Participative education with nurses: potentialities and vulnerabilities in the breast and cervical cancer tracking.

OBJECTIVES
to systematize permanent participatory education experience with Primary Care nurses on breast and cervical cancer screening, identifying potentialities and vulnerabilities.


METHODS
systematic account according to Holliday, in five stages: starting point, initial questions, recovery of the lived process, background reflection and arrival points. It was the product of two workshops with 96 nurses and analyzed in the light of the ministerial guidelines and Ayres' concept of vulnerability.


RESULTS
the potentialities are related to the nurse's work implementing the principles of the Unified Health System. The difficulties are complex and expose individual, contextual and programmatic vulnerabilities in the practice of screening.


FINAL CONSIDERATIONS
permanent education and participatory pedagogical strategies allowed a wide and playful exchange of learning and the participation of a significant number of professionals. There is a need for studies on the institutionality of programmatic guidelines and nurses' space to be the initiator of new practices within the scope of Primary Care.


INTRODUCTION
Cancer is a multifactorial disease, of national and international visibility due to its epidemiological, social and economic magnitude. Non-communicable morbidity, occupies a prominent place in scientific recommendations for the development of methods of diagnosis, detection and early treatment, in addition to those for the evaluation of primary prevention programs (1) . The Sustainable Health Agenda for the Americas 2018-2030 sets the goal of reducing premature mortality due to non-communicable diseases using prevention and treatment by one third by 2030, including breast and cervical cancer (2) .
Estimates from the National Cancer Institute José Alencar Gomes da Silva -INCA, for the years 2020 to 2022, point to breast cancer as the most incident and cervical cancer occupying the fourth place, disregarding non-melanoma skin. The annual estimate in the referred biennium for breast cancer is 66,280 new cases and an estimated risk of 81.06 cases per 100 thousand women. For cervical cancer, the annual estimate is 16,590, with an estimated risk of 15.43 cases in 100,000 women (3) .
Prevention activities are necessary to positively impact the indicators of female breast and cervical cancers. The detection of these diseases occurs through early diagnosis and screening. The first, performed on people with signs and symptoms of the disease to identify the disease in its initial phase; the second refers to the testing of healthy people, in order to identify diseases in their asymptomatic or preclinical phase (4) .
The nurse's work in Primary Health Care is essential for the primary and secondary prevention of female breast and cervical cancers. However, there are divergences in the performance of these professionals in relation to ministerial guidelines (4) for the detection of these diseases -divergences arising from aspects related to municipal management, nurses' knowledge and adherence to the guidelines (5) .
The continuous training of these health workers can contribute to improving screening. Ordered by Ordinance MS/GM n 1.996 of 08/20/2007, it offers the normative bases for the implementation of the National Policy of Permanent Education in Health (PNEPS) (6) . In its conduction, PNEPS counts with the Teaching-Service Integration Commissions (CIES) that bring together professionals from different sectors and institutions related to the management, training and social control of work in the Unified Health System (SUS). Higher education institutions (HEIs) that train health workers, within the scope of CIES, participate in its composition.
Authors of this report participated in a training course on breast and cervical cancer screening, promoted by the Brazilian Association of Obstetric Nursing (ABENFO/RJ and ABENFO/PI) and International Society of Nurses Cancer Care (ISNCC) and, in return, they pledged to multiply it in their workplaces. As HEIs teachers and researchers, one of them, representative at CIES, considered it opportune to replicate the training for Primary Care nurses in the coastal lowlands of Rio de Janeiro, through workshops using participatory methodological approaches consistent with the PNEPS (6) .
It was proposed that the workshops discuss the work of nurses in screening, guided by the following questions: What lessons can be learned within a practice of permanent education, based on participatory approaches with nurses, can be generated to face vulnerabilities in cervical and breast cancer screening? What difficulties and potential difficulties were observed in the nurses' care practice?
The analysis of the workshops' product is based on ministerial guidelines and the concept of vulnerability proposed by Ayres et al (7) . The author states that the perception of illness is not restricted to the set of individual aspects; it is also found, in an inseparable way, in the collective and contextual aspects. The complexity of the factors that operate in the screening of breast and cervical cancers has been evidenced by other studies on the subject (5) .

OBJECTIVES
To systematize a participatory continuing education experience with Primary Health Care nurses focused on screening for breast and cervical cancer, identifying the potentialities and vulnerabilities that permeate this care.

Methodological path: intersections of education, research and assistance
Systematic experience report that approaches a methodological possibility of participatory action research in health, widely experienced in Latin America in the field of popular education, but little explored in the field of health. Oscar Jara Holliday stated (8) , systematizing experiences is a political and pedagogical challenge based on the dialogical relationship and the search for critical interpretation of the lived processes, it uses its own experience as an object of study and theoretical interpretation, enabling the formulation of lessons and their dissemination.
The power to systematize experiences goes beyond the documentation of an event or specific event, but lies in the possibility of transforming subjects' work processes, through reflection on the meaning of their practices, of the analysis of the expected and unexpected results that arise and of the relationships and reactions between the participants. To describe the process, Holliday (8) points out five times: the starting point, initial questions, recovery of the lived process, background reflection and the arrival points.

The starting point
The first stage aims to participate and record the experience (8) . The experience was based on the participation of members of this team in the "Training course and improvement of nursing care for women in the prevention and screening of breast and cervical cancer -Enable the multiplier", held in Teresina (PI), in October 2017, promoted by ABENFO/RJ/PI and ISNCC. After the course, one of the researchers was awarded a grant from ISNCC, in order to multiply that knowledge locally. Concomitantly, the project "Participatory action research and permanent education with Primary Care nurses: preventing cervical and breast cancer" was conceived, linked to the Universidade Federal Fluminense (UFF) of Rio das Ostras/RJ, within the Collective Health Teaching, Research and Extension Group (GEPESC/CNPQ). In this sense, efforts to implement the training workshops were added to the initial research work. Participation in the CIES/BL of the state of Rio de Janeiro facilitated the discussion of the proposal in this collegiate body, as well as its partnership, mediating contact with the Bipartite Commission of Intermediates of the coastal lowlands. Based on these contacts, the two workshops for nurses in the nine municipalities in the coastal lowlands of the state of Rio de Janeiro were agreed upon.
Carry out both a permanent education intervention, focusing on assistance, and a research project required to standardize the team's knowledge in active and participatory methodologies. Thus, the "Participatory Health Research-Action Workshop (PAPS): an approximation with participatory methodologies" was held, in April 2018, which included the entire research team. It was proposed a training practice capable of enhancing permanent education workshops as moments of shared construction of knowledge. The objective of this preliminary PAPS workshop was to equip the research team with the participatory action research approach to health, convergent methodologies and group activities using the World Café methodology (9) , which consists of a conversation technique, very close to the Focus Group and that simulates the environment of a cafe, oriented based on a theme, facilitating constructive involvement in complex issues. The World Café was only used in this workshop with the group of researchers and scholars.

Initial questions
The second stage starts with the systematization, based on the starting point, and presents three essential questions: Why do we want to systematize? What experiences do we want to systematize? What central aspects of these experiences are we interested in systematizing? (8) In this sense, experiencing permanent education workshops with nurses, addressing the screening of breast and cervical cancers, applying active methodologies and systematizing them, gave the research team the opportunity to experience the learning built in the previous step (PAPS), analyzing its feasibility for training and knowledge production based on the potential and difficulties expressed by workers in their workplaces.

Recovery of the lived process: a crossroads of knowledge and practices
The third stage emphasizes the descriptive aspects about the experience in order to reconstruct the history, as well as order and classify the information (8) . The first workshop, held in May 2018, featured 53 nurses from the Primary Health Care services and had a workload of eight hours. The program included a theoretical part, with the presence of specialists who offered data on cancer tracking and updated information on technical consensus on the topic, favoring the technical-pedagogical capacity of workers.
Epidemiological indicators and the tracking recommended by current public policies were also addressed. In our case, there was an effort to overcome these limits using visual illustrative materials of professional practices, case studies as examples of theory-practice dialogue and epidemiological data from the region, in addition to the construction of that space as a dialogical possibility of knowledge.
After the theoretical exposition, the nurses were divided into six groups, of eight to nine people each, to answer some questions that involved the nurse's care in the screening of breast and cervical cancers. In this report, the answers to the following triggering question for the reflection of the participants are presented: "Talk about your difficulties and potentialities in the screening of breast and cervical cancer. " For each group, a facilitator or spokesperson (member of the training team) was assigned, whose role was to stimulate nurses' reflections and discussions. At this stage, it was possible to probe the difficulties, potential and challenges related to the screening that involves the nurse's work process in a shared and dialogued way. Each group wrote down the key points of the discussion on sheets of craft paper. None of the workshops were recorded, and all content was recorded on craft papers.
The second workshop, developed in September 2018, with an eight-hour workload, featured 43 nurses who participated in the first workshop, along with 10 other new professionals. Following the same methodology as the first, an activity was carried out with technical content taught by specialists in which the early detection of cervical and breast cancer and the reorganization of the oncology network of the coastal lowlands were discussed. In the second workshop, it was possible to rescue the work produced by the reflection of the groups from the previous workshop, with the re-reading of the material and holding the plenary with the results.
By analyzing the material produced by nurses in the two workshops, in the light of public health policies and ministerial guidelines, it was possible to answer the guiding question of this report, with the organization of responses in thematic groups presented in Tables 1 and 2, bringing the findings closer to the categories proposed by Ayres et al. (7) when the author analyzes the vulnerability.

Background reflection and arrival points
The fourth and fifth stages of this methodological proposal deal with the ordering, reconstruction and critical interpretation of the systematized experiences. In this stage, it is intended to formulate the conclusions and communicate the learning (8) . In Chart 1, it is observed that many of the potentialities reported are related to the principles of SUS, such as creating a bond, conducting an active search, working as a team, welcoming and intersectoriality. It is inferred that the implementation of the National Primary Care Policy facilitated the insertion of nurses in Primary Care as a professional who coordinates their team, plans, offers direct care and performs educational activities. All participants performed screening actions with some autonomy, but with differentiated practices.
Although the difficulties present numerous challenges to be overcome, the need for training managers was highlighted by the workshop participants. The approach of a more participatory pedagogical strategy addressing the reality of the participants with the traditional dialogued exposition of the normative and technical aspects of the programs also proved to be relevant and promising. More participatory approaches in lifelong education aim to transform systems and encourage a shift away from the traditional focus of providing individual-centered care to initiatives that promote community involvement (10) .
action of a single professional category. Combining permanent participatory education with the PAPS methodology would help to improve the care processes (asymmetry between programmatic proposals and practice) (10) , minimizing individual, social and programmatic vulnerabilities (7) of health/illness processes in search of the care, especially preventive, increasing the production of knowledge for application in specific contexts. Study (5) assumes that inefficient communication can impact the practice of professionals and users adhering to the recommendations of the ministerial guidelines on breast cancer; and barriers related to their tracking are due to interdependent conditions, which synergistically increase in practical, systemic and organizational dimensions.

Study limitations
The depth and scope of this study are limited because it is an experience report, as well as the fact that it is based on the exclusive participation of a single professional category, the nurse, since health work in Primary Care excels at team work.

Study contributions
It was intended that the potential of involving, besides nurses, other workers, managers and users in future qualifications is envisaged, expanding the resolution capacity of the critical nodes presented, with proposals for innovative and more participatory strategies in order to improve breast and cervical cancer tracking.
There is a need for studies on the institutionalization of programs and guidelines of the Ministry of Health in the municipalities and about the possibilities and limits for nurses to institute new practices, under pain of believing that the lack of technical knowledge is the only limit they need be transposed.

FINAL CONSIDERATIONS
In view of the constant updates of knowledge and challenges in the health area, it is essential to use permanent health education in order to empower Primary Care professionals, managers and users involved in the care of screening for breast and cervical cancer, aiming at carrying out the actions recommended by the current public health policies. At the end of this report, there are some experiences learned that deserve to be highlighted. First: the importance of continuing education, as a policy and pedagogical conception to improve the training and practices of nurses in Primary Health Care. Second: how the SUS principles are perceived in the practices of professionals, potentiating them. Third: the approach to the concept of vulnerability illuminated other themes to guide new training involving staff, managers and users. The identified problems can signal innovative paths, not yet taken, aiming at a better quality of care in the tracking of these cancers and positively impacting local health indicators. It is expected that this qualification process will help nurses and managers of Primary Care in the dynamics of care that involves screening for breast and cervical cancer in the SUS, from planning to evaluating the actions performed.