Professional training in physiotherapy : barriers to the diversification of practical learning scenarios and for teaching-service integration

Introduction: Professional training in health, at present, aims to develop competencies and skills for a performance according the principles of the Unified Health System (SUS, in Portuguese). In this sense, the Ministries of Health and Education have set up devices for training reorientation that prioritize teaching-service integration and diversification of learning scenarios. Objective: To describe barriers to the diversification of practical learning scenarios and for teaching-service integration in a physiotherapy course from the perspective of teachers and students. Methods: This is a qualitative research developed according to the case study method, with the participation of 16 students and 11 teachers-physiotherapists. *APMG: MS, email: anagauer@unochapeco.edu.br FF: PhD, email: ferrettifisio@yahoo.com.br CRPAT: PhD, email: carlateo@unochapeco.edu.br


Introduction
The reorientation of professional training has been placed as a priority in the health area, with the aim of promoting the development of skills and abilities of graduates of undergraduate courses so that they can work according to the principles of the Brazilian Health System (SUS) [1,2].The objective is to achieve a training that discusses and integrates knowledge and professional practice [3].In the health area, physiotherapy is considered a recent profession, in its early forties, which has strengthened itself as responsible for the rehabilitation of people, with a training focused on a biomedical, curative and rehabilitation model [4,5].
In the perspective of a professional training to work within the SUS, in 2001, the Ministry of Education approved the National Curricular Guidelines (DCNs) for Health Graduation Courses [6].In 2005, discussions on this process intensified, and the Ministries of Education and Health created mechanisms to reorient professional training -among them the National Program for Reorienting Professional Training in Health (Pró-Saúde) and the Education Program through Work for the Health Area (PET-Saúde) [7].
Pró-Saúde aims at the teaching-service integration and the diversification of practice scenarios in the teaching-learning process [7].The PET-Saúde seeks to foster interdisciplinary tutorial learning groups within the scope of the Family Health Strategy (FHS), with the participation of students, professors and professionals in the services [8].There is evidence that the courses that participated in these programs have diversified the practices in the training process, strengthened the actions between courses, improved students' knowledge about the SUS and promoted closer approximation of service professionals with teaching [9 -13].
However, some constraints limit the advancements already made and the continuity of the process, such as poorly articulated planning for health services; the low insertion of students in Primary Care (PC); curricula targeted at a training that does not enhance interdisciplinarity, which may hinder teamworkaspects that do not promote training with a broader view of health care [14 -19].
Considering that the physiotherapy course in which this research was carried out has been participating in Pró-Saúde and PET-Saúde since 2008, thus interacting with the actions and proposals of two of the main devices for reorienting training in the present day, we sought to know and describe the obstacles experienced in the training process that limit the diversification of practice scenarios and the integration between teaching and service from the perspective of teachers and students.

Methods
The methodological chosen for this study was the qualitative approach, guided by the case study method, which is an adequate research strategy for exploratory and descriptive studies [20].The study was carried out in an undergraduate course in physiotherapy created in 2004 at a community university, which has been implementing Pró-Saúde since 2005.Eight classes have already graduated by this course and it is inserted in Pró-Saúde and PET-Saúde projects since 2008.
In order to select the collaborators, we have prioritized the subjects with characteristics that the researcher intends to know and research, with enough amount to saturate information and to guarantee the diversity of the subjects [20].In this sense, the individuals were chosen intentionally.The criteria for selecting the students invited to participate in the research were: being enrolled in the last two years of the course, since they had already experienced several practices and had experienced all the training course in the higher education institution (HEI); in addition, students that had contact with devices for reorientation of professional training, also in the last two years of the course, should be included.
Participants were 16 students who were attending the sixth and eighth semesters of the physiotherapy course at the time of the research.Of these, five had been scholarship students of the professional training reorientation programs in the years 2014 and 2015.In addition to the students, 11 physiotherapist teachers also integrated the study population.
The invitations for participation were made in person and formalized via e-mail.We also used chat applications and social networks to organize the meeting schedule according to the participants' availability.In order to enable data collection with the students, a focus group was held in the afternoon shift and other in the evening shift, since the students who were doing internship only had availability in the third shift.Also, students who had participated in reorientation programs were all in the eighth stage, out of a total of eight students.All were invited to participate in the study, and five expressed interest and availability.
Three focus groups were held, two with students and one with teachers.The focus group should have between six and 12 subjects, as larger groups limit the deepening of ideas.In conducting the focus groups, we sought to meet the premise of "being sufficiently provocative to allow for enthusiastic and participatory debate" [21].The focus groups with students were attended by six and ten students, respectively; the focus group held with teachers was attended by nine teachers.
The focus groups were held at the university, with participants sitting in a circle to encourage participation.It was started with the personal presentation of the moderator and the participants, presentation of the research objectives and orientations regarding the routine and duration of the meeting.They were also informed about the use of recorders in order to record the data, the presence of an observer to record the information and also the guarantee of preservation of their identity.The groups were moderated by the researcher and the study advisor assisted in the collection and annotation of information.
The first focus group was held on a Tuesday afternoon.It lasted one hour and 15 minutes; the transcription time was 18 hours, with participation of six students.The second focus group with students was held on a Thursday, lasted one hour and 20 minutes and the transcription time was 20 hours, with participation of ten students.Combining the two groups, sixteen students participated, six from the sixth semester and ten students from the eighth semester of the undergraduate course in physiotherapy.
Three attempts were made for the focus group with professors.In the first one the eleven teachers were invited, however, only five confirmed availability.A second date was then scheduled with the confirmation of five teachers.In the third attempt, of the eleven professors, nine participated in the focus group, one teacher was on maternity leave and the other did not justify the absence.The focus group lasted one hour and 2 minutes, with a transcription time of 19 hours.
In order to increase the collection of data, the interview technique was also used with the articulating teacher of the Pró-Saúde program of the course and with the coordinator of the course.The interview is a conversation between two or more people aimed at building relevant information to a research object.Among the different modalities of organization of the interview, in this study, we chose the semi structured [21].
Both interviews and focus groups followed a pre-elaborated script by the researchers with questions about the obstacles experienced in the training process that limit the diversification of practice scenarios and the better teaching-service interaction.Interviews and focus group discussions were recorded and subsequently transcribed.The textual material was analyzed by thematic content analysis, performed in three stages -pre-analysis, exploration of the material, treatment of results obtained and interpretationaccording to Minayo's proposition [21].
The project that gave rise to this study was appreciated and approved by the Ethics Committee of Research with Human Beings of the Higher Education Institution of origin, under protocol nº 1,309,640.This study ensured compliance with the ethical principles of Resolution 466/12 of the National Health Council.In order to guarantee privacy and preserve the identity of the individuals, codes were used to identify the speeches: S for students, SS for scholarship students, P for professors.The presentation of the research results was carried out through a seminar in one of the research groups of the institution, in which professors and students of the physiotherapy course and the managers of the health science area participated.
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Results
The Pro-Health proposal encompasses that the reorientation of professional training in health should take place from three axes -theoretical guidance, practice scenarios and pedagogical guidance.The axis of practice scenarios, the focus of this study, has three vectors: teaching-service interaction, diversification of learning process scenarios and articulation between university services and SUS [7].
According to Pró-Saúde, practice scenarios are spaces in which students perform their teaching-learning activities with autonomy and in increasing complexity, in several places.In addition to spaces in the public health services, they should include educational and community equipment, providing the student with work on real problems, as a care provider agent.The diversification of the scenarios is understood as one of the strategies for curricular transformation, by bringing students closer to the daily life of the population, in which a more critical view is developed [7].Inserting the student into real scenarios ensures an experience directly related to the population's health problems and needs.In the same way, it offers the student a different training from the traditional one, breaking with the methodologies of transmission of knowledge and allowing reflection on the knowledge acquired and applied.
The interpretation of the empirical material arising from the interviews and focus groups through thematic content analysis gave rise to the following categories that indicate the findings of this study on the obstacles to the diversification of the practice scenarios and the teaching-service integration: low insertion of students into public health services; saturation of spaces in public health services for practical activities; low number of physiotherapists in primary care; indirect relationship between the clinical school and SUS.

Discussion
One of the main obstacles mentioned by the students was the low insertion of students in public health services, as illustrated by the speeches: In general, we perform few practices in public services; there is the need to improve in in primary care (SS3).
As for the practices in the public health services, I believe that the course could have explored a little more, maybe some experiences or some visits, with actions that are actually developed (S13).
The speeches reveal a distancing from the daily life of services, which is, to some extent, corroborated by the fact that practices, in the said course, occur in some spaces of the public health network with occasional activities.In this regard, it should be noted that the physiotherapy course constituting the context of this study is inserted through the curricular internship in collective health in four Family Health Centers (FHC), in which activities are carried out with the community, with the Community Health Workers (CHW) and with specific groups of users, in addition to home visits and waiting room guidelines.In this dynamic, the main scenarios used are the neighborhood's community halls and the FHC waiting rooms.In the internship of hospital physiotherapy, practices are performed at the Hospital Regional do Oeste, which is one of the public health services of the municipality.
It is argued that public health services seem not to be potentialized as learning scenarios in order to favor the construction of skills and competencies for collective work, since students do not arrange with the health team from the needs of that territory, the actions to be developed.In other words, the students are inserted in the services in a fragile integration logic, in which they do not built with the health team the planning of actions they will carry out in that space.
The core of the physiotherapeutic or professional knowledge is the one that has the greatest hours in the studied physiotherapy course.In the area of musculoskeletal dysfunctions and orthopedics, the practices occur in the laboratories of the HEI.This also occurs in cardiovascular physiotherapy, in which the practical classes take place in the course laboratory and in the physical therapy school clinic.The area of neurological physiotherapy distributes its intervention practices in the school clinic, laboratories of the course, complementary health services such as Apae, Capp and the practices of therapeutic horseback riding in a private stud farms.
One possibility of diversifying the practice scenarios of these disciplines would be to get closer to the service or to the professionals and to plan actions related to these specific areas in the community, articulated with the demands of the FHS.Another perspective would be an integrated planning in the Health Science Area of the HEI in order to potentiate practices between courses Page 06 of 11 and stimulate multidisciplinary and interdisciplinarity, with practices in increasing complexity in primary care.
To bring about changes in teaching actions, it is necessary to recognize the association between work and education and its interfaces, which present a wealth of values and processes, together with the diversity of looks and subjectivities of this complex system, in the search for the transition from a healing model of care to health promotion [7].The subjects' speeches and the Pró-Saúde document demonstrate the importance of planning teaching-learning activities in agreement with the SUS service network, which would consequently strengthen the teaching-service interaction.
The daily life of SUS services is an important space for students to practice, since in this scenario, knowledge gains materiality [22].On the other hand, training processes in which practices are more centralized in clinics and university laboratories, with little or no integration with the service network and with a focus on tertiary care, can be distanced from SUS and PC.In this perspective, it is important that practices in public services assume the focus of comprehensive care, contemplating health promotion and the prevention of injuries, which will certainly cause changes in training, thus attenuating characteristics of the biomedical model of care.
A study that evaluated the insertion of undergraduate students in Primary Health Care from the perspective of the users showed that the community insertion of students makes them potential modifiers of reality, in the same way that their presence and collaboration in care interventions qualify the health care, which can be a subsidy for the training of professionals with awareness of the social reality and with capacity for promotion, health education and the prevention of injuries, thus improving the work process in the services and the training of the student, resulting in qualified health care for the population [17].Another research that described the changes in health practices from the perspective of the FHS professionals who accompany the actions of students in primary care showed that the insertion of students in the services has been recognized as a transforming element of the practices of the professionals working in the teams, mainly due to the opportunity for shared discussion among teachers, students and professionals about the actions carried out jointly [23].
A study that analyzed the meanings of performance in physiotherapy in the context of Primary Health Care and the reflections generated by these experiences concluded that the insertion of training processes that articulate learning with practice in the territories will cause changes in the training of physiotherapists, leading them to expand their understanding of the demands and complexity of the work in SUS [24], a fundamental factor for a professional, which is provided in the Family Health Support Center (NASF).
Given this scenario, assuming the commitment to articulate the practices in the health services, in the various areas of the physiotherapist, with a planning carried out jointly with the municipal health management and the educational institution, becomes fundamental to reorient training for SUS.
Although joint planning may be a possibility to overcome the low insertion of students in public services, another outstanding aspect that directly interferes with this issue is the saturation of spaces in public health services for practical activities, as reported below: As the places receive many students, I think that this flow of scholars in public services is very limited... (S8).
We have many students, from various universities, for few vacancies, because they [referring to the Municipal Health Department] have a limit by territory or by space (P11).
At this point, it should be clarified that some scenarios, such as the FHCs, in which the HEI articulates its activities in this municipality, have a high demand coming from the health courses of several institutions.In this municipality, currently, there are four universities generating demand and using the services as a practice space.This situation caused the Municipal Health Department to organize schedules and establish the limit of six students per space for each shift, which has generated difficulties for the course under study, in the sense of diversifying the practice scenarios.In this direction, expanding the scenarios to other small regions and municipalities in the surroundings can constitute a way to overcome such an obstacle.
The individuals still pointed out that the mentioned saturation is associated to the flow, the territory of the municipality, the demands of several disciplines of the same course and the impact on the work process of the professional in the network, who often does not perceive the student as a potential in the service.

The first difficulty is the very large flow of disciplines; not so much by course, but I think by the place, its work organization, the service professional [...] (SS5)
I think the spaces are very saturated ... the academics of this institution and from other universities settle in these places and also end up hampering the work process in that environment (S4).
So, it's a very large number of students in the same internship space [...] because there are many courses.The obstacles, today, are the large number of students to few spaces that the Municipal Health Department allows us.For example, in physiotherapy, there are four territories in which students can practice.This may be a limitation; we have the aim to diversify [...], but we are not managing to do it (P10).
The speeches presented here point out some important issues that are probably implicated in the saturation of health services; among them, the work process of the teams is highlighted.In seeking a closer relationship between the university and health services, it is crucial to look at the work processes characterizing each of these institutions, since the HEI aims at the production of knowledge -the knowing -and health services are focused on the production of health care -the doing [18].There is still a mismatch, in some situations, as to what each institution expects from the insertion of the student in health services.It is therefore a question of reconciling objectives, work processes and expected results.
Although the Ministries of Health and Education have invested in reorienting professional training in the last decade, curricular reforms in health education do not reflect all this investment [25].In order to overcome the difficulties, there is a need to strengthen the dialogue between HEI managers and health service managers and professionals, with a view to producing strategies to enable greater inclusion of teachers and students in teachinglearning activities in public health services.
Diversification, when planned in partnership with the professionals of the care network, can expand and make feasible practices in scenarios other than the Basic Health Unit (BHU) -the occupational health services, the mental health care network, specialties and reference in the areas of cardiology, vascular area, orthopedics, elderly outpatient care, 24-hour emergency care unit, children's hospital, among others.There is, therefore, a diversity of spaces that may constitute potential scenarios for the diversification of practices and minimization of the saturation of public health services.
In this scenario, another aspect, from the perspective of the subjects, emerges as an obstacle, namely the low number of physiotherapists in primary care: We know that here in this municipality we have few physiotherapists working in primary care and NASF, so we do not know how this professional acts in the service (SS5).
When I went to the health unit there was no physiotherapist working [...].But I believe we could have this contact, because I really do not understand how they act in Primary Care (S14).
One difficulty is the lack of the physiotherapist in the NASF in the municipality; I think this is an impediment.Our students have little or no contact; this would be a professional in whom they could mirror, after all he should be the link with the family health strategy (P11).
The insertion of the physiotherapist in the primary care took place in Brazil through NASF teams in 2008.NASF aims to broaden the scope and coverage of primary care actions, as well as their solubility, supporting the insertion of the FHS in the service network and the process of territorialization and regionalization from primary care [26].
The municipality where the physiotherapy course under study is located presents a difficulty in hiring physiotherapists to work in the NASF, counting with 10 open positions and having only one professional in the service.In previous years, there were eight professionals working 20 hours a week [27].This low number of physiotherapists working in the NASF may be due to the non-opening of a public tender to fill vacancies in the last year.In the last public tender, the two physiotherapists approved chose not to assume the position.In addition, the service has also not performed temporary contracts.
A study carried out in 21 municipalities of Rio Grande do Sul corroborates this observation, since, in seeking to identify how the physiotherapy care to the population is structured within the scope of the PC/ FHS, it observed that in only two municipalities this professional is inserted in the NASF [28].In the same sense, according to data from the National Record of Health Establishments, there has been a concentration of physiotherapists working in specialized services, performing rehabilitation actions [29].This only reinforces that the physiotherapist's role in NASF and FHS is still an under construction.
The absence of the physiotherapist in the PC, for the participants of this study, represents a barrier to the practice, since supervision and follow-up, when performed by the professional inserted in the network, potentiates the exchanges and the construction of knowledge according to the health reality.We start from the premise that, in order to develop a critical and reflexive sense, teaching needs to relate theory and practice.However, if the student does not visualize that field as a future work space, he will hardly choose to perform in that context after his professional training.Physiotherapy still needs to be consolidated as a necessary profession, and recognized as such for primary health care, as highlighted by a professor's report: This issue of the physiotherapist integrated in family health is crucial to the health-disease process for issues related to SUS [...].However, in the FHS, the physiotherapist is not a mandatory professional; if it is not required, it will not be inserted.Sometimes, the professional is hired by the municipal services, but does not play the role of the physiotherapist in Primary Care (P10).This reality has already been well explored in several studies that pointed out the need for physiotherapy in Brazil to build changes in its training process to overcome the stigma of rehabilitation professionals, as well as the lack of knowledge of managers, team professionals and users of about the role of the physiotherapist in PC [28, 30 -33].
Based on the reality presented by the study subjects, it is necessary to strengthen the practices in Primary Care with the supervision and/or follow-up of other professionals of the FHS and NASF teams in situations in which the physiotherapist does not integrate the team, expanding the field of insertion to other contexts and other municipalities.
On the other hand, it is also necessary to approach the professionals of the service with the teaching.NASF professionals can assume a role of articulating planning together with the SUS network, in addition to approaching the teaching-learning practices of the service through preceptory or tutoring in Primary Care.Performing practices close to these professionals will enable the student to participate in actions such as matrix support, home visits, health promotion groups, diversifying the experiences in this context.
Another important action is the training of the service professional on pedagogical issues, strengthening the relationship between theory and practice in these spaces.It is not about denying the importance of technical knowledge, since it is necessary to provide training to the student in his/her practice of "how to do", but rather to support pedagogically the professional so that he/she experiences in a positive way the preceptory/tutoring and according with the presuppositions of the pedagogical project of the course.
For greater teaching-service integration, in addition to the aspects already mentioned, another obstacle needs to be overcome, according to the opinion of the study subjects, namely the indirect relationship between the School Clinic with SUS.According to reports, it is difficult to make this service of the HEI articulated with the SUS, either due to the demand or due to the absence of a consultation scheduling center linked to SUS, which weakens the performance of referral and counter-referral actions: Until then, we have met the repressed demand of the Basic Health Units in the mandatory internships without problems [...].From the moment that it began to be produced in a financial way through an agreement with the Municipal Health Department and to provide service, considerations arose by the municipal health management in relation to the demand that could be produced by the university, by the number of attendances, which would bring an imbalance in the quotas of the agreed clinics [...].Therefore, it was established that the attendance by the health plan would only be carried out by the physiotherapist and the interns of this professional (P5).
The Municipal Health Department does not allow our students to attend the SUS patient.So, that limits us to make that flow and those returns.One factor they pointed out is that the physiotherapy clinics linked to the SUS state that we are an unfair competitor because our care is differentiated and also because of the production of a financial part (P10).
The course that participated in this study counts on a clinical physiotherapy school in which the students meet the repressed demand of the SUS, that is, patients without referral from the municipal appointment scheduling center.This model of organization makes it difficult to articulate the HEI with SUS and prevents the functioning of referral and counter-referral mechanisms, which are predicted to be fundamental to the process of reorienting professional training [34].The SUS is considered one of the main scenarios for teaching activities and, in this sense, the non-integration of the HEI's own services hinders the production of learning and does not bring the student closer to the real scenario.
A research on the importance of service-education integration in the of professional training showed that the organization of practices and internship Page 09 of 11 environments should take place collectively, and that approach and planning mechanisms together need to be created in each course in the health area, through reflection and dialogue, provoking negotiation situations to achieve success in the intersectoral work of health and education.In this direction, it is necessary to integrate school clinics to the SUS because this action is configured as another strategy to strengthen the interaction between teaching and service [35].
The course under study presents practices in BHU and in the community, but to some extent, specific and with little interaction with the service, so that these activities may be insufficient to reach and consolidate a condition of reorientation of the training.In order to overcome these obstacles and seek ways of articulating continuous actions with the professionals of the FHS and/or NASF and SUS, it is relevant that the course articulate, with the support of the institutional management, moments of greater interaction with the services so that, in an articulated way, observing the demands and norms of both institutions, it can find strategies to qualify the training process with a view to integrating the HEI's own services with the SUS and to diversify the scenarios in the teaching-learning process.

Conclusion
The obstacles pointed out in this study detail the difficulties experienced by the course to ensure a closer approximation of teaching with health services and to diversify professional practices.With a view to overcoming this issue, we believe that there is a need to carry out a collective movement that encourages dialogue and greater integration between HEI managers, health service and courses.Making agreements, organizing, negotiating and planning the insertions in PC with practices between courses, in which there is dialogue about the needs of the community, and not of an individual, course by course, is a way to overcome this issue.This strategy needs to be fostered in semester planning, in order to effectively produce changes.
The institutionalization of the practices of Pró-Saúde and PET-Saúde is necessary, since not all students and teachers are involved in the programs and projects developed, rather it is usually only a small portion.This is one of the greatest challenges to be faced.In order to overcome the stigma of a professional who works mainly on tertiary care, the professional training in physiotherapy needs to enhance interdisciplinary and multiprofessional practices during graduation, enabling students to carry out interventions in different teachinglearning scenarios, with the participation of students from different courses, working in the perspective of discussion about the role of each area in the work of the professional team.By experiencing and reflecting, during undergraduate course, about this health work, which is not only mediated by biotechnological and physiotherapeutic knowledge, we will move towards other reflections, with a critical analysis about the training of this professional.