, to teach SNC in technical level education.Through class 5 lexicography, "Benefits in including NT in SNC" (14.67%), professors of the technical course reflected on the contributions that the nursing technician could accomplish by being integrated in the SNC, which runs through his/her role as a professional who is closer to the patient, able to contribute with patient-centered care and with the assessment of health conditions, which can be seen in the statements of professors: He [the nursing technician] is directly and daily with the service user, he is fundamental.(P4)

[...] it would result in care that valued these human issues, ethical issues [...] that would result in care that generates life. (P6)
The similarity analysis summarizes, through the organizing words of the professors' typification, the lexical content learned from the classes presented (Figure 1).In this analysis, the size of the words and the thickness of the lines that unite them translate the relevance of terms to understanding the studied phenomenon.
It is noticed that the highlighted words reveal the organizing elements for the discussed classes: 1) the elements in correlation with the typification about the need to teach SNC to the NT are associated to the term "to have" 2) the doubts and fears of professors about not knowing how and when to implement the SNC education at the technical level -an aspect related to the biographical situation of participants which co-occurs with the term "no"; 3) jointly to the terms "like" and "go", the possibilities to consolidate this teaching are visualized; and 4) the words that reveal the reasons, to consolidate the integration of NT in SNC are associated with the term "to be".

Discussion
The small number of professors who participated in focal group sessions stands out as a study limitation.This might be due to the high demand of activities among these subjects, which made it difficult to hold meetings with more participants.This fact also denotes that the study data reflect a specific reality, so that our findings cannot be generalized.
Th e typifi cation reveals that the SNC education for the technical level should be consolidat-ed.Th e fi ndings can contribute to increase awareness and debate on the studied phenomenon to encourage the inclusion of theoretical discussion of SNC in all areas of nurse training, which can lead to the consolidation of SNC in care and daily practice, and thus solidify the potential benefi ts of this methodology, which has been widely studied and pursued.
Th e biographical situation of nursing technical course professors who participated in this study, underlies a bigger problem: the training of nursing technicians is conducted without an indepth discussion on SNC, which infl uences and is infl uenced by a reality that still perpetuates the separation between planning and delivering care, an aspect that has been indicated in the literature as an specifi c obstacle to the accomplishment of SNC. (5,6)h e formation process of nursing technicians may be a causative factor or a reinforcement element of this problem, which highlights the history of fragmentation in nursing care: on one side we have a high level professional who plans the care, and on the other side we find the technical workers that perform care, in an environment where communication between these professionals is either incipient or nonexistent. (6)eanwhile, teaching at a technical level perpetuates a neuralgic issue about distortions that still prevail in the average level of education, which remains "[...] at the center of the contradiction: it is professional, but it is not; it is propaedeutic, but it is not." (15)aced with such challenges, what remains indisputable is the importance of integrating the technical nursing staff in the SNC.There is a need for greater cohesion of the nursing staff, since the accomplishment of SNC requires collaboration, involvement and commitment of all nursing team members in favor of the potential benefits to the profession, patient, professional and the health institution. (5,8,16)tudy participants are in line with this assertion when they understand that nursing technicians are a fundamental element for the consolidation of the SNC, as pointed out in the rationale for teaching SNC to nursing technicians, and the need to include this issue at technical level education.
It is understood that the formation of the nursing technician needs to be permeated by the guiding principles of the health system, the Brazilian Education Guidelines (LDB) and the National Curriculum for Technical Professional Education Guidelines, regulations that guide the formation of ethical, critical and committed professionals for the health system and its users. (4)or the nurse training scenario, it is imperative to overcome the dichotomy between thinking and performing, since the development of activities in the biomedical context at any level requires prior theoretical and practical preparation. (6)Thus, the theoretical basis about SNC is fundamental to all nursing team members. (8)rom this perspective, as reasons for teaching SNC to nursing technicians, professors highlighted the role of the university in changing the care reality to overcome the separation between doing and thinking in nursing.
Participants reflected on the importance of the academic environment as the center of the struggles for changes in the healthcare environment, in favor of improvements for care process in the health sector and nursing profession.Regarding SNC, professors perceived that the university may contribute to the education of skilled nursing professionals to consolidate it and, empowered by this knowledge, modify the health environments where this working method is not used.
Therefore, the integration between teaching and practice is understood as a support for nursing care quality. (1)It is necessary to rethink the teaching of nursing technicians regarding the SNC.
The training space needs to be recognized for its potential to form individuals involved with evidence-based health care, not solely on developing skills to perform procedures and technical care. (3)n this context, the importance of educational institutions is highlighted, especially the ones where the professors work, because it is understood that the professor needs to believe the framework and find strategies that can help the teaching-learning process to teach nursing and more specifically SNC. (17)n short, it is stressed that allowing the SNC to be the basis of professional nursing practice requires efforts from everyone involved, especially the educational institutions, which represent the foundation of this process, which should not be restricted to higher education but also should integrate the curriculum of all nursing professionals, regardless of the level of training.
The biographical situation from both professors and students was revealed as the main obstacle to strengthening the teaching of SNC to nursing technicians, which translates into immaturity and inexperience that needs to be overcome.
These aspects reinforce the need to think of tools that can support the inclusion of SNC in training at the technical level, which presupposes a reflection of professors about the reasons to perform this teaching.

Conclusion
Professors in the technical nursing course admitted the importance of teaching SNC to nursing technicians and emphasized the need to include this subject in technical level education.Therefore, while denoting doubts and fears about not knowing how or when to provide the teaching of SNC to nursing technicians, they reflected on the possibilities and needs to consolidate such teaching.

Figure 1 .
Figure 1.Similarity analysis of textual corpus

Table 1 .
Characteristics of participants in the focal group (n=7) Chart 1. Composing classes of the dendogram textual corpus the SNC will happen[...]and then that to me is immature, I do not have the maturity to find that moment [...] I am aware of the importance, but I'm not mature yet to identify how this learning process will happen.(P2) *p<0,0001; SNC -Systematization of Nursing Assistance; NT -Nursing technicians [...] Once again, I return to the practical question.