Teaching-service integration : building the educational workshop in healthcare

OBJECTIVE
To identify the pedagogical strategies and the elements that determine the construction of the educational workshop in healthcare at the teaching-service integration process.


METHOD
Collective case study with qualitative approach. The cases consisted of two undergraduate courses in nursing. Thirty-one interviews were conducted with healthcare professionals, professors and students, in addition to participant observation in seven basic health units (UBS) that received the students interviewed.


RESULTS
The following analytical categories emerged: teaching-service integration: articulating idealized situations with real situations; pedagogical workshop in health: development of collective pedagogical actions; reflection on the experiences in the pedagogical workshop in health: articulating the knowledge of the work world with the teaching world.


FINAL CONSIDERATION
Despite the integration difficulties between teaching and service, we can conclude that their encounter generates a fertile field for the development of the educational workshop in healthcare. To this end, the agreement of the strategies presented in the constitution of the workshop is necessary.


INTRODUCTION
Actions committed to the social relevance of the university and the training of Brazilian health and nursing professionals have sought, for at least 50 years, to approximate teaching and service, aiming at articulating the training spaces with the diversification of the scenarios of the real life and of production of health care (1) .
An important milestone in changing the professional profile started with university and health reforms, which demand a health professional that acts in different fields of practice, more qualified and open to changes for accommodating the populations' real needs.Thus, one can perceive that universities tend to articulate with healthcare services to provide better professional training (2) .
At the same time, contradictorily, higher education institutions around the world are increasingly emphasizing the acquisition of a broader range of skills or attributes in the curriculum, aimed at raising the chances of the student's school success, in particular, to the labor market (3) , often referring to a specialized and hospitalcentered education.
In addition to teaching and service integration, studies highlight the importance of using student-centered pedagogies evidenced in the scientific literature as positive for the learning-teaching process (4) .There is the recognition that pedagogical practices assist in the consolidation of critical and reflective students, influencing the determination of the awareness degree of the world and in their ability to promote the necessary changes (5) in the reality they act on.
The teaching-service integration can provide critical, creative and reflective thinking because it deals with a deep interaction between its protagonists and reality of health services.To this end, one must use pedagogical strategies and an effective approach with healthcare services, aiming at promoting such integration.However, the teaching-service integration can also be a limited pedagogical strategy, both for teaching and for service.It cannot occur without a reciprocity between both, in a lonely practice of teaching in the service, without a dialogical relationship that promotes reflection on the experiences among its protagonists (professors, students, health professionals, public administrators, community, among others).
The encounter and the reciprocity between teaching and service stimulate the reflection on the problems of practice, the debate about the experiences, the reflective dialogue and a mutual growth, named educational workshop in healthcare.
The educational workshop in healthcare is a space intended for the entwinement of the service with the teaching, of the practice with the theory, from the learning immersed in a constant process of reflection on the actions developed.This entwinement is permeated by the reflective dialogue, by the sharing of related goals and by the re-signified knowledge in the development of the actions on health.It is a fertile space for the learning and the training of health professionals, in which the sharing of knowledge and the building of new knowledge are merged with the curiosity of the protagonists of this process.
For the teaching-service integration, in the proposition of the pedagogical workshop, to become a practice of consolidation and construction of new knowledge, forming professionals capable of acting in the reality, it is assumed that pedagogical strategies anchored in the epistemology of reflective practice are necessary.This practice is considered a highly interpersonal experience, in which the dilemmas of learning, the vulnerability of students, the behavior of professors and students critically influence the results of the pedagogical process (6) .
In the epistemology of the reflective practice, the reflective teaching has three levels of activity: 1) the reflection in action is performed during its development, rethinking strategies for solving a certain problem; 2) the reflection on the action constitutes a retrospective moment to reflect on what was done; and 3) the reflection on the reflection-in-action consists of the observation of the answers given to the activities (6) .
The epistemology of the reflective practice (6) in the teachingservice integration requires strategies that encourage students to use the diversity of scenarios of health services as a moment of consolidation of their technical and theoretical knowledge, a space of construction, in group, of the new, the critical, the reflective.Thus, appropriate solutions are sought to the needs of the existing health and education.In this context, the relevance of pedagogical strategies for the training of nursing professionals capable of acting in a critical and reflective manner in the context of the Brazilian Unified Health System (SUS) strengthens the purpose of the teaching-service integration.

OBJECTIVE
To know the pedagogical strategies and the elements that determine the construction of the educational workshop in healthcare at the teaching-service integration process.

Ethical aspects
This research was approved by the Research Ethics Committee with Human Beings (CEPSH), considering the provisions of Resolution CNS no.466, of December 12, 2012.All participants signed the informed consent form (ICF).To ensure the anonymity of the cases throughout the text, participants were identified as Case A (CA) and Case B (CB).For professors, the letter P was assigned followed by a cardinal number (1,2).The same was held for health professionals (HP) and students (S).

Study type
This is a qualitative research using the collective case study method.It consists in studying several cases to better analyze, comprehend and theorize the universe they belong to.The cases are studied and compared individually to express common features from the understanding that all knowledge brings a comprehension, a theorization about a larger set of representative cases (7) .

Study scenario
The cases in this study were two public undergraduate courses in nursing in southern Brazil, contemplated with the Reorientation National Program in Health Professional Formation (Pró-Saúde), notices 2005 and 2007.The choice of courses that participate in the Pró-Saúde occurred because of its essence: integration between the world of education and of work as a strategy of change of the process of training and work in health (8) .
It is understood that the participating schools reformulated or perfected their curricular practices according to the axes of the program, focusing the teaching-learning process on the reality of services and community, establishing competences based on the care comprehension and on liberator pedagogical practices that stimulate the development of the reflective professional from the teaching-service integration process.
For the case selection, the following criteria were adopted: schools contemplated with the notice no. 1 of the Pró-Saúde, thus having proper time to accomplish the changes proposed by the program in their curricula; older nursing schools of each State; municipal schools and health departments that have agreed to participate in the research.

Data collection
Data were collected between October and December 2015.Participant observation and the interview, which used a semistructured schedule, were conducted at the same time.The observations were held in seven basic health units (UBS) during the development of the supervised internship in the last year of selected cases.The UBS were set together with the course coordinators of the cases studied, as well as the indication of the protagonists to be interviewed.The observations were recorded in field diaries.
Thirty-one protagonists were interviewed and divided into professors working in higher education for more than four years (9), students in the last year of the nursing course (12), and health professionals who received students in service (10).The choice of professors working in higher education for more than four years is related to their participation or follow-up in the Pró-Saúde program of the case studied.The choice of students in the last year of the nursing course occurred because they had a wider look over the training process and could better detail it.
The interviews were recorded and transcribed in full.All students and health professionals interviewed were observed.

Data analysis and theoretical framework
The analysis of a case study occurs concomitantly to data collection, being guided by data encoding processes to signal concepts that allowed responding to the objective of the research (7) .
Results were organized into three analytical categories that complement each other.The categories were analyzed from the epistemology of the reflective practice proposed by Schön (6) .

Teaching-service integration: articulating idealized situations with real situations
The insertion in service is considered, by the participants, as crucial for students to know the reality of their profession and the challenges that will be experienced in their everyday life, based on a problematized pedagogy.To that is added the possibility of adopting guidelines that are plausible to be carried out in accordance with the reality of SUS users.However, there is a clash between the ideal and the real.

The student has to be inserted into what is real. In the unit that has no material, that has a lacking region or not, that has no community agent […] one would not be able to visualize a nursing professional without this insertion in the field of practice. (P3CA)
We use the case of the patient to learn, not always the service is as in theory.Then, many cases could not be seen in practice.(S1CA) The observation notes of students' practical activities showed there is a timid process of teaching-service integration, permeated by the absence of dialogue between the protagonists and by the actions in health aimed primarily at the development of technical skills.
The planning of the activities that articulate the service and the teaching is conducted differently between both cases.In CA, the participants reported that the activities for the next semester will be planned based on the evaluation of the semester executed.Professors and students assess the frailties and the strengths.Service professionals report that they receive the invitation to participate in meetings that are held within the university.However, public administrators often do not discharge them or the meetings are scheduled in the period that the UBS is in operation.
Another factor that may hinder the planning of these activities, according to the interviews with professors, may be related to the density of contents to be developed in a short period.Despite this, during the development of the internship, feedbacks on the student's development are given and the need of working with some service problems on the part of the service professionals, especially the internship supervisor in the field, arises.

We chat a little with the nurses about the progress of the internship and what needs to change. Problems and priorities are indicated by the professionals and from this indication is that the students develop themselves [Situational Strategic Planning]. (P1CA)
In CB, the planning of activities seems to be more consolidated, harmonious and shared.By requirement of the Municipal Health Department, coordinator of the nursing course first needs to go to the UBS and require the authorization of the coordinator of the unit for conducting the activities, regardless of this partnership between teaching and UBS that lasts over ten years.
When they were reorganizing the curriculum, we sat down and wrote together.At the beginning of the school year, we sit down with the professors and discuss what are the goals, the objectives, the proposals, how they should be approached when the student comes.(HP4CB) We emphasize that, in both cases, the supervisor professor evaluates the internships very closely to the periodic visits, as observed.However, there was the need of intensifying the dialogue with the team, not being restricted to contact between the professor and the coordinator at the UBS.The articulation between the teaching and the service is a fertile field for the planning of the final course assignment.In CA, the planning is focused on the concretization of a healthcare practice project.Students observe, record and, from it, expose their questions based on the reality to apply them in the next semester.The final course assignment will be the need presented by the service and the community.The CB uses the healthcare practice and the research to develop the work.It may be focused on a direct need of the service or a necessity of the academy in developing certain research.

Educational workshop in healthcare: development of collective pedagogical actions
The concretization of the teaching-service integration, in both cases, begins with a more observational phase, debating on the health-disease process and focusing on interdisciplinary actions, especially among the courses of the university itself.During the undergraduate course, students will expand their theoretical knowledge in accordance with each cycle of life, culminating in the supervised internship and, with that, their performance on the service.
In the first year, the student is quite immature, depends on a closer follow-up, having little to contribute to the service.The service contributes more with these students.In the supervised internship, they will systematize and consolidate the learning.At this time, they contribute a lot more to the service.(P2CB)

The modules integrate only in the last year, because, until then, everything is compartmentalized: adult's health, child's health, woman's health, mental health. There [supervised internship],
we should join what we study and apply it in practice.(S2CB) In the supervised internship, the student perceives the need of bonding with the team, highlighting the figure of the professor as a reference.As well as feels the need of acting as a professional inserted in the space.

It is us with the team and we have to handle it so all that bond that our professor has during the internships is what we have to build during the [supervised internship], it is an objective […] to create this bond and work on equal terms. (S3CB)
The integration between theory and practice is strengthened in the development of the internship from the theoretical framework of students' actions and perceptions, using numerous strategies, as the use of portfolio and lectures once a week, besides the encouragement to the concretization of case reports.
The portfolio in CB is a pedagogical strategy that encourages the reflection from the practice, which can be expanded or more punctual, according to the guidelines received from professors.However, as noted during data collection, despite the stimulus to the portfolio concretization, the service professionals have no access to the document.It is a moment of the student and of the professor, opposed to the situational strategic planning (PES), which is built and shared with the team of healthcare professionals.
In the CA, field diaries are used, which are considered a crucial element for the development of PES that also aims the narrowing of the relationship between the nursing course and service.

The idea that the building should be with the team […] we stimulate the dialogue with the team […] to recognize the place, the territory, see what this territory has e think especially with the team. (P1CA)
What is reinforced according to observation record: Student presents the PES for the team, who agreed with the notes, giving suggestions on how they could solve the problems raised.The presentation took place during a team meeting.They also suggest that some problems are written, because they are punctual and cannot be generalized to the entire team.Students agree with the suggestion.(Observation data CA) An one-week period is recommended for conducting the lectures, exploring the activities developed and working the contents that assist students in expanding their look on what they experience in practice.The CA holds four theoretical encounters throughout the semester to discuss the PES steps.Students and professors of the last year of the course participate in the meetings.

We then come to the basic unit without having any theory, then we get to know, try to understand how the job is, the organization, and then we start having lectures […]. In class, we see that it is really not what they are doing, we can cross the data, see that the reciprocity here is totally different from what is stated in theory and it adds a lot, because the search for understanding it later starts from us, I think that the entire undergraduate course is like this. (S3CB)
Students can compare what they observed in practice with the theory, seeking strategies that actually contribute with the reality and mentioning the permanent education in health.The students, in both cases, assume a dialogic stance in order to solve the problems that arise during the internship along with health professionals.
It is not enough for us to sit back and harp on the same string, "yeah, I think that this and that have to be done" [...] so, it has to start from us, nurses that will graduate, make the difference Teaching-service integration: building the educational workshop in healthcare Khalaf DK, Reibnitz KS, Lima MM, Correa AB, Martini JG.
and try not a continuing education, but rather a permanent education.(S3CB) Student admits a pregnant woman who is in a lot of pain, referring the case to the health team.Together, they discuss the case, raise hypotheses and agree with the referrals.(Observation data CB) Reflection on the experience in the educational workshop in healthcare: articulating knowledge of the work world with the education world The reflection made with the service is considered timid due to the demand on services or a dense schedule, with little time for the activity to be carried out, being more strongly developed in the supervised internship.
The integrated understanding of action and reflection as a mean to achieve the profile of student that aims at graduating is highlighted.
The student must know why he chose to do that technique and not the other.You do not split [action and reflection], the process is joint.We do not want only a good task executor, but rather a professional that knows why he is performing that task.(P1CA)

Sometimes, in the first week, they say: "I conducted two prenatal appointments, went home visiting", then we say what we do not care how many procedures you made, but how you made it, what was the situation, how you managed to solve the problem. (P2CB)
During the internships, a few moments of reflections with the team about the experienced in act were observed by the researcher.However, in one of the UBS, the students were extremely encouraged to think about what they were doing, to articulate the making as theoretical knowledge, based on conversations incited by the healthcare team, especially by the supervisor nurse.In another UBS, the students were integrated to the routine of the team with reflections conducted with the professor/internship supervisor.Punctually, the nurse entered the room, questioned, but, in general, it was a moment of the professor and the students.As well as it was observed in an UBS in which the student was completely lost, wanting to integrate with the team; however, without finding spaced to debate, to be included.
The observations showed the spaces for reflection depend on how health professionals assume or withdraw from the responsibility with the students' training process, as well as how the professor conducts the internship and stimulates the integration with the team.In the observations, in any moment the students were distant from their responsibilities, not wanting to integrate with the team or with the conduction of an activity.

There is an agenda to fulfill, one must do this and that but, after we stop […], we [reference to the UBS nurse, academics and nurses in residency] exchange a lot of information about patients, then we can understand […], we discuss the case, go talk to the UBS coordinator to be able to make a decision, […] we keep searching, exchanging a lot of information. (S3CB)
From a different perspective, professionals and professors report the work demand in which they recognize the importance of stopping and reflecting, but with no adequate time for such action.
There lacks the time for these girls to make a reflection because, in several times, a very large demand arrives since, in our case here, we are in the periphery, where the prenatal number is very large, preventive numbers have to be collected […] then, we see that there is no time.(HP2CB) When questioned about the existing relationship between the knowledge of the world of work and of the world of education, all participants stood a few seconds in silence and, then, asked aloud "what is the existing relationship?".Most interviewees could not respond, in a clear and objective manner, to the question, which does not mean that they do not know the existing relationship, but it is presupposed that there is need for time to answer this question, time to reflect what relationship, what articulation this is.
Some participants attributed the execution of technical procedures with higher dexterity and skill to the relationship between theory and practice, evaluating signs and symptoms in a safer manner.For others, the relationship consists of bringing the theory for the reality, for the experience of the team and community, of an associated, dialogic, questioning practice with the student in the practice scenario.
The university, it does not promote only the theory, it promotes the associated practice, when we make the student stop to reflect, search the knowledge before the reality of a fact.(PS1CB)

DISCUSSION
Results point that schools concern about integrating the theoretical knowledge approached in the classroom with the everyday practice of services.However, this integration results in the confrontation between the idealized and the real at times as pointed in the line of the student that cannot visualize the case that she studies in theory and its application in the practice of service.
The confrontation between real and ideal can have as origin the way it faces a problem.It can be ruled by a rigorous practice, based on the technical rationality or it can have the consciousness that we are walking in undetermined, swampy zones, that are beyond the guidebooks about certain knowledge in which the problem, many times, not even appears as a problem (6) .
To overcome the challenge of integrating the real world with the ideal one, we must integrate teaching-service as the basis of the curriculum design, at the same time in which healthcare services need to recommend the inclusion of the permanent education process in every level of health care in the organization of their work, building an unique field, in which the limits of the teaching and providing care become imperceptible (9) .
The insertion in reality can facilitate the students' teachinglearning process because it puts them in a swampy zone in which the demand for service in health is real, the people are real and, many times, their problems do not even appear clearly as a problem.It collaborates for the students to become critical and reflective, concretizing the theory in the practice and, when bringing their experiences, it extends their horizons of possibilities in the search for knowledge (10) .
The results presented evoke the reflection on the role of the educator of the nursing assistant.In the perception of participants from this and other study (11) , some nurses that receive students of supervised curricular internship, sometimes, do not play the role of educator.That is, the nurse, along with the professor, should be following up the student's development, integrating himself to the technical and theoretical support, as well as in a constant process of reflection about the experienced in service, participating of the evaluation and of the sharing of knowledge.This is the educator nurse assuming his/her commitment with the training of new professionals.
In the integration between teaching and service, there are ups and downs among their protagonists that not rarely not even talk with each other.However, to form professionals committed with the SUS, one must claim responsibility with the training and with the care provided to the population.For changes to happen, the protagonists must interact and contribute for both growths (12) .
The conduction of the situational strategic planning is used as a pedagogical practice to identify and intervene in the population problemas and approximate teaching and service.However, its conduction is a challenge, given that its implementation requires dialogue and openness of all protagonists involved (13) .
The dialogue in the process of planning and evaluation of the activities developed in the integration between teaching-service is one of the crucial strategies to widen and, in some UBS, even create spaces of reflection on the actions performed.It is highlighted that the reflective dialogue is focused on the reflection about the practice and, through it, one seeks to contribute to the decision-making, the comprehension of the reality and the sharing of experiences and knowledge (14) .In this perspective, teaching and service can revise the work process, the teaching process and how they can be enhanced, with no overload for both, making the purpose of internships clear for the team and how bond that strengthen the teaching-service integration can be created.
For such, one also needs to be distanced from the knowledge in action, which is a tacit process that works really well, providing positive results as long as everything is within a normality parameter (6) .Thus, we must revise the dense curricular structures because they limit the time necessary for students to experience, create, learn and make from their own knowledge and re-significations with the scientific theory under the cautious and questioning look of the facilitator, field supervisor and healthcare team.
The professor's periodic supervision in field can be considered a pedagogical strategy that strengthens the teaching-service integration, without having the feedback on the students' actions as the only purpose, but rather, in the contextualization of the practice, the debate on the experiences and a horizontal dialogue.The dialogue, the debate on the experienced, represents an essential strategy for the flow of the reflection on the crucial aspects of health care (15) .
In the students' academic trajectory, schools focus on the complexity of the real world, approximating the academic of the reality of the community and the services already in the initial stages of the course.Gradually, new knowledge is incorporated using different pedagogical strategies to integrate theory and practice, being emphasized the portfolio as a strategy that assists the critical thought.
The reflective portfolio is an instrument of dialogue between professor and student.It allows the student another way of learning and doing, making the learning something meaningful.The constant self-reflection process is the professor's responsibility, opening him/herself to new feedback possibilities for the student and on his/her practice as professor (16) .
At the same time, the reflective portfolio is an evaluation instrument that can contribute to the improvement of the internship, stimulating the student to develop the critical and reflective thought.The professor evaluates/contributes with this process.The service was also supposed to be part of this construction, considering it as a pedagogical strategy that refers to the reflections on the field actions that are being shared between teaching and healthcare services.
From the results presented, we must question the existing relationship between teaching and healthcare services, considering that this relationship is directly related to the comprehension of teaching-service integration of its protagonists.After all, this integration is an action agreed on behalf of the quality of health care and service, or as a scenario of practice and development of technical competences which, in literature, are more and more obsolete, but that, in practice, still can be observed.
Thus, we move forward to describe the pedagogical strategies and the elements that refer to the reflective thought in the process of teaching-service integration, derived from this investigation, using the Figure 1.
The entwinement between real world (services) and ideal world (teaching) in health needs to make a pact between teaching and service to build a common, solidary field, of exchange and of practices, knowledge and powers of the protagonists involved, resulting in the pedagogical workshop in health.
The pedagogical workshop in health is structured in the intertwinement of elements located in the teaching and service, originating the strategies that constitute the reflective teaching.Its constitution aims the sustainability of policies directed to the reorientation of health training, promoted by the Brazilian ministries of Health and of Education and Culture, and should be based on proposals for education that can approximate theory and practice, the knowing and the making.
The encounter of these two contexts -teaching and servicestimulates the reflection on the problems in practice, the debate about the experiences, the reflective dialogue and a mutual growth.However, to this end, the protagonists of this meeting must engage in reflective dialogue.The epistemology of reflective practice (6) maintains that dialogue is accomplished through words and actions, providing for the professor and student to conduct, mutually, the reflection-in-action (10) .The pedagogical workshop in health can be conceptualized as a space in which occurs the union of pedagogical strategies held by the ideal world with the elements that emerge from the real-world practice, based on the learning by doing, immersed in a constant process of reflection on the actions developed.The entwinement of the two worlds is permeated by the reflective dialogue, by the sharing of related goals and by the re-signified knowledge in the development of the actions on health.
The teaching-service integration is classified from the epistemology of the reflective practice, i.e. from a reflection process capable of generating concerns between the context of service and teaching and, from these concerns, of producing changes in the current training and healthcare practices.In this way, one has a workshop that provides the generation of knowledge about itself, its demands, its actions in the present and the planning of the future.

Study limitations
As study limitation, we highlight that the financial costs and the time necessary for the conduction of the pedagogical workshop in health were not calculated.The latter is considered ideal in the nursing curriculum, as well as the proposition of the workshop can be constituted only if teaching and service are integrated.However, this study contributes to this debate, for the strengthening of actions that enable the teaching-service integration, for nursing praxis, for the strengthening of the SUS in its doctrinal principles and the ethical and political commitment with the reality of the Brazilian population.

Contributions to the field of nursing and public health education policies
The proposition of the workshop has as objective that the teaching-learning process encompasses the needs of individuals and collectives and their contextualization with the political, economic, social and professional dimensions, especially before the dismantlement occurring with the free heath care of quality.As well as it focused on the training process based on health needs, considering its structural origins and its reflections on the uniqueness of people and the health-disease process.

FINAL CONSIDERATIONS
The results highlight the encounter of the teaching -with its pedagogical strategies -and the service -with its elements of practice -, conforming the encounter of the ideal world with the real one.This encounter causes confrontations between theory and practice, becoming thus a fertile field for the development of the practical reflective education that aims at the transformation of the reality from its understanding of totality.
The conduction of a reflective teaching in the field of service is what is called a pedagogical workshop in health, a space for sharing the actions held by the teaching in the service and vice versa.We emphasize that the success or failure of the pedagogical workshop in health does not depend on a protagonist or another, but, rather, on part of a commitment of responsibility from all, including in governmental level.
The challenges for the consolidation of the teaching-service integration as a pedagogical workshop in health are several and have some particularities between the cases, but as the similarities, it is highlighted the needs for: a) having clear what the existing relationship between the knowledge of teaching and the context of service; b) agglutinating pedagogical strategies to elements found in practice of services; c) transformation of the service space in the fusion of the ideal and the conducted; and d) making this context a space for the reflective dialogue.

Teaching-service integration: building the educational workshop in healthcare
Khalaf DK, Reibnitz KS, Lima MM, Correa AB, Martini JG.they discuss the progress of the activities.Professor asks the students to validate the problems surveyed with the team.Orientation lasts 20 minutes.(Observation data CA) To reflect is not criticizing, nor praising, it is actually making the reflection, what it has of negative, what I would improve, what I would not say, what I would cease doing, what I would put as priority, and see if it matches with the pre-established standards.[…] If I slip up, […] a light will turn on.(E1CB)

Figure 1 -
Elements of the practical reflective teaching in teaching-service integration, Brazil, 2017