Competency-Based Curriculum and Active Methodology: Perceptions of Nursing students

This study identifies the perceptions of undergraduate students at the University of São Paulo at Ribeirão Preto, Brazil, College of Nursing (EERP-USP) concerning the teachinglearning process in two courses: “Integrated Seminar: Health-Disease/Care Process in Health Services Policies and Organization”, which was offered to first-year students in 2005 and 2006 and “Integrality in Health Care I and II”, which was offered to second-year students in 2006. The courses’ proposal was to adopt active methodology and competencybased curriculum. Data were collected from written tests submitted to 62 students at the end of the curse, focusing on the tests’ pertinence, development of performance, structure and pedagogical dynamics, organization and settings. Thematic analysis indicated that students enjoyed the courses, highlighted the role of the professor/facilitator at points of the pedagogical cycle and learning recorded in students’ portfolios. Students valued their experience in the Primary Health Care setting, which was based on, and has since the beginning of the program been based on, the theory-professional practice interlocution and closeness to the principles of the Unified Health System (SUS).


Introduction
The education of the generalist nurse, capable of working in the complex context of health care, has preoccupied and mobilized Brazilian health professionals who seek to understand the National Curricular Guidelines The defined actions/tasks direct the development of students' professional performance in a process of action-reflection-action in health care.
The organization of learning experiences in concrete environments where nurses' professional work is carried out is the differential proposed by the new curriculum, which seeks to connect knowledge areas that guide primary health care (5) .
Students have to integrate information with reflective observation and experimentation with theory, using previous knowledge as a reference point. The ability to think critically is an essential attribute for health professionals, which requires them to become familiar with their object several times, in addition to developing technical aptitude (6) .
The selected contexts should allow students to use strategies to immerse in reality in order to experience and reflect on situations that will be recorded as acquired knowledge. The individual or group reflective process that is promoted with the active presence of professors should raise learning questions to guide the search for qualified information so that students can understand reality and ground their actions (tasks). This process directs the return to the setting and transforms actions (enlarged), as evidenced in their performance.
Experiences close to professional practice promote significant learning, the construction of knowledge, skills and attitudes, along with autonomy and responsibility.
Such processes must be documented in students' portfolios.
Portfolios activate reflective thinking with records of the learning process evidenced in self-reflection, indications of cues that link with strategies of selfdirection, reorientation and self-development (7) .
Students who are encouraged to reflect take the initiative and assume responsibility in a real context of nursing and develop competencies, i.e., the ability to mobilize different skills to deal with situations inherent in professional practice. When students combine attributes -cognitive domain (knowledge), abilities -psychomotor domain (know-how) and attitudes -affective domain (know to be and to live with) it is possible to acquire a broad view of their field of work (8) .
Evaluation is a continuous and co-participative process given the students' learning and development,  Copies of the courses' evaluations, secondary data, were carefully explored. Thematic analysis (9) proceeded through reading of the material to grasp the meanings that composed the subjects' report. A careful rereading, question by question, was carried out and the diversity of meanings were underlined by pencil until no more new information was found and data saturation was achieved. This stage constituted pre-analysis.
Afterwards, data were transcribed and composed, organized into charts to ease analysis of obtained results and their interpretation.
Analysis of empirical data by saturation takes into account one of the limitations of qualitative research, which implies paying attention to the size of the study's universe, that is, reduce the sample to the representative essential set.

Results
Following, we present the structural elements of the written evaluation, highlighting the courses in the first two years of the program, and illustrations of empirical data of the studied individuals. The students' opinions differed in relation to the learning obtained in SI and ICI and II. They report their first developed communication, with the ability to seek new information and having a constructive critical attitude (10) .
The pedagogical proposal that grounds the integrated curriculum oriented by competencies seeks to connect the professors' actions to the teaching proposal, practice to theory, and the educational institution to the community, valuing phenomena that are essential for professional education (11) , where interdisciplinary knowledge is applied.
As students enter the university, they are put in contact with the professional practice and the daily routine of health care, which enlarges the classroom environment and provides a concrete view of the health system and its complexity. Thus, theoretical-conceptual knowledge is based on reality and discussions related to it, which is a methodology that uses data collection to understand the health needs of population segments, enlarging the individual approach to the health services organization and management, including the formation of bonds among people in the school and in the contexts where students are immersed.
The integration of teaching and work in a curriculum demands organization of content so that students understand the reasons for actions (tasks), which gives them the opportunity to develop several aptitudes, both theoretical and social, and also allows them to explore themes and problems beyond conventional boundaries of courses and fields of traditional knowledge (8) . This way, students become able to develop critical awareness, relating information acquired and assimilated during the program with the applied and recorded re-constructed knowledge.
For the knowledge to be actively processed, students are included in the healthcare context and routine, not only as spectators, but also with members from the health team. Students face situations that permit them to appreciate the real health needs of individuals and communities. Thus, students integrate Rev. Latino-Am. Enfermagem 2010 Jan-Feb; 18(1):109-15.
new knowledge into practice through these learning experiences. This process of construction is didactically structured. Students construct their critical-reflective thinking while they are immersed in different scenarios, relating practice to theory they obtain in their research, group discussion and with real healthcare teams.
In this teaching-learning process, evaluation is carried out in a planned schedule following the development of students, allowing them to detect difficulties to be faced during the learning process, focusing on the development of competency and skills (11) .
It breaks with the traditional objective of knowledge, which is disconnected from its real implementation, aiming only to classify and attribute grades, or only to contexts of practice in a movement of action-reflectionaction (8) . The studied subjects understand that the courses help them to develop critical thinking and closeness to reality, which are both useful in forming a professional with attributes and competencies that help them to integrate theory with practice.
Because it is an integrated competency-based curriculum, there is a need to provide tools to professors and students to use an active methodology in a significant and qualified manner so that it is linked and committed to a problem-solving capacity in health care situations (10) . Therefore, investing in the education of professionals who seek to develop a practice oriented to the health needs of populations and to the exercise of autonomy coupled with investigative thinking, creativity, ability to communicate and a solving-problem capacity, in which work is carried out in an interdisciplinary team, focused on the human being and the profession (11) , is needed and urgent.
The re-definition of the students' role in the pedagogical constructivist approach is based on active methodology and on significant learning (8) . Under this approach, students construct knowledge integrated with practice and theory in each situation of pedagogical experience, critically recording their impressions in a reflective text, ordered according to the points on the cycle, which composes their portfolio. The portfolio is therefore an important strategy that needs to be improved (10,12) .

Final Considerations
The construction of this pedagogical process seeks to educate nurses committed to their social role, subjects in life and work, with a generalist, humanist, critical and reflective education, seeking to break with the practice of placing distance between theory and practice, adopting an active methodology of teaching and learning in real contexts.
In the face of this new pedagogical proposal, from the perspective of the integrated curriculum and dialogical competence, it is necessary to involve the community in the school to improve and review its conceptual and methodological bases and also invest in the planning of evaluations, promoting mediation between the work process, teaching and learning.
The analysis shows that students value integrating courses, which are characteristic of the current curricular  In summary, the importance of an active methodology in the curriculum is evident but there is also the need to make adjustments involving the groups' integration and professors' support considering that students are the main focus of the teaching-learning process.