Political and pedagogical projects of nursing residency to the elderly from Paulo Freire's perspective.

OBJECTIVE
to analyze political and pedagogical projects of nursing residency to the elderly from Paulo Freire's perspective.


METHOD
a descriptive, exploratory study, qualitative approach using documentary analysis. Data source was pedagogical political projects of nursing residency programs in the health of the elderly. The data were collected between March and May 2017. Data analysis was based on Bardin's Thematic Analysis. It had as analytical categories specific dimensions of the proposed theoretical framework.


RESULTS
twelve pedagogical political projects showed that learning dimensions appear in an incipient, fragmented way, demonstrating the reproduction of banking education, disregarding the importance of bringing the student as a subject of learning.


CONCLUSION
there is a gap in pedagogical political projects from Paulo Freire's perspective. It is necessary that regulatory institutions can systematize and encourage so that pedagogical projects of these programs are based on Paulo Freire's epistemological bases, enabling the so desired holistic training.


INTRODUCTION
The article deals with the nursing residency programs in health care of the elderly in Brazil and the learning dimensions proposed by Paulo Freire (1) . Permanent Health Education (PHE) is referred to in the National Permanent Education in Health Policy (PNEPS -Política Nacional de Educação Permanente em Saúde) as a political and pedagogical proposal based on meaningful learning and perspective of transformation of professional practices (2) .
Health residency programs are fundamentally human resources training programs for the Brazilian Unified Health System (SUS -Sistema Único de Saúde), in order to address the various complexities of health services. The Political and Pedagogical Project (PPP) guides Nursing Residency Programs, being aligned with health care policies and enabling universities to play a key role in the legitimacy of the success of these programs and their graduates, attentive to the needs of the population.
In their educational objectives, residency programs have the purpose of improving the quality of services and health care, promoting positive impacts in practice settings (3) . Multidisciplinary health residencies aim to create strategies to train professionals capable and committed to the SUS to work (4) .
The transformation of reality is not an imposition on the population to rebel or mobilize to change the world, but rather that transformation and freedom are built every step of the way. In this production of dialogic knowledge, to teach is not to transfer knowledge, but rather to create the possibilities for its production or its construction (1) . It is in the sense of the dialogue of the possibilities of this training process that stands out, more than a demand for the SUS, the aging population as a social phenomenon that affects a large part of the world population.
In Brazil, the period is a demographic transition with accelerated aging of the population, with implications for individuals, families and society, as well as a great impact on public health care policies. There is, in this population segment, the increase with growth rates of over 4% a year in the period from 2012 to 2022, reaching 41.5 million in 2030, and 73.5 million in 2060, with challenges for society to discuss possible ways of dealing with the phenomenon (5) .
In this setting, care for the elderly has as one of the most important challenges the inadequate training of the workforce both in terms of numbers and competence to offer primary care in geriatrics (6) . The expansion and implementation of health care programs for the elderly is very difficult, and the lack of professionals trained to attend this public is still a challenge (7) .
In this challenging setting, there is a necessary commitment to "problematizing" teaching, as opposed to "banking" teaching, overcoming the authoritarianism's error with banking and emerging the authenticity of teaching-learning in practice through a total pedagogical, aesthetic and ethics, with decency and seriousness (1) . Thus, nursing residency programs in health care for the elderly can be a space for the training of specialists capable of meeting the demands of this population segment, if they are aligned with problematic, humanistic and dialogical pedagogical proposals.

OBJECTIVE
This study aims to analyze political and pedagogical projects of nursing residency to the elderly from Paulo Freire's perspective.

Ethical aspects
In order to maintain the anonymity of the Institutions, PPPs were distributed randomly by letters from A to L. The present study was approved by the Ethics Committee of the Universidade Salvador, under Opinion 1,986,579.

Type of study
Documentary research, descriptive and qualitative approach. Documentary research is in the nature of the sources, since this form uses those that have not yet received an analytical treatment, or that can still be re-elaborated according to the objects of the research (8) .

Data source
After identifying the Higher Education Institutions (HEI) that offered vacancies in nursing residency programs in health care for the elderly, through registration of the Comissão Nacional de Residências Multiprofissional em Saúde (CNRMS -freely translated as National Commission for Multidisciplinary Residencies in Health), telephone and e-mail contacts were made with those responsible, requesting PPPs with active registrations in 2017.
The criteria established for inclusion were: 1. Residency programs in Health officially registered in the CNRMS platform, with the nursing category, which contemplated the health of the elderly person alone or associated with another thematic area/knowledge; 2. Resident health care programs for the elderly in a specific health or multidisciplinary area. The criteria established for exclusion were: 1. Elderly health care residency programs that contained in the subject area/knowledge: elderly health, but are not residency programs in the elderly care; 2. Programs with repeated enrollments in university; 3. Programs of the same university that have changed their name over the years. 4. PPP programs that did not emphasize the specificity of elderly health care.

Collection and organization of data
The data collection took place between March and May 2017. Among 1,591 processes of the programs officially registered in the Sistema de Informação da Comissão Nacional de Residência Multiprofissional em Saúde (SisCNRMS, freely translated as Information System platform of the Multidisciplinary Health Residency National Commission), following the criteria of the programs that contained the word "elderly" or "aging" in the title or in the thematic area and knowledge, 220 programs were selected. After reading the contents of these programs, the programs that were not specific in health care of the elderly were discarded. There were 19 Nursing Residency Programs with emphasis on the health care of the elderly, representing only 1.2% of the total number of programs enrolled at MEC (Ministry of Education). Of the 19 nursing residency programs in the health care of the elderly, 12 (twelve) sent the PPPs and seven (seven) programs did not respond to the calls to participate in this study.

Data analysis
Once collected, the information was transcribed for the unique instrument elaborated specifically for this study, later analysis of PPP content, considering Paulo Freire's framework. Analytical categories were: Problem Dimension, Humanistic Dimension and Dialogical Dimension.

RESULTS
In Brazil, 6,575 vacancies of health residencies are offered. The nursing category has the highest number of health professions, with 1,608 vacancies, that is, 24.45% of the total vacancies of non-medical health residents in Brazil are destined for nursing (9) . Of these, only 45 nursing vacancies are destined to residential care programs for the elderly, representing 2.79% of nursing vacancy vacancies offered in Brazil, as opposed to epidemiological statistics for the need to care for the elderly population. Thus, it made insufficient coverage of the real assistance needs for this population follow-up.
In the analysis of the twelve PPPs available, three analytical dimensions were proposed, proposed by Paulo Freire, presented below.

Problem Dimension
Analytical markers considered for this dimension were: problems and their derivations, contextualized practice, think-act-think, reflection/action, active methodologies, tutorials, problem-based learning, cases or cases for resolution, problem-question. Such markers and their derivations of synonymies identified in PPP, as well as terms or situations that lead to the reflection by the student in the decision-making before a problematizing thought were framed in this dimension.
PPP-A responds to this dimension by registering "[...] we opted for critical-participatory or problematizing education in an interdisciplinary approach, where health professionals are seen as protagonists of teaching-learning".
PPP-B aims at the training of qualified professionals to the requirements of the SUS and contribute to the exercise of citizenship in the space of professional activity, insofar as it favors the continuous learning, making it possible to collectively construct solutions to the problems that affect users.
PPP-C brings in its pedagogical proposal the training concern "to reflect critically on the health situation, adopting the active methodology of teaching" predicting "to be used the following pedagogical strategies: problematization of services real situations, elaborated previously by the preceptors ". Such pedagogical guidelines are in line with complexity and training need of specialized professionals.
PPP-J "suggests a problematizing methodology to be used in teaching issues". To think about a PPP of a multidisciplinary residency in the attention to the health of the elderly person is to direct the proposal so that the professor and student can interact in teaching-learning and promoting the meeting of both and the transformation of the practice.
PPP-K emphasizes the insertion of the resident's practice in the social context of the reality in which. Complementary didactic activities should, whenever possible, use the elements of the social reproduction profile, the epidemiological profile of the population of its territory of professional activity and of the social organizations that integrate it, especially those of health, with reference frames to social epidemiology, strategic planning and problem-solving methods of reality.
For PPP-H, HEI demonstrates its training concern in line with SUS principles, the Permanent Education Policies in Health and the problematizing dimension, indicating that "such guidelines will be developed by active methodologies, centered on the subject of learning, with the conception of that the person can build his knowledge proactively".
PPP-E, PPP-F, PPP-G and PPP-L did not include analytical markers for this dimension. Problem-solving leads the learner to think about aspects of practice that they had not previously seen or reflected. In nursing residency programs this happens, when varied situations are brought to knowledge, reflection, change of concepts and action.

Humanistic Dimension
For the Humanistic Dimension, analytical markers and their derivations were considered as synonyms in PPP, terms or situations such as: respect for the learner, active listening, humanitarian (attending the difference to humanized care), attentive look, reception and derivations, relationships based on social ethics, values and moral-ethics.
PPP-B registers, in its partnership with the executing institution, the experience and success already enshrined nationally by humanized care: "Contribute to the humanized, ethical and specialized training of professionals for health care".
The other PPPs, in their totality, do not bring specificity in this dimension in training, only emphasizes the humanistic dimension in the professional preparation for an interprofessional action based on the actions of competencies and professional responsibilities against the target public of the elderly person, guiding this service in humanistic bases.
This affirmation is repeated in the other PPPs as observed in the PPP-E, in which, in its introduction, the pedagogical guidelines of the program are based on the actions that involve activities for multidisciplinary activity and the training based on interdisciplinarity that should allow scientific training and technology, with human beings as the priority center of their actions. Nevertheless, in the course of the content of this PPP, one can see the concern in the service of the community with humanistic care. However, it does not bring, in any moment, the humanization of training.
PPP-G demonstrates its commitment to complying with SUS principles of comprehensive care, by affirming its purpose as multidisciplinary training, articulation of the different levels of care, as well as providing subsidies for the development of research, by proposing to improve and qualify the capacity of analysis, confrontation and proposition of actions that aim to materialize the principles and directives of SUS, with special emphasis on the promotion of comprehensive care. For PPP-K, the main guidelines for comprehensive health care of the elderly are: promotion of active and healthy aging, maintenance and rehabilitation of functional capacity and supporting the informal care development, emphasizing biological training, without humanistic training forms.
Humanization is often present in PPPs evaluated only with the aim of forming for the humanized care the elderly. Nevertheless, this concern is still insipient, when considering the relation and importance of the humanization of training.
The humanistic dimension in the training of nurses who are specialists in health care for the elderly is fundamental to the training foundation, because it is "people" caring for "people". And in this fragile relationship that has already been strengthened by age and the complex dynamics of care, it is that in residency programs, this exchange of knowledge must be humanizing.

Dialogical Dimension
In this dimension, the analytical markers and their derivations were considered synonyms, terms or situations, such as articulation between professor and student knowledge, dialogue, listening, communication, skills assessment, dialectic-integration, student involvement in discussions, autonomy of the student. This dimension was present in PPP-A, B, C, H, I, J and K.
PPP-B seeks, as a final result in the resident's specialization, a training not only humanized, but with scientific knowledge based on the scientific and their daily actions, multidisciplinary work with dialogues, aiming to develop skills for health interventions in the elderly care and your family, at different levels of system attention.
PPP-C notes that the emphasis on communication skills has the power to promote collaborative learning, teamwork, diminishing power struggles, and maintaining a pleasant and upbeat organizational climate.
PPP-D, when bringing information of a more technical and structural nature of partnerships and technologies, does not inform the pedagogical actions that underpin the program, directing the attendance to the needs of the population, without emphasizing dialogic moments during training.
The same lack of opportunism in the dialogic dimension was present in the PPP-E, despite presenting that "The opportunity to broaden their vision of comprehensive citizen's care will be given by going to the community attended by the SUS, in Basic Health Units and interacting with professionals who work with the community".
In turn, PPP-F does not contemplate pedagogical framework, being restricted to the obligatory precepts of the training axes with the modules to be taught, without correlating content or providing participatory dialog spaces.
PPP-K brings as one of the skills to be developed by residents to "reflect on the nature of the work process of each category in the multidisciplinary team. " And in the attitudes based on ethics and professional commitment, among others, that of "autonomy for the accomplishment of health practices". This project makes possible an active and dialogical reflection, when opportunizing self-learning, respecting the previous experiences of the resident.
PPP-I presents, among its objectives of training the resident, among others, "to promote the training of Nurses for Nursing Care for the Adult and Elderly, aiming at improving the quality of care for individuals, families and social groups through teachingservice-community integration". Furthermore, in proposing this integration of knowledge and action, he takes over dialogical commitment not only interprofessional but intersectoral and demanding effective dialogical actions, ratified with the affirmative: "it is aimed at breaking the false dissociation between basic/ primary and secondary care".
PPP-J, based technically on the guidelines of the SUS and PNEPS, approaches the dialogical dimension when affirming: "At certain moments the discussions, reflections and the acquisition of scientific/technological knowledge will be common to residents".
In spite of PPP-L, "the interdisciplinary perspective, where it intends to construct a differentiated practice, experiencing the performance in health services, considering a more integrative and articulated vision of SUS users and their health needs" does not describe dialogic moments in specialization training.
PPP-D, E, F, G and L did not address this dimension. Despite the difficulty of the dialogical dimension in PPPs, the nursing home is a propitious program for the pedagogical exercise of dialogue. It is considered the extensive practical workload and the almost obligatory opportunity for dialogue to permeate this training. Even with these operational characteristics, there is fragility of this dimension in the evaluated projects.

DISCUSSION
The lack of sufficient elements in PPPs to analyze the proposed analytical dimensions confirmed with findings from another study (3) . Although the CNRMS establishes minimum criteria for the elaboration of the projects, it is important the commitment of the HEI involved in the elaboration, evaluation and dissemination of the curricular proposal.
In Brazil, RS offerings with an emphasis on the health care of elderly people, considering the clinical specificity of Chronic Noncommunicable Diseases, their aggravations, and the sociodemographic profile of this population.
Much has been written, read, reflected on pedagogical practices and the possibilities for changes in more traditional teaching trends. Nevertheless, it is in the action of educating, teaching and learning that these new strategies should be realized. However, it does not always happen for a variety of reasons. It is in practice in the relationship between those who teach and those who learn that formal education. Thinking about education requires a reflection on its practice that can be transformative, changeable and unfinished (10) .
Problematizing is the provocation that the educator throws to the students and the restlessness that motivates so that they can deepen the reflection on aspects of the reality that they had not perceived of critical way (1) . Education can no longer be an act of depositing or narrating or transferring or transmitting "knowledge" and values to the learners, mere receivers, the way of "banking" education, but a cognitive act, a problematizing education (11) .
In this sense, it is pertinent to conduct education from the awareness of the context in which we live. This can be accomplished in the area of the health of the elderly, when we motivate the student to reflect on demographic and epidemiological changes, relating them to the demands of this population. In this way, we will distance ourselves from the banking practice that, by transferring knowledge, makes it impossible to promote this awareness, because it does not allow the exercise of problematization in the circumstances presented (12) .
The study of PPP of the HR has as its guiding axis the comprehensiveness, the integration of knowledge and practices in favor of the development of shared competences for teamwork, with the intention of transforming teamwork, the process of training for work and health management (3) .
This training highlights the importance of specialist nurses as they play a fundamental role in the organization of geriatric followup care, not only during hospitalization, but in the post-discharge period, highlighting the maximization of patient independence (13) . Problematization encourages the autonomy of the subjects; they learn through research and critical reflection their learning objectives relating them to reality and, therefore, transforming it (14) .
Residents inserted in the respective settings of practice constantly problematizing in the daily life they are inserted, exchanging knowledge and learning, shows that problematizing education would be in opposition to banking practices. The educator would no longer be the one who only educates, "but what, while educating, is educated, in dialogue with the educated who, being educated also educates" (11) . "The very object of knowledge that mediates the relationship ceases to be the property of those who teach and becomes the focus of attention of both educator and educator" (11) .
The mechanical memorization of the object's profile is not true learning of the object or the content. In this case, the learner works much more like patient of the transfer of the object or the content than as critical subject (1) . This reinforces the importance of PPPs to problematize situations that lead learners to the most effective and distant learning of content storage.
Education encouraged by a problematic curricular construction should be collective, based on questions and problems. The action of the educator, identifying himself early with that of the students, should guide in the sense of education of both (11) . It is necessary to transcend the naive vision to the apprehension of reality, making it a knowable object, thus taking over an epistemological stance on knowledge. Awareness is a critical entry with historical commitment, and reality can undergo revisions, and involve practical, theoretical and ethical aspects.
Problematizing education contributes to the overcoming of the naive consciousness, a curiosity of common sense, of empirical knowledge, a perception that does not allow an in-depth look at an epistemological consciousness that is characterized by the apprehension and actuation on reality. This transformation -from naive to epistemological is only achieved through action-reflection-action (1) .
In Paulo Freire's conception, teaching must be problematizing, but without losing the humanization of relations and the greater focus of the exchange of knowledge, as opposed to the imposition of knowledge (1) . This conception of the humanization of learning relations in HR practice is still a great challenge. A training process in the humanistic dimension seeks the intersubjectivity of man. Camouflaged selfishness of false generosity is an instrument of dehumanization (11) .
Humanization dimensions were presented as emerging, informing a value base to consider potentially humanizing and dehumanizing elements in public health systems and interactions, particularly in relation to the development of new knowledge about what is humanizing and dehumanizing in research and practice (15) .
By the creative spirit of man and by the increasing possibility of creation for his work in relations with the world, it is possible to transform it more and more. "This transformation, however, only makes sense insofar as it contributes to the humanization of man; in so far as it is inscribed in the direction of its liberation" (16) . "Being more" is a fundamental term for understanding the perception of the human being, since "being more" presents itself as a challenge of man by his own humanization.
The competence of man to assume a critical attitude towards reality can be considered the search for "being for himself" as a movement for "being more", configuring himself in a conscious attitude that can be considered the awareness, stage which precedes awareness, since awareness is a process of consciousness by which man understands himself as a man in the world, an unfinished being. Awareness is this mysterious and contradictory ability that man has to distance himself from things to make them present (17) .
The difficulty in meeting the humanistic dimension in the projects evaluated may occur due to the extensive theoretical/practical hours under direct supervision. Training is strongly marked by the Cartesian paradigm, fragmented and interventionist, still very present also in health institutions, contrary to what is proposed by SUS that demands the comprehensiveness and humanization of care. Given this context, it is only through the articulation of educational institutions and services that encourages students and health professionals to become aware of everything that involves care, it will be possible to modify these social actors in such a way as to reflect their "praxis as inseparable relationship between reflection and action, inherent in a paradigm of liberating and problematizing education" (18) .
Another dimension discussed was the dialogic one. Dialogue is fundamental in any educational process, especially in the education of residents inserted in the context of the practice. Mechanization of knowledge and practices does not account for the complexity of the real settings. Rather than accumulating information, the resident needs to develop the capacity for criticism, analysis and reflection for appropriate intervention.
"Education is communication, it is dialogue, insofar as it is not the transference of knowledge, but an encounter of subject interlocutors who seek the signification of meanings" (16) . Through the dialogue, professors transmit specific guidelines on a particular procedure to be carried out by the student in practice, criticize the care provided and propose suggestions on how he can improve his knowledge. The dialogical relationship between educator and educator supports and enables reflection in both the theoretical and practical contexts. "The activities developed in the daily life of services become more challenging for the pedagogical relationship, while the demands arise from real and concrete needs" (19) .
For HRs with 80% of their hours in practice settings experiencing the daily life of these institutions, it is a challenge "to incorporate and adopt the concept that this human capital should have access to continuing education, valued career and treatment as real assets of organizations to which they serve. "In this sense, humanization and dialogue are fundamental dimensions for success (20) .
The projects analyzed did not present the dialogical dimension in a clear way. Dialogue allows for an affective relationship, and dialogical training cannot be purely technical. Dialogue is a human phenomenon consisting essentially of the word, which has two closely related dimensions: action and reflection. Action and reflection are not dimensions that can be understood in an isolated way, or, prioritizing one to the detriment of the other, so that dialogue can only be established when action and reflection are put together and articulated (1) .
Dialogicity is the essence of education as a practice of freedom. Dialogue is treated as a human phenomenon, "if it reveals itself to us as something we can already say to be itself: the word. Nevertheless, as we find the word, in the analysis of dialogue, as something more than a means for it to be done, if we are required to seek, also its constitutive elements" (11) . Dialogue is imperative to human existence, and can be considered the meeting between men mediated by the world. Through dialogue, it is possible to have action-reflection-action aiming at the transformation and humanization of men. In order for a true dialogue to exist, man's love for man and for the world is necessary, for love is an act of value that constitutes itself in the dialogue itself ( ¹ ) .
The education model proposed by Paulo Freire is consistent with the purposes of PNEPS and SUS itself. It differs from traditional education, there is no room for a dominant relationship typical of HR programs, where the supremacy and predominance of knowledge of preceptors and/or tutors over residents, even professionals, but as apprentices, prevailing. the educator's domain about the student. Paulo Freire's framework differs in proposing a liberating and non-mechanical education based on questions and not on answers, on doubt and not on certainties (11) . An integrative, comprehensive and non-fragmented training intended not only to train specialists, but individuals aware of their rights and duties as citizens. Different, above all, for its humanistic character, so difficult to find in the pedagogical projects of the HR, although all seek the humanized care.
It is necessary to understand that the dialogue, as communication, establishes actions of collaboration between the subjects. Paulo Freire's dialogue is solidary and loving, breaks with the competitive and classificatory attitude of traditional practice.
Furthermore, it allows a horizontal relationship between individuals and constitutes the critical thinking so that those involved can transform society and humanize themselves (21) .
By systematizing and inducing pedagogical projects based on the proposed dimensions, we will be taking an important step in the sustainability of training for nurses who specialize in caring for the elderly in this format, preparing them adequately for this population demand, especially respecting them, despite professionals still in training.
In this context, when thinking about a PPP for nursing residency programs with emphasis on the health care of the elderly, it is important the presence of problematizing, humanistic and dialogical dimensions in the proposal to achieve the transformation of the practice and following the precepts proposed by Paulo Freire with "action/reflection/action".

Study limitations
One of the limitations of the study was the absence of other studies that could subsidize the discussion of the results, due to the scarcity of publications related to this topic in the articles. Another limitation was the number of e-mails and phone calls made to HEIs requesting the sending of PPPs without obtaining a return.

Contributions to Health and Nursing
The results of this research contribute to the construction of new PPPs for nursing homes in the elderly, considering the pedagogical dimensions based on Paulo Freire's framework, making possible the long awaited quality holistic training. Simultaneously, it respects human relations and enables the emancipation of the learner, providing sustainability in the training actions, without overlapping of forces and imposition of knowledge.

FINAL CONSIDERATIONS
The analysis of the PPPs in the light of Paulo Freire's theoretical framework showed that only the PPP-B contemplated in the training process all the proposed dimensions, offering to the specialists the necessary training and expectations of all agents involved: residents, HEI and society. New inductive actions should be discussed in society, starting with the remodeling of political actions that seek to be proposals that adequately redesign the ideal preparation of nurses in face of the population growth of the elderly in Brazil, with the necessary dimensions for this training: problematization, dialogue and humanization.