The nurse in the area of collective health : conceptions and competencies

Objective: to learn coordinators and professors’ conceptions from undergraduate Nursing courses of public universities in northern Brazil regarding collective health and to know the necessary competencies to work in the area. Method: data were collected through semi-structured interviews and subjected to thematic analysis. Results: the participants consider population health as an essential area for the training of nurses, where professionals have autonomy and confi dence. It is an interdisciplinary, intersectoral and multidisciplinary fi eld, with extensive scope, that studies the Unifi ed Health System (SUS). The competencies to work in population health identifi ed were: to work at the SUS, to understand the health and disease process and its determinants and to develop actions towards integrality, to conduct health education, researches and systematization of the nursing care. Conclusion: the variety of conceptions about collective health among participants might refl ect in training of nurses and their working area.


INTRODUCTION
Collective health is a structured field with structuring practices and theoretical, practical and political knowledge, which criticize the naturalistic universalism of medical knowledge and the monopoly of biological discourse (1) .Having as theoretical framework the dialectical and historical materialism, collective health understands health as a social phenomenon and considers the existence of numerous determinants that interfere in it, making the health-disease process a dynamic one (2)(3) .
The collective health term is recent.It emerged in Brazil in the 1970s, however, it is the result of discussions and actions initiated in the nineteenth century that intensified in the second half of the twentieth century.It has its origins in social medicine, preventive medicine and public health.Nevertheless, it seeks to conceptualize, through studies and discussions on the evidence of its frontiers, its scope and identity (1) .
The interaction between different knowledge and practices, strengthening ties between population and health professionals and the appreciation of the social and subjectivity values are important conceptual frameworks of collective health.In addition to these, we can cite the overcoming of the hegemonic biomedical model centered on illness, procedures, specialization and hospital centered and health care organized in lines of care (not disease) with an emphasis on integrality and equity (4) .
Practices in collective health are social practices, built in different work processes and are closely articulated with the structure of society and the dynamic forces of their social groups (2) .So, there is a variety of scenarios where such practices occur but have privileged space of action in primary health care (PHC).
In Brazil, the creation of the Unified Health System (SUS 1 ) required the use of the term PHC, in order to differentiate itself from the basic health care, until then related to minimum services and generally poor quality throughout Latin America.PHC is defined as a set of individual and collective actions on the primary care level, aimed at health promotion, disease prevention, treatment and rehabilitation (5) .Currently, the two terms are used synonymously by the National Policy of Primary Care, which recommend family health as its priority strategy for expansion and consolidation (6) .
The work in collective health, especially in the Family Health Strategy (FHS), redefined the identity and appreciation of the Nurse, whose practices had been only related to medical work and strictly technical actions.Among the many tasks carried out independently by nurses in the FHS we may cite planning and performance of actions in collective health, supervising direct care to the population, performing actions of promotion, prevention, treatment and rehabilitation, mediating inter-sectoral actions, managing health services, developing health education and continuing professional development (7) .
It is important to highlight that the work of nurses in the PHC and FHS contexts, does not, by itself, guarantee the development of a practice supported by the theoretical framework of collective health.When these professionals do not assume health as a social phenomenon and do not understand the health-disease process and its determinants, they continue to reproduce the biomedical and medicalized model, still propagated by technical professional schools, to which collective health is against.
In this context, educational institutions have sought ways to include in their curricula content and practices necessary for the training of professionals who will work in the SUS.However, it is observed that the changes promoted in teaching do not adequately satisfy the requirements of the labor market.They are also not able to prepare professionals fully focused on humanized, planned and contextualized care (8)(9)(10) .
From its pedagogical project, each educational institution plans the course for their students for professional training making every syllabus unique.At the moment of syllabus planning, laws and guidelines are involved for professional training, the institutional context, the experience and the professors' intent, the reality in which the course is inserted and the characteristics of the students.
During their first bachelor's degree, students are expected to develop competencies to work with collective health.However, no understanding of key concepts and theoretical framework of collective health by the actors involved in training may harm the teaching-learning process and focus on learning procedures.
There is a plurality of approaches to the understanding of the term competence, ranging from the spelling of the word in other languages to the understanding of the theories, cultures and approaches in which the concepts were born (10) .In this study, we assume that "competence is the ability to mobilize a set of cognitive resources (knowledge, skills, information, etc.) to solve, with relevance and effectiveness, a number of situations" (11) .
It is noteworthy that the National Curricular Guidelines (DCN2 ) of 2001, a document directed to Nursing education, does not define a list of competencies in collective health.This task was carried out by researchers (12)(13)(14) of the area to identify this gap.Thus, it is understood that for the actors responsible for the training, competencies that must and can be developed for the work of nurses in collective health, are not always clear.This hinders their alignment with pedagogical projects of the courses with the needs and goals of nursing training (15) .
The objectives of this study were to learn the concepts of coordinators and professors on collective health and to know the competencies necessary to work in the area.

METHOD
In this study, we present part of a bigger qualitative research of exploratory and descriptive approach about collective health teaching in nursing bachelor's degree courses in public universities in northern Brazil.In the first phase of the study, undergraduates in their final year of the course answered a Rev Bras Enferm.2015 sept-oct;68(5):548-54.questionnaire about their courses, especially on the developed competencies.In the second phase, course coordinators were interviewed along with professors about their Nursing syllabus proposals.In addition to these features, coordinators and professors had the opportunity to comment the answers given by students about nursing competencies in the area of collective health and also expressed their conceptions on it.
All nursing bachelor's degree courses offered by public universities in the capitals of the states Acre, Amapá, Amazonas, Pará, Rondônia and Roraima were included, totaling eight courses.We excluded nursing courses of the Tocantins state due to the absence of undergraduates.
Data were produced between January and May 2012 through interviews with eight coordinators and two professors of collective health, who voluntarily agreed to participate in the study by signing the Consent Form (CF).We used a semi-structured script with questions divided into four core topics: (a) syllabus, (b) professors, (c) teaching-service articulation (d) difficulties faced.During the interviews, we presented the answers from students on the questionnaire regarding collective health teaching in their courses, presented in graphics.Thus, the subjects were also able to discuss the perceptions of students.
The conceptions of the research subjects on the field of collective health and the identification of the competencies required to work in the area emerged spontaneously during interviews and build the object of this study.
The interviews were recorded in audio format and were fully transcribed for analysis.We used the content analysis technique, thematic modality, with floating reading for all the material (pre-analysis) followed by a deepen and exhaustive reading.We identified context units (CU), which resulted in recording units (RU) and, finally, the categories (16) .
This research received authorization to be developed by the Research Ethics Committee of the Universidade Federal de São Paulo, protocol No 873878.

RESULTS
In the thematic analysis of the interviews, we identified 55 CU containing 112 RU about the conceptions of the course coordinators and nursing professors about collective health and the competencies required for the work in this field.Specifically with regard to concepts, the first dimension of the study, we identified 69 RU from which six categories and five subcategories emerged, presented in the box below.
The course coordinators and professors of the field expressed different concepts of collective health.While some referred to collective health using the term public health and vice versa, leading to the understanding that the two are equal, or at least similar.Others made it clear that they are different.
The first category, Essential area of work for Nurse, emerged from the understanding of the coordinators and professors that collective health is a core area for nurses to work with, being essential part of their training.The change that the collective health brought to work in nursing, traditionally marked by the dependency of the nurse in relation to other professionals, is promoting the empowerment of the nursing staff.
The nurse has much more autonomy in collective health.So they end up having more security within that space of collective health.(N4) Collective health characteristics that differentiate it from other areas were identified, leading to the category Knowledge area with specialties, being one of its subcategories Stimulus to critical thinking.The subcategories Subjectivity and abstraction, Need for extensive reading and Very dense content present specificities identified as cause for difficulties of teaching in collective health courses due to the negative comments from some students.The subcategory Association with personal ideology is the identification of health professionals working in the area with the ideals of the Brazilian health reform, considering health as a social phenomenon.
Collective health is also highlighted by the subjects as a Study area of SUS, its history, policies and strategies, creating a third category for this dimension.In this context, the teaching of public health policies is closely linked to collective health teaching.

When you have to work with programs or even something in the hospital area, we'll always be talking about public health policies. (N4)
For participants of the research, collective health practice, aimed at individuals, families and communities, seeks to understand their problems and health problems for planning interventions.Thus, the fourth category of this study emerges: study area of population problems.

I think serving the community, being able to identify the problems, getting to do a community situational diagnosis [...]. (N1)
The fifth category emerged was Interdisciplinary, intersectoral and multidisciplinary field, which present the plural character of public health, identified by the interrelationship of the many areas that comprise it.The interdisciplinary character suggests a close relationship between areas and disciplines that make up the collective health.Thus, they do not only speak of an area formed by others, but an area composed of strong links between different areas of knowledge that interact with each other and produce new knowledge and transformative practices.
Box 1 -Categories that represent the concepts of coordinators and nursing professors of the Nursing courses in public universities in the Northern Region on population health Professors and course coordinators understand collective health as a Great scope area, sixth and final category of this dimension.Its scope is given both for health care levels as the practice scenarios and the multiplicity of actions.They claim that, as a theoretical and practical field, collective health is not restricted to blocked actions from the PHC.
[...] They think that collective health can only happen there [in primary care unit], but it happens here too in the hospital when you provide orientations, when you referer a patient.(N2) The second dimension of this study, competencies needed to work in the area of collective health, we identified 56 RU resulted in six categories and ten subcategories, presented in the box below.Thus, categories and subcategories represent the competencies identified by the participants.
Working for the SUS is an important competence in the field of collective health identified by course coordinators and professors.Specifically, they see as a necessity, Understanding and promoting public health policies in order to understand the proposal and the dynamics of the health system to guarantee the social rights.Managing health services is also a competence of the nurse to work in the SUS, for which should Working in an interdisciplinary, intersectoral and multidisciplinary perspective.Also in the context of the competence Working for the SUS, the subjects believe that contributing to FHS consolidation is a competence of nurses, understanding it as an important health care policy and main strategy of PHC reorganization.
A second competence identified by the subjects is understanding the health-disease process and its determinants.This competency is essential to work in collective health in any area or level of the health system.

Working with the health-disease process in the health of communities, populations, not only urban but rural and indigenous. (N5)
The competence developing actions for integrality of care was identified assuming that in the North, the nurse is trained to This competence requires the ability to meet the regional and local health demands, considering their differences and peculiarities.

[...] the nurse must have a cultural bias, because we're in an area in the Amazon region, which is a very big cultural mosaic. (E10)
The competence performing health education actions is materialized in the meeting with individuals, families and communities where there is exchange and mutual learning, understanding of the reality of the other and knowledge of responsibilities and rights to health.
Although recognized as undeveloped by nurses in the area of collective health, the subjects also identified the competency Developing research and systematize nursing care (SNC).They reported the importance of research for knowledge production and highlight the work of nursing area and they understand the SNC as a unique activity of the nurse who scientifically organizes their practice.The last competence, Developing specific skills, emerged from the understanding that working with collective health requires from the nurse: critical thinking , leadership, organizational capacity , continuing professional development skills, political involvement and social commitment.

DISCUSSION
The analysis of the concepts of professors and especially of nursing courses coordinators on collective health as well as the competencies identified for the work of nurses in this field, is important for the advancement of knowledge Box 2 -Categories that represent the competencies needed for the work of nurses in the area of population health, according to coordinators and nursing professors of the courses in public universities of the Northern Region on the training of future professionals to work in this area.A first aspect detected was some confusion regarding the terms collective health and public health: some consider them to be synonyms, others see them as similar, and for others, they are still different.This divergence is considered understandable since collective health has its origin in public health, preventive medicine and social medicine and thus keep aspects of these areas.Because it is a term coined in Brazil, it is commonly translated as public or collective health in foreign languages to suit the reality of other countries.
The emergence of collective health allowed the identification of points of convergence with the renewal and restructuring movements of public health by the emphasis it attaches to the historical dimension and the amounts invested in the discourses of normal, abnormal, pathological, life and death (17)(18) .
Collective health is concerned with public health while the health of the community, whether individuals, groups, social classes and populations (18) .On the other hand, the concept of collective health is a break with the conception of public health, by denying the monopoly that biological discourses hold in the health field understanding that health problems are more comprehensive and complex than the naturalist reading of the biomedical knowledge (17) .
Collective health comprises public health, epidemiology, preventive and social medicine, and keep interconnection relationships with other subareas (4) .In this sense, it can be seen as a wide field with gathering subfields, including public health, with a stronger sense such thematic and historical.
The growing importance of collective health for nursing work is supported by the coordinators and professors when considering the constituent area of professional practice in nursing.In it, the nurse finds a broad spectrum of activity that gives greater freedom in the use of space for transformation of local realities.The nurse proposes actions, establishes how their work should be constituted and maintains considerable autonomy in their practices (19) .
Because it results from the interrelationship between various disciplines, including the social sciences, collective health seeks to go beyond techniques and procedures.It is seen by the coordinators as an area that encourages critical thinking, being strongly linked to personal ideologies.On the other hand, the need for extensive reading in initial training or in continuing professional development is sometimes seen as a difficulty to the rapprochement and deepening in the area.This results in the return to a more technical work, focused on routines.Thus, it is necessary that teaching outweighs the biologicist paradigm and establishes interdisciplinary actions with psychology, social sciences and humanities (health and society, health and history) and the humanities (affective and cognitive psyche) for a reformation of not only instrumental education, but political-pedagogical projects (4) .
Policies and the Brazilian health system, as well as the health problems of communities, are emphasized as key study areas of collective health.However, it appears that many nurses are unaware of health policies and SUS as guiding principles of the health care actions for the population.
Knowing and understanding the principles of SUS, as well as the broader concept of health, are essential competencies for the production of changes in health according to the local reality, essential objective of nursing in collective health (20)(21) .
The collective health as an interdisciplinary and intersectoral field was also evidenced in this study.The interdisciplinary approach emerges from the criticism of the knowledge fragmentation that usually focus on the view of the disease at the expense of health as a process and expression of psychosocial, institutional and sociodinamics determinants (22) .It brings together knowledge and practices that not only overlap, but also interact and renew.Thus, creating a demand for teamwork built by professionals from different backgrounds, areas and levels of training, with different perspectives and formulations on health needs (4) .
Both for the conceptions of health, as for the competencies, the subjects emphasize the importance of understanding and working for the SUS, since its implementation has expanded the performance and the inclusion of health professionals in community and social field in a process of resignification of nurse work.The opportunities offered by FHS gave greater visibility to nursing, evidencing the professional role of nurses in the various locus of territory care (23) .
Nurses can contribute to the consolidation of the FHS principles, with repercussions for SUS, through training and organization of the nursing work in health services, power for teamwork and organization of services in BHU, from their diversity of actions developed in collective health and strategic spaces that they occupy in health policy (24) .
Inside the FHS, the nurse, a member of a multidisciplinary team, is responsible for a population inserted into an attached territory and develops care activities, management, education and research.In care, nurses' work include activities such as planning, consultation and nursing procedures, home and territorial visits developed in and out of BHU, to ensure integrality of care to individuals, families and communities.
Integrality is a principle of SUS and should guide all health practices aimed at individuals, families and communities, seeking to act on the determinants of health-disease process, ensuring that the activities of promotion, prevention and recovery of health are integrated in interdisciplinary visions which incorporate in practice the wide concept of health (12) .
In addition to the integrality of care, ensuring full user access to the health care system is necessary, that is, in the various levels of care.The means necessary to effective care, such as medical consultation, nursing consultation, tests, hospitalization, educational activities, treatment, among others, should be arranged according to the degree of complexity of the attention in order to implement the integrality of care (21) .
The SNC is a competence identified by the subjects of study as required in the collective health area.The reasoning nursing diagnosis, although recent, has transformed the practice by its scientific character and applicability in various areas of nursing work.The SNC is related to professional and user autonomy, and also to biological and social needs of the cared population (25) .
From the management's point of view, the nurse, besides being a leader, should contribute to the knowledge production, competencies development and implementation of innovations.FHS is also directly and indirectly responsible for various bureaucratic and managerial actions regarding the staff and BHU functioning.Not always such actions are planned as its functions and emerge as practice demands (7) .Conducting health education actions was also identified as an inherent competence of nurses in collective health being part of their work.In formally planned educational activities (educational groups, activities in schools and waiting rooms), in carrying out other activities (consultations, procedures and home visits) and even living with the population, health education should be a dialogue-based and participative practice that generates the transformation of the health reality of the subjects and assisted social groups.Thus, the educational practice is closely related to the principle of integrality recommended by SUS (12) .
As an educator, the nurse chooses didactic strategies that lead to the transformation of socially inserted individuals, increasing their ability to understand the complexity of the determinants of being healthy.
The continuous search for knowledge is an important trait and competence currently required for health professionals.It is understood that training does not end at the end of a bachelor's degree, but extends over the working life, when new knowledge and new competencies are required.Thus, it is important to have continuing professional development spaces in which professionals can discuss and deepen their knowledge in order to improve the care provided (26) .

FINAL CONSIDERATIONS
According to the conceptions of coordinators and bachelor's degree lectures in nursing of public universities of the Northern Region, public health is a key essential area of nursing professional training.An important field of action of nurses and has the SUS as the main area of study.
The recognition of SUS as a field of study and the collective health action reaffirms an already established relation between the area and the national health policy in terms of historical construction and way of thinking and doing health.
Multiple competencies are necessary to work as nurses in the area of collective health.Among them, coordinators and professors believe that working for the SUS is a competence that involves others, working in an interdisciplinary, intersectoral and multidisciplinary perspective, developing management actions and contributing to the FHS consolidation.It is also the responsibility of nurses to promote educational activities and actions to ensure the integrality of the human being in health care.
We highlight the important contribution of the collective health to the empowerment of nurses within the current Brazilian context and the world.Collective health appears as a new perspective of knowledge and practice: the theoretical possibilities are extended beyond the nursing centered on procedures and in the biological body; autonomy and teamwork resignify the practice and attributes of nurses such as social commitment and critical thinking are identified not only as characteristics of the human-citizen being, but also the human-professional nurse.
With regard to academic background and training, there is no doubt of its importance for the development of the professional nurse prepared for the work in collective health.We believe that further research should be undertaken with a view to improving training in nursing.Among them, investigations with actors such as course coordinators and professors and lectures of the area, it is important to look at them, for their conceptions and, consequently, their ways of teaching.

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...] they work with service organization, very strong in the area of collective health, and work with management of health services.(N7) [...] handling the family, society, the individual as a whole.(N6) If you are working with collective health, you are working in an interdisciplinary way, [...] with multidisciplinary teams.(N3)