Enhancing the process of teaching and learning homecare

Objective: to identify possibilities for improvement in the process of teaching and learning homecare in nursing, pharmacy, medicine, nutrition, dentistry and occupational therapy courses. Method: qualitative research using the Grounded Theory approach. Sixty-three semi-structured interviews were conducted with students, teachers and graduates of the six mentioned courses at a public university in the south of Brazil. Data analysis was performed through open, axial and selective coding. Results: the possibilities for improving the process of teaching and learning homecare included: scientifi c production in the area; use of different teaching techniques; development of extracurricular activities; extension projects; curricular reformulation; and laboratory simulation. Final considerations: the strategies cited in this study enable undergraduate courses in health to envisage the possibility of enhance the process of teaching and learning homecare. Descriptors: Homecare; Patient Care Team; Higher Education; Teaching; Professional Training. RESUMO Objetivo: apontar possibilidades de aprimoramento no processo de ensinar e aprender o cuidado domiciliar nos cursos de enfermagem, farmácia, medicina, nutrição, odontologia e terapia ocupacional. Método: pesquisa qualitativa, que utilizou a Teoria Fundamentada nos Dados como método. Foram realizadas 63 entrevistas semiestruturadas com discentes, docentes e egressos dos seis cursos mencionados de uma universidade pública do sul do país. A análise dos dados ocorreu por meio da codifi cação aberta, axial e seletiva. Resultados: destacam-se, entre as possibilidades de aprimoramento no processo de ensinar e aprender o cuidado domiciliar, a produção científi ca na área, utilização de diferentes técnicas de ensino, desenvolvimento de atividades extracurriculares, projetos de extensão, reformulação curricular e simulação em laboratório. Considerações fi nais: as estratégias citadas neste estudo permitem aos cursos de graduação em saúde vislumbrar a possibilidade de incorporar ou incrementar o processo de ensinar e aprender o CD. Descritores: Assistência Domiciliar; Equipe de Assistência ao Paciente; Educação Superior; Ensino; Formação Profi ssional. RESUMEN Objetivo: señalar posibilidades de mejorar en el proceso de enseñar y aprender el cuidado domiciliar en los cursos de enfermería, farmacia, medicina, nutrición, odontología y terapia ocupacional. Método: pesquisa cualitativa, que utilizó la Teoría Fundamentada en los Datos como método. Fueron realizadas 63 entrevistas semi estructuradas con discentes, docentes y egresos de los seis cursos mencionados de una universidad pública del sur del país. El análisis de los datos ocurrió por medio de la codifi cación abierta, axial y selectiva. Resultados: se destacan entre las posibilidades de mejorar en el proceso de enseñar y aprender el cuidado domiciliar, la producción científi ca en el área, utilización de diferentes técnicas de enseñanza, desarrollo de actividades extracurriculares, proyectos de extensión, reformulación curricular y, simulación en laboratorio. Consideraciones fi nales: las estrategias citadas en ese estudio permiten a los cursos de graduación en salud vislumbrar la posibilidad de incorporar o incrementar el proceso de enseñar y aprender el CD. Descriptores: Atención Domiciliaria de Salud; Grupo de Atención al Paciente; Educación Superior; Enseñanza; Capacitación Profesional. Enhancing the process of teaching and learning homecare Aprimorando o processo de ensinar e aprender o cuidado domiciliar Mejorar el proceso de enseñar y aprender el cuidado domiciliar Ana Paula Hermann E-mail: anaphermann@gmail.com CORRESPONDING AUTHOR


INTRODUCTION
The health area presents a fragmented educational panorama, since most of the curricula of the undergraduate courses are divided into basic and clinical cycles, with departmental organization of the disciplines, while care experiences are concentrated in the clinical cycle and in hospital environments culminating in low contextualization of learning (1) .
Educational training in this area requires co-responsibility between training institutions and health services, which impacts on the quality of vocational training (2) .Although higher education institutions are mobilizing to overcome the various barriers, they face many difficulties when dealing with policies in this area, which have limited results (1) .This highlights the structural, methodological, administrative, financial, and above all, human difficulties.
The hospital care advocated in the biologicist training has proved to be insufficient to meet the population's health demands, since each scenario, whether hospital, home, outpatient, among others, has specificities for practice and for learning; many of these are not transferable from one to another (1) .
The World Health Organization has for years emphasized the importance of homecare (HC) in response to the epidemiological, demographic and socioeconomic challenges facing the world (3) .In this sense, the Sistema Único de Saúde (SUS) [Unified Health System] envisions HC as: A health care system integrated to the Health Care Networks, characterized by a set of actions to prevent and treat diseases, rehabilitation, palliative care and health promotion, provided at home, thereby ensuring continuity of care (4) .
In recent years, HC initiatives have been implemented in various localities of the country, such as the Home Hospitalization System in the city of Londrina, Paraná, the Interdisciplinary Home Care Center of the Hospital de Clínicas, Faculty of Medicine of the University of São Paulo and the Home Care Program of the Hospitalar Conceição Group, in Rio Grande do Sul, among other home care programs that are seen as "a potential strategy to achieve continuity of care" (5) .
Added to this context was the launch of the "Melhor em Casa" [Better at Home] program on November 8, 2011 (6) , which reinforces the fact that HC will be increasingly present in Brazilian municipalities,counting on nurses and doctors in its multi-professional HC teamsand multi-professional support teams, including: pharmacists, nutritionists, dental surgeons and occupational therapists (4) .Thus, the performance of a variety of professionals in the households will be increasingly demanded, a fact that requires specific training.
Regarding the specific abilities forHC practice, it is observed that, in the National Curricular Guidelines of nursing, pharmacy, medicine, nutrition, dentistry and occupational therapy courses, there is no specific mention of training in this area; however, skills are mentioned that indicate training should be targeted to the population'shealth needs.
In addition to these curricular guidelines, the class councils themselves recognize the existence of professional practice at home and the need to create respective norms.Thus, in recent years, they have created several resolutions that govern HC practices.The Federal Nursing Council (7) is cited, which in 2001, approved nursing activities of lower, medium and high complexity at home; The Federal Council of Pharmacy (8) , which in 2002 ruled on the duties of the pharmacist in the field of home care; The Federal Council of Medicine (9) , 2003, laid down technical norms necessary for HC of patients; The Federal Nutrition Council (10) , 2005, decided on the definition of areas of activity for nutritionists and their attributions, including HC; The Federal Council of Dentistry (11) , 2002, established the areas of expertise for dental specialists, indicating that patients with special needs can be cared for at the domiciliary level; and the Federal Council of Occupational Therapy (12) , 2012, established Occupational Therapeutic Care Parameters in various modalities, including HC.
Although interdisciplinary work at home is required, health professionals have an incipient formation for HC, since not all courses and higher education institutions (HEI) include this type of care in their teaching plans (13) .
Thus, the objective of this study is to identify possibilities for improvement in the teaching and learning process of HC in nursing, pharmacy, medicine, nutrition, dentistry and occupational therapy courses, with reference to the interpretation of the potentialities gained for HC training in these courses.

METHOD Ethical aspects
The research was approved by the Research Ethics Committee of the higher education institution in which the research was developed, complying with the national and international norms of ethics in research involving human beings.

Theoretical-methodological reference and type of study
Qualitative research was carried out using the Data-Based Theory approach."Grounded theories, because they are databased, tend to offer better insight, improve understanding, and provide an important guide to action" (14) .The construction of theories is relevant because it enables the development of the field of knowledge, and not merely a set of results (14) .This article originated from the thesis entitled "The experience in teaching and learning home care in undergraduate courses in health", which has the following objectives: to interpret how teaching and learning HC is experienced by students, teachers and graduates of courses in nursing, pharmacy, medicine, nutrition, dentistry and occupational therapy at a public university in the south of the country; Construct a substantive theory that explains the experience in teaching and learning HC in these courses; and propose strategies that strengthen the incorporation of contents and practices of HC in these courses.Thus, the present article explores the findings from the latter objective of the thesis.

Study scenario
The study was developed in a public HEI in the south of the country.The initial contact with the participants took place via telephone, e-mail or at the HEI itself, and the interview was held Enhancing the process of teaching and learning homecare Hermann AP, et al.
in a place chosen by the participant (residence, place of work or at the university).

Data source
In Grounded Theory, theoretical sampling is developed during the data collection and analysis process, based on the concepts that arise and are significant for evolutionary theory (13) .In this research, the theoretical sample consisted of 63 participants, divided into three sample groups:the first sample group consisted of 37 seniors from the nursing, pharmacy, medicine, nutrition, dentistry and occupational therapy courses; the second sample group was composed of 16 teachers who teach content related to HC in these courses; and the third sample group was composed of 10 graduates of the six mentioned courses that work professionally in HC.

Data collection and organization
Data were collected through a semi-structured interview held at a place chosen by each participant, from January 2010 to December 2013.A script of initial questions was elaborated for the first sample group, which was reformulated for each new subject interviewed.The questions addressedthe process of teaching and learning HC, highlighting their personal experiences in this area during graduation.The sequence of questions and the insertion of new questions were based on data analysis, which ensured that the data collected at the end of the research confirmed the initial data.

Data analysis
Data analysis was performed using open, axial and selective coding, as recommended by the authors of the method (14) .In open coding, the data were rigorously examined and compared for similarities or differences.In axial coding, the data were regrouped and related to their subcategories.The last stage consisted of selective coding, the stage in which the process of integration and refinement of theory occurred, with the emergence of the central category.

RESULTS
The collection and concomitant analysis of the data allowed us to indicate possibilities for improvement in the process of teaching and learning HC in the six courses studied, configuring this to be an opportunity for singular and differentiated homecare practice.
The initial part of the data refers to the individualities of each course, sincewith the different methods of teaching and practicing HC; it is not possible to make generalizations that could affect the veracity of the information.
The nursing course is at the forefront of scientific productions related to HC.There are various books, book chapters, scientific articles, monographs, dissertations and published theses, which are the subject of regular discussions in the research group: The way the teacher sensitizes the subject is important as well, because there are students who have no tact to deal with the people, to deal with the environment, to deal with the context, not to be sensitized with that, and this is important, I think important, I'm sensitized and I think it ' The pharmacy course uses various teaching techniques, such as the role playing game, in which students simulate that one is the patient and the other is the pharmacist.The student, who represents the patient, can bring real-life information about the drug therapy of relatives or people he or she knows, and the student, who represents the pharmacist, will have to provide pharmaceutical assistance focusing on the actions to be carried out by the patient at home.The teacher will, at the end, make a critical analysis of the situation presented by the students.The medical course, during the internship period, allow the academic to choose which activities to develop.These include a course in family health, in other HEIs address issues related to HC with theoretical discussions and development of the practice through home visits.The nutrition course has different extension projects that involve issues related to home enteral nutritional therapy as well as personal diet activities.Although the actions of dietary personnel are directed to a more select public, it is an opportunity for entering the home.The dentistry course was undergoing a curricular reformulation during the period of this research.In this reformulation, it was planned to expand the collective health discipline for four periods during the graduation -first, second, fifth and eighth periods -increasing the number of home visits, which are an opportunity for students to approach HC.
Home care or home visit is something new in dentistry; in addition, we are looking for a theoretical basis in the nursing literature.(Dentistry Course Participant) The occupational therapy course has a laboratory with adapted kitchen and bathroom, which simulates the reality of Enhancing the process of teaching and learning homecare Hermann AP, et al.
the domicile.In this laboratory, academics can develop practical HC classes, by simulating situations that can be found when they are in a patient's home.
We have an adapted kitchen, bathroom adapted, so that [.

..] we can really train in the face of different disabilities or clinical situations. (Occupational Therapy Course Participant)
Besides the possibilities of strengthening the process of teaching and learning HC mentioned in each course, other actions pointed out by the participants of this research, mentioned generically for all the courses will be presented.Among them, emphasis is given to the necessary expansion of opportunities to practice in homes.
Thus, the workload for internships and/or practical classes in this modality should be amplified so that students can return to the homesin order to follow the evolution of the case and establish bonds with patients, relatives and caregivers.It is emphasized that the caregiver and the family are essential in HC, but it is only possible to make the maximum use of these individuals if there is coexistence and partnerships between them and the students.
I think I would need more practice [...] would be more productive, if I had a little more knowledge, the discussion would be better, so I think there should be more.(Nursing Course Participant) Strengthening partnerships with teams from the Home Care Service, primary care units and private homecare companies allows new fields of study, with different geographic, economic and social realities.At home, the ideal is not that each professional acts in isolation, but in an integrated way, with case discussions and a joint action, thinking about the totality of patients, relatives and caregivers.Thus, the realization of a HC stage allows academics to experience multidisciplinary teams, which must develop an interdisciplinary action, aiming at transdisciplinarity.

I think it would be more interesting to visualize the integrated areas. Dentistry sees the work of nursing or medicine, all working together. (Dentistry Course Participant)
In order for this transdisciplinary view of HC to be expanded, it is necessary to have professors who are experts in the field, since they can awaken students to the perception of singularities present in HC and the need for transdisciplinary action.

I realize that it could be improved [the teaching of home care] with the hiring or availability of teachers with experience in the area of family health.(Medical Course Participant)
It was also pointed out by the participants that there is a need to promote discussions aimed at improving the regulation, implementation and execution of HC in public and private initiatives, as well as discussions to adjust the curricula of the courses, which would allow advances in professional training for HC.
[...] we meet weekly, they are exhaustive meetings, we discuss discipline by discipline, period by period, and negotiating workload ... we will be able to contemplate the issue of home care.(Nutrition Course Participant) The improvement proposals mentioned aim to contribute to the process of teaching and learning HC, thereby allowing future professionals of the six courses studied a training capable of preparing them to work in the homes more safely, while focusing on the singularities of each patient, family and caregiver.

DISCUSSION
Changes in the training of health professionals have been discussed worldwide since the 1970s.In Brazil, this discussion gained prominence in 1996, with the Law on Guidelines and Bases of National Education, continuing in 2000 with the National Curricular Guidelines (15) .The reorganization of training for health professionals faces many challenges and obstacles to its consolidation (16) ; However, this process of modifying the training of health professionals is essential for the consolidation of SUS (1) .
Thus, expanding the teaching scenarios for the training of professionals is a necessity for the concretization of changes (16) , emphasizing, in this sense, the importance of HC teaching in undergraduate courses in health, since there is a growing demand for this care in the Brazilian population.
Supervised internship in domiciles is important for the generalist education that is expected of the health professional at the present time, with multi-professional (17) and inter-sectorial homecare as a means of coping with the current demographic and epidemiological profile of the Brazilian population (1) .
The inter-sectoral configuration of HC requires professionals are trained from an interdisciplinary perspective, who perceive the "importance of acting on multiple fronts and fields of knowledge".Community education is one of these fronts because it provides diverse opportunities for acquiring knowledge and developing attitudes and skills (16) with a combination of different teaching strategies.
Among these strategies, this study found that simulation is used for teaching HC.There are many benefits of using simulation as a teaching strategy, namely: allowing the academic combination of technical skills with the expressive dimension of care; stimulating reflection on clinical practice; and by presenting situations that may be difficult to find at the internship institutions.Such benefits lead to the rapid absorption into curricula of the use of simulation in preparing students for practice as a way of complementing their experiences during internship (18)(19) .
In order for the simulation to materialize into a valuable teaching strategy, quality indicators are needed:for alignment of the simulation to the curricular objectives; use of technologies and approaches that take into account the fidelity Enhancing the process of teaching and learning homecare Hermann AP, et al.
of the environment reproduced; preparation and orientation of students for this type of activity, such as familiarization with mannequins and equipment; training of the facilitators who will accompany the simulation; technological capabilities, such as the use of mannequins; and discussion groups, which should take place immediately after the simulation to facilitate reflection on practice, self-assessment and feedback from experience (18) .
The combination of strategies is also stimulated, such as the combination of simulation and role-playing (19) .The use of different methodological strategies can help to overcome the fragmentation and the compartmentalization of knowledge, which, hashistorically been divided into disciplines and as such represents a challenge for HEIs (20) .
Although simulations are extremelyenriching, HC should be a field of study offered to students, even if for a short period, to allow them to confirm if they really would like to work in this area.Students who undergo domiciliary care practice consider the experience beneficial (21) .In addition, a home offers the opportunity to work with all stages of the life cycle (child health, women's health, mental health, family health, among others) as such it is a field for all areas of health care.
Developing extension HC projects is a differential in undergraduate courses, for inserting the academics into the reality found in homes and allowing the creation of bonds with patients, relatives and caregivers, since one of the characteristics of these projects is that they are inserted in the community, working with real-life situations, thus stimulating the student to specialize in the area in which the project was developed.In this sense, the broadening of activities carried out in HC, as developed by Pet-Saúde, now denominated GraduaSUS, will also bring the students closer to the reality found in home environments.
It should be underscored that there are extension projects that aim to introduce students from various undergraduate courses in health, to an integrated and interdisciplinary methodology, in the provision of HC for health promotion, rehabilitation, injuries and disease prevention (22) .
With the development of HC extension projects, students have an innovative teaching environment and are able to "see in practice what literature describes, sometimes in a distant manner", thus intervening and generating changes in home care (22) .
In addition to theoretical knowledge and clinical skills, it is necessary to be familiar with several types of technology, since many HC companies have adopted telehomecare systems to monitor and manage the patients within their homes; this being an opportunity for the management of chronic diseases.Thus, there are possibilities for growth of telehomecare and other innovations, and it is necessary to be prepared for this (23) .In Brazil, there is Telessaúde [Telehealth], which offers teleconsulting, telediagnostics, tele-education and a second professional opinion for professionals and workers in Health Care Networks in the SUS, who can contribute to the professional's in-home practice (24) .
The need to continue the construction of the HC knowledge framework via participation in the various courses in the health area is highlighted, because although many aspects are found in common, each course has its characteristics and provides a look at the actions that are carried in homes.This construction will be facilitated by strengthening research groups working with HC and the expansion of projects in postgraduate courses and scientific initiation in HC.
In addition to allowing the student to participate in extracurricular activities, it is fundamental to develop such opportunities, such as the creation of courses or disciplines on HC that are open to students from other HEIs.
Curricular reformulations are necessary to begin the reconstruction of those curricula disconnected from the reality of life.At the time of implementing these reformulations, it is necessary to consider that HC is a reality present in the health system and an area of activity for each of the six professions studied.Thus, its content should be an integral part of the course timetables and preferably considered as a specific discipline, or at the least a specific subject within another discipline and allocated an appropriate period of course time.
In addition to the aforementioned possibilities for improvement, HEIs should consider the unique learning needs of each student, the appropriate teaching staff development, and the incorporation of best educational practices (25) .

Limitations of the study
The limitations of this research are related to the impossibility of generalization from certain data, which are specific to each course, which in turn generated different ways of presenting the research findings.The potentialities of each course are possibilities to improve the process of teaching and learning HC and should be explained so that other courses perceive a variety ofmeans to improve this process, since it was not possible to make generalizations.

Contributions to the area of nursing, health or public policy
The demand for HC is growing in the Brazilian health system, which requires adequately qualified professionals.Thus, the contributions of this research to the professional practice in health derive from the expanded view on the peculiarities of HC, enabling future professionals to understand their multidimensionality.The findings of this research contribute to HEIs through various suggestions for the incorporation or increment of HC teaching in undergraduate health courses.

FINAL CONSIDERATIONS
The home is a potential scenario for building knowledge in the health area, which deserves to be valorized during the training of professionals.However, the training process in this area has not been able to keep up with the same speed of progress in this modality of health care; this research showed that the training of health professionals working in HC needs to be strengthened.Graduation in the health area should allow students to explore the home care environment with work experience and multi-professional discussions, considering the diversity of homes and realities.
Enhancing the process of teaching and learning homecare Hermann AP, et al.
Thus, the strategies cited in this study allow undergraduate courses in health to envisage the possibility of incorporating or increasing the process of teaching and learning HC; however, there is no pretension that such strategies are incorporated in their amplitude, such that the proposals outlined here offer possibilities for new discoveries in this process.
During the last two years of the course, we have the possibility of taking courses in other institution, so I chose to do [...] a training with family physicians, within a specialization of health family [...] there I had guidance of what to do during a home visit, how you deal with the medications, what you have to organize, what you have to take to the visit.(Medical Course Participant) There is the Personal Diet project [...] where you go to a home to visit [...] the person's refrigerator, give tips.(NutritionCourse Participant) [...] they are inserted as trainees within the health unit [...] still do not have it [...] there is a plan, but it depends on partnerships, which are fundamental.(PharmacyCourse Participant) s super important that you see what's wrong [...] you come out with a vision of home care, I think it's a shame that not all courses have [specific course time for home care].(Nursing Course Participant) We used a technique called role playing [...] one of the students pretends to be a patient in a particular case and we try to attend the patient immediately, [...] with the book in hand there to look at if you need to, you try to talk to him, pass all the information, and then the teacher gives feedback, follows along and gives feedback to see what could have been said, if we forgot to say something.(Pharmacy Course Participant)