Nursing training and professional practice: an integrative review of literature

Formación en enfermería y la práctica profesional: una revisión integradora de la literatura

ABSTRACT

Objective:

to identify themes addressed in studies on the repercussions of nursing training in professional practice in Brazil.

Method:

this is a qualitative research, following the assumptions of Ganong's Integrative Literature Review (1987). The keywords or terms "Health Care" were used; "Nursing"; "Higher Education"; "Teaching in Higher Education"; "Health Service"; "Human Resources" and "Nursing Undergraduates" in consultation with the Virtual Health Library and the CAPES Portal of Journals. Sixty-four studies were found, of which 41 met the inclusion criteria.

Results:

in the analysis, three themes were highlighted: pedagogical processes and the role of professors and students; curricular structure in nursing education; management of health training.

Final considerations:

we observed the need to incorporate the Brazilian Unified Health System (SUS) principles and directives in nursing education in the country so that the training is consistent with the needs of professional practice. The study points out to the challenges that emerge with this incorporation.

Descriptors:
Nursing; Training; Professional Practice; Curriculum; Education

RESUMEN

Objetivo:

identificar temas abordados en estudios sobre las repercusiones de la formación en enfermería en la práctica profesional en Brasil.

Método:

investigación cualitativa, siguiendo los presupuestos de la Revisión Integrativa de Literatura de Ganong (1987). Se utilizaron los descriptores o términos "Asistencia a la Salud"; "Enfermería"; "Enseñanza superior"; "Educación universitaria"; "Servicio de Salud"; "Recursos Humanos" y "Egresos" en consulta al Portal de la Biblioteca Virtual en Salud y al Portal de Periódicos Capes. Se encontraron 64 estudios, de los cuales 41 atendieron los criterios de inclusión.

Resultados:

en el análisis, se destacaron tres temas: procesos pedagógicos y el papel de los educadores y educandos; estructura curricular en la formación en enfermería; gestión compartida de la formación en salud.

Consideraciones finales:

observamos la necesidad de incorporar los principios y directrices del Sistema Único de Salud (SUS) en la enseñanza de la enfermería en el país para que la formación sea acorde con las necesidades de la práctica profesional. El estudio apunta a los desafíos que emergen con esa incorporación.

Descriptores:
Enfermería; Graduación; Práctica Profesional; Plan de Estudios; Educación

RESUMO

Objetivo:

identificar temas abordados em estudos sobre as repercussões da formação em enfermagem na prática profissional no Brasil.

Método:

pesquisa qualitativa, seguindo os pressupostos da Revisão Integrativa de Literatura de Ganong (1987). Foram utilizados os descritores ou termos "Assistência à Saúde"; "Enfermagem"; "Ensino Superior"; "Educação Superior"; "Serviço de Saúde"; "Recursos Humanos" e "Egressos" em consulta ao Portal da Biblioteca Virtual em Saúde e ao Portal de Periódicos Capes. Foram encontrados 64 estudos, dos quais 41 atenderam os critérios de inclusão.

Resultados:

na análise, foram destacados três temas: processos pedagógicos e o papel dos educadores e educandos; estrutura curricular na formação em enfermagem; gestão compartilhada da formação em saúde.

Considerações finais:

observamos a necessidade de incorporar os princípios e diretrizes do SUS no ensino da enfermagem no país para que a formação seja condizente com as necessidades da prática profissional. O estudo aponta para os desafios que emergem com essa incorporação.

Descritores:
Enfermagem; Graduação; Prática Profissional; Currículo; Educação

INTRODUCTION

Health in Brazil is regulated as a universal right by the 1988 Federal Constitution and regulated by the Organic Law 8.080 of 1990 on Health (Lei Orgânica da Saúde) that created the Brazilian Unified Health System (SUS)^(1-2). This system emphasizes attention focused on the promotion and protection of health and not only on its recovery. In this context, vocational training assumes a fundamental role in contributing to the consolidation of the Unified Health System. It can be emphasized that nursing, in its professionalization trajectory in Brazil, has undergone relevant transformations with regard to training, following the historical, political, economic and social context, and its repercussions on education and health⁽³⁾.

The National Curricular Parameters (NCP) for nursing training indicate necessary changes in vocational training⁽⁴⁾, but other devices are needed to encourage reorientation of professional training in health, which need to be in harmony with these directives.

For the Ministry of Health, the investments with the services are in vain, in case health professionals do not engage in the actual construction of SUS. Therefore, the articulation between the training institutions and the services can correct the mismatch between training and principles, and directives of the SUS. The training processes should train professionals and citizens who are critical and reflective with knowledge, skills and attitudes to act in a qualified and integrated health system⁽⁵⁾.

However, to reach this profile, higher education must overcome practices to transmit technical and cognitive knowledge and train militant professionals to work in health as a project of society. There is a need for professionals with skills, knowledge and expertise able to help build a health system that deals with people's lives⁽⁶⁾. In this perspective, training institutions should provide adequate means for the training of professionals who act as protagonists in the development of the SUS, who are flexible to the control of society in the sector, expressing the social relevance consistent with the health reform⁽⁷⁾.

Looking for a theory to base the discussions on what the authors mentioned above talked about education and training of health professionals, it seems that the theory of education that approaches what is proposed is the ethical-critical-political theory of Paulo Freire, professor and Brazilian social scientist known worldwide⁽⁸⁾. For Paulo Freire, education happens because people are incomplete and change permanently, in the relationships they establish with other subjects and with the world, in the quest to be more human. In the relationship with the world and with others, people are completing themselves and helping others to complete themselves. Paulo Freire emphasizes that knowledge is born of action; it is acting in the world that people build knowledge, being the subject of their action⁽⁹⁾.

Among the elements that deserve to be highlighted in the direction of a training that leads the student to be subject and protagonist of the teaching-learning process are the pedagogical practices. On the one hand, such pedagogical practices must transcend traditional methods and adopt active methodologies, in order to promote greater co-responsibility and cooperative attitudes among the subjects involved. On the other hand, it is essential to develop practices that enable students to better recognize social needs, taking into account the historical, cultural and social dimensions of the population. This requires training to include the approach to the determinants of the health-disease process, throughout the entire curriculum structure. These aspects presuppose the effective construction of the teaching-service integration, so that the interaction between health and education managers is reciprocal, allowing the creation of conditions with the purpose of improving care and the teaching-learning process⁽⁵⁾.

Understanding the challenges inherent in the consolidation of the SUS, which requires the construction of a new training model, the present research had as a question: what subjects are addressed in studies about the relationship between nursing training and professional practice in Brazil?

OBJECTIVE

To identify themes addressed in studies on the repercussions of nursing training in professional practice in Brazil.

METHOD

This is an exploratory-descriptive research, based on qualitative documentary data, following the assumptions of Ganong's Integrative Review of Literature⁽¹⁰⁾.

The research protocol was elaborated and validated in October 2014 and the following steps were: choice of the research question; definition of the inclusion and exclusion criteria; sample selection; inclusion of selected studies in chart format built from Microsoft Excel; analysis of results, identification of themes, convergences, divergences and conflicts; discussion and analysis of results; and presentation of the study in manuscript form.

Papers published in the format of scientific articles (original articles, systematized reviews, experiences reports, theoretical trials, reflections); works published in the period from 2006 to 2014; works in English, Portuguese and Spanish; works available online in full; papers that reported research or experiences developed in Brazil; works whose focus contemplated reflections on the training, as well as the professional practice in nursing were considered as inclusion criteria.

Search strategies were performed based on the following Health Science Descriptors (DeCS) or terms: "Health Care"; "Nursing"; "Higher education"; "Teaching in Higher Education"; "Health Service"; "Human Resources" and "Nursing Students". The descriptors and terms were cross-referenced in the databases of the Virtual Health Library (VHL/BIREME) and CAPES Portal of Journals in December 2014.

For free search for articles in the VHL, we select the item "search in VHL" using the crossword of the descriptors or terms with quotation marks; selecting the "integrated method", "all indexes", "all sources". After that, we used the "year of publication" filters, selecting the years 2006 to 2014, "language", Portuguese, Spanish and English, and "document type", only articles.

For free search of articles in the CAPES Portal of Journals we select the item "research" using the crossword of descriptors and terms, selecting "any", "heading", "author", "subject" and "contains" and using as filter "year", selecting the years from 2006 to 2014.

In both searches, only the documents available in full format were selected, resulting in the quantitative documents indicated in Figure 1.

Figure 1
Flowchart of the collection process and composition of the study corpus

Crosses in the VHL/BIREME and CAPES Portal of Journals databases resulted in 407 items; of these, 12 were not articles, totaling 395 documents. Afterwards, we carried out the individual reading of the headings and abstracts of the works found. Of these, 156 studies were repeated, remaining 239, of which only 64 met the inclusion criteria. The 64 studies were saved in a single file, using alpha-numeric code (ex: A01, being A of article and 01, order number). In the second stage of the selection, there was fluctuating reading of 64 documents, of which 23 did not meet the inclusion criteria, totaling 41 articles that were included. The included works were analyzed by extracting elements that incorporated the Matrix 1 of the study, namely: code, year, period, authors, heading, objective, type of study, approach, study scenario and results, and the themes addressed which relate nursing education and professional practice.

The study followed the analytical model of Ganong⁽¹⁰⁾ (1987), which enables the Integrative Review of Literature. The analysis was carried out by means of a meticulous reading of the full articles, in order to verify the adherence to the objective of this study. From this reading, it was possible to recognize how the articles address the relationship between nursing training and professional practice, which guided the thematic analysis developed. In order to follow the directives of the Integrative Review, the findings were organized into a Microsoft Excel chart and analyzed from the related items that made up Matrix 2. In this matrix, interest records were placed, which generated records units with significance for the study and, subsequently, the identification of codes and categories. Within each item, ideas were grouped by similarity, making it possible to develop a narrative overview.

The study had no involvement with humans, so no research evaluation was required by the Ethics Committee on Research with Human Beings.

RESULTS

Chart 1 shows the 41 articles selected, according to the periodical and year of publication:

Chart 1
Publications on Nursing Training and Professional practice

Code	Heading	Journal	Year
A01	Nurse’s managerial competence: knowledge published in Brazilian periodicals(11)	Cogitare Enfermagem	2009
A02	Health’s integrality - guiding changes in the graduation of the new professionals(12)	Ciência e Saúde Coletiva	2010
A03	The experience of a public institution in the training of health professionals to work in primary care(13)	Ciência e Saúde Coletiva	2014
A04	Process of training and insertion in the labor market: a vision of nursing graduates(14)	Revista Gaúcha de Enfermagem	2014
A05	Integrated Management of Childhood Illness (IMCI) in the practice of nurses graduated from USP(15)	Revista Gaúcha de Enfermagem	2011
A06	Nursing administration: unveiling its conceptual, methodological and pedagogical basis in teaching in João Pessoa – PB(16)	Ciência, Cuidado e Saúde	2008
A07	The training of health professionals in Institutions of Higher Education in Divinópolis, Minas Gerais(17)	Revista Trabalho, Educação e Saúde	2010
A08	The laboratory education model as a teaching strategy for nursing formation: perceptions from egressed/students who had left the course(18)	Ciência, Cuidado e Saúde	2008
A09	Workshops as a teaching-learning strategy: a nursing educator report(19)	RECOM – Revista de Enfermagem do Centro Oeste Mineiro	2012
A10	Teaching undergraduate management: perception of nursing students(20)	Texto e Contexto em Enfermagem	2009
A11	Opinion of the nursing graduate student on the formation of nurses for SUS: an analysis of FAEN/UERN(21)	Revista Escola Anna Nery	2010
A12	Development of competences in the Nursing Course: perception of graduate students(22)	Revista Ciência, Cuidado e Saúde	2008
A13	Nursing supervised training in hospitals as a teaching-learning space: an evaluation(23)	Ciência,Cuidado e Saúde	2006
A14	Nursing and the National Policy of Education for Health Care Professionals for the Brazilian National Health System(24)	Revista Escola de Enfermagem USP	2011
A15	Nursing undergraduates experiences with nursing management subjects(25)	Revista Invest. Educ. Enfermagem	2012
A16	Teaching of education in undergraduate nursing courses(26)	REBEN – Revista Brasileira de Enfermagem	2010
A17	Educational practices of health practioners: nursing estudents experiences(27)	REBEN – Revista Brasileira de Enfermagem	2008
A18	Aspects that facilitate or difficult nurse’s training in primary health care(28)	Revista Invest. Educ. Enfermagem	2011
A19	Comprehensiveness as a pedagogical principle in nursing education(29)	Texto e Contexto em Enfermagem	2013
A20	The academic participation and its influence on the professional life according to the perceptions of nurses(30)	Cogitare Enfermagem	2009
A21	Background and managerial practice of nurses: paths for transforming praxis(31)	Revista Latino - Americana de Enfermagem	2008
A22	College program evaluation according to graduates(32)	Revista Escola de Enfermagem USP	2009
A23	Evaluation of nursing education according to the perception of ex-students(33)	Acta Paulista de Enfermagem	2008
A24	Education process of nurse leaders(34)	REBEN – Revista Brasileira de Enfermagem	2010
A25	Political-ethical skill development in nursing undergraduates(35)	Revista Escola de Enfermagem USP	2013
A26	The perception of the egresses about the curricular changes occurred during the nursing course(36)	Revista Educação Temática Digital	2012
A27	Linkages and challenges in the training of professional nurses(37)	REBEN – Revista Brasileira de Enfermagem	2010
A28	Freire’s theoretical framework and the professional capabilities of nurses, physicians, and dentists for the Brazilian Universal Healthcare System(38)	Acta Paulista de Enfermagem	2009
A29	Managemental performance of the nurse in the perspective of the just-egresses of the nursing course(39)	Revista Escola Anna Nery	2006
A30	Job market placement: professional trajectory of nursing graduates(40)	Revista Escola Anna Nery	2013
A31	Management competences in the formation of nurses(41)	REBEN – Revista Brasileira de Enfermagem	2010
A32	Manifestations of graduates from a nursing course(42)	REME – Revista Mineira de Enfermagem	2011
A33	The FENFE/UERJ nursing graduate in the working world(43)	Revista Escola de Enfermagem USP	2011
A34	Professional development and entering the labor market: the perceptions of nursing graduates(44)	REBEN – Revista Brasileira de Enfermagem	2012
A35	Broad nursing care(45)	REME – Revista Mineira de Enfermagem	2009
A36	Integrating teaching, nursing work and citizenship(46)	Revista Gaúcha de Enfermagem	2010
A37	Services Needs and Requirements of the Academy: a Possible Links(47)	Revista Brasileira de Ciência da Saúde	2009
A38	The Academic Healthcare System1 under the Federal University in Santa Catarina and the Florianópolis Municipal Health Secretariat2: effects of the Pro-Health I and II projects(48)	Revista Brasileira de Educação Médica	2012
A39	The Educational Program for Health Work at the Federal University in São Paulo: Contributions to Institutionalization and Integration between the University and Healthcare Services(49)	Revista Brasileira de Educação Médica	2010
A40	Knowledge, skills, and attitudes towards management of nursing graduates of a Brazilian public university(50)	Revista Invest. Educ. Enfermagem	2012
A41	Living the international classification of nursing practices in public health: report of experience(51)	Revista Escola Anna Nery	2013

• Note: USP- Universidade de São Paulo; SUS-Single health system; FAEN/UFSC-Faculty of Nursing/Universidade Federal de Santa Catarina; FENF/UERJ-Faculty of Nursing/ Universidade do Estado do Rio de JaneiroUFSC/SMS-Universidade Federal de Santa Catarina/Municipal Secretariat of Health.

Chart 2
Overview of the results according to the studies and respective themes to which they belong

Theme	Sub-theme	Main Results
Educational processes and the role of professors and students	Methodologies/Educational practices	- Changes in educational practices are a challenge in nursing(11). - Problematic educational practices aim to introduce the student into the community, enabling the recognition of the context(17-18). - Research is a form of meaningful learning, requiring more encouragement(20-21). - Active methodologies contribute to multiprofessional, interdisciplinary and transdisciplinary integration and develop the autonomy of critical and reflexive subjects(12-13). - The preference for traditional methods is related to previous experiences or lack of preparation of professors(14-16-27). - Assessments are still loaded with non-emancipatory and reductionist characteristics and are not consistent with a reflective educational model, and they can develop the learning of co-responsibility when done in a dialogical way(16,17,23).
	Protagonism of students	- Undergraduates take or are led to take a passive stance, which affects professional practice(18). - The lack of protagonism can be related to the vulnerabilities of the structures of power. The undergraduates consider that it is up to the one who teaches the knowledge. Institutions of Higher Education should develop strategies to facilitate participation(32). - The lack of autonomy interferes negatively in the training(33-34);
	Role of the professor	- The students’ lack of interest in the educational work from problematizing methodologies needs attention of the professors(16). - The responsibility of the Institutions of Higher Education is to train critical and reflective leaders capable of creating and recreating their reality(18,28,35-36). - Students should be encouraged to have autonomy, but with the support and follow-up of the professor(20). - Students should participate in the didactic-educational organization of the institution(21,23). - The school plays an important role in participatory experiences, and the teaching-learning process can influence adherence to the participatory process(32). - Most professors are not able to teach(17,24-25). - In health education, teaching requires the preparation of professors for the use of active methodologies(18). - The professor has a facilitating role in this process and the relationship is mutual learning(13,19,29-30,32). - The figure of the professor is important for the student to develop a taste for the future profession(14-26,28),
Curricular structure in the Nursing training	Insertion and articulation of standards in the training process	- Fragmented knowledge hinders the ability to deal with diversity(11,15). - The principle of integrality does not have continuity in teaching, being addressed only in isolated courses of Primary Care(19,29). - The integrated courses favor the teaching-learning process and the performance of the multiprofessional team(22).
	Teaching Model	- The labor market emphasizes skilled labor over critical-reflexive training(11,14,18,26-27,32,37). - The reproduction of the traditional model of health care places the learning of technical skills to the detriment of collective practices(13,31,38). - The collective construction of teaching facilitates the observation of the individual as a whole. Integral education facilitates integral vision and practice(15,28,39,41). - Some Educational Course Projects present articulated courses that indicate better adaptation to current legislation(17,22,29,34-35,37,42-44). - The lack of preparation in teaching to supervise and lead the team and few opportunities for professional experience in the field of management are some of the realities(40). - Contents related to Health Policies and SUS are present during the training(41).
Shared management of the training in Health	Theory and Practice	- The nurses’ training process comprises the apprehension of the theoretical content, reflecting this knowledge in the practical field(14). - The interaction of the theoretical-practical aspects and the cultivation of critical thinking are essential for the domain of the profession(20). - Greater links between theory and practice enrich undergraduate education and enable the development of problem-solving skills and systematize assistance(30).
		- The student’s approach to reality establishes meaningful and effective learning. Teaching should enable the student to experience the reality of the labor market in different settings(20,34,37,46). - The lack of internship opportunities is one of the weaknesses found in nursing undergraduate courses(22,30,44). - The receptivity of the field has an important role in the development of practical classes, allowing to experience what is learned in theory(25). - Divergences between the role of the nurse that is understood in the university and the reality of professional practice, generating contradictions between discourse and practice(30-40-42-47).
	Teaching-service integration and Permanent Education in health	- The sharing of the technical knowledge of the service nurses with the students occurs only in part(14-15,46-47). - Permanent Education is an educational process that makes it possible to think and do at work(18,34,39,46,48). - Physical structure of practice spaces is inadequate to meet students. Health education should be considered as a permanent process by the teaching-service partnership(28,51), - The training of nurses still lacks a link between teaching and service(36). - The discussions that occur involving students, professors and service nurses have a transformative perspective between teaching and service(38,40,46,48-49). - The nurse assistant assists in the training process by the domain of practice, integration of the students with the team and theoretical learning of the practical activity(42,50).

Most publications (40%) date from the year 2009 and 2010, as can be seen in the chart above. In an Integrative Review on the Training of Human Resources for SUS, covering the years 2001 to 2012, the author found that the largest number of publications dates from the year 2007, 2009 and 2011⁽⁵²⁾.

Of the studies found in this review, 73.80%, are empirical studies with field research. Regarding the approach, most studies (78.57%) are qualitative. The journal with the largest number of publications was the Revista Brasileira de Enfermagem (REBEN), with 14.28% of the publications. The majority of the authors are women, totaling 84.45%. The region of the Brazil that developed the most studies on the subject was the southeast region, with 47.50% of them, followed by the southern region, with 35% of the studies carried out, and the northern region had no studies.

Analyzing the articles found, the following themes were obtained that relate nursing training to professional practice: pedagogical processes and the role of professors and students; curricular structure in nursing education; and, shared management of health education.

The following chart shows a general overview of the main results found in the study by identified themes and sub-themes and the characteristics of the studies that stand out in each one.

DISCUSSION

1. Educational processes and the role of professors and students

Discussions about the educational processes in health have become essential, since the recognition of the complexity inherent to the new times reinforces development of the autonomy of the subjects as challenges, in co-responsibility with the collective.

The educational model that proposes the training of a new profile of nurses, with a view to transforming professional practices, goes through the teaching-learning methodologies used in the spaces of knowledge construction. Also, teaching-learning educational processes must take into account several aspects, among which, the prominence of the individuals involved.

In articles^{(11-12,14-15)} there is a reinforcement of the need to transcend educational models based on the transmission of knowledge to a model that places professors and students in a dialogical way in the construction of knowledge.

In relation to educational models, the proposal is to construct ethical, critical, reflexive and transforming processes that transcend the limits of technical training for the training of a historical being based on the dialectic of action-reflection-action⁽⁵³⁾.

A educational model may be based on one or more theories and paradigms of learning or may be the reinterpretation of these. This implies admitting that this is not limited to the teaching-learning methodologies used, but should be consistent with the system of theoretical premises of how the curriculum is approached, materialized in educational practices⁽⁵⁴⁾.

Based on the Federal Constitution, which assures health as a right of all, and the duty of the state, with prerogatives of change in care practices, which consider health promotion and prevention of diseases beyond recovery, health care models need to be rethought. Several discussions are leveraged by these changes and Nursing in Brazil initiates a movement to rethink the training of professionals with profile to meet the demands of the new health system of the country. Later, this movement culminates in the reformulation of the National Curricular Parameters for nursing undergraduate courses.

In this direction, the training institutions are invited to change their educational practices in the effort to approach the social reality; training professionals as social individuals with ethical, political and technical skills, and endowed with knowledge, reasoning, criticism, responsibility and sensitivity for the issues of life and society; that they are able to intervene in the contexts of life with their uncertainties and complexities⁽⁵³⁾.

At the same time, we can say that active methodologies use questioning as a teaching-learning process in order for students to give new meaning to their findings. The questioning leads the student to seek solutions to problems, promoting their own development⁽⁵³⁾. In the questioning, students reveal their understanding of reality in their relations with the world, being this reality in a process of transformation, which allows them to perceive critically how they are in the world, finding in the dialogue the unveiling of this reality.

Difficulties are referred to in articles^{(11,14,16-18,27)} regarding the use of differentiated methodologies in the construction of knowledge and often blame students on preferring traditional methods. Professors are also cited as responsible for this preference that is associated with the lack of preparation to work with active and different methodologies.

On the other hand, other articles^{(16,18,21,23,25,28,32,35-37)} state that it is the responsibility of educational institutions to modify curricula, encouraging the use of active methodologies that propose the construction of knowledge from the dialogical relationship between professors and students.

In the practical field of the nurse working in the SUS, several professional assignments are established, among them, team coordination, management, service management, and their important contribution in the training of new health professionals. The studies^{(13,18,24,27)} cite some of the obstacles of learning in the practical field that are affected when the student is received by professionals with little experience or with little knowledge about primary care. The high turnover of professionals and the lack of training to act in primary care are factors that, in addition to causing damages to primary care assistance, negatively interfere in the teaching-service articulation, in the training of new professionals and in the process of Permanent Education in health. The inheritance of the biomedical model and the lack of educational strategies in training to make professionals more critical and active in the learning process do not favor space for personal, collective and permanent learning.

A positive point found in the studies^(28,34-35) regarding the professional practice of the SUS, in the positive contribution in training, concerns the importance of the presence of more experienced professionals at the beginning of the career of new professionals. The daily work of nurses is an intense relationship of knowledge. Thus, it is urgent to review the educational strategies used and the articulation theory and practice in order to question the educational practices performed in the health services, promoting the autonomy of nurses to be in constant learning, incorporating it in practice for the constant transformation work processes and reality.

Nurses working at the SUS have an important role in training new professionals. This is because the education of health professionals must be based on the reality in which theory and practice become inseparable, allowing professionals and future professionals to respond to the challenges of contemporary times and to be protagonists in the construction of their histories⁽²⁰⁾.

It is possible to affirm that adult education presupposes that, in addition to the use of active teaching-learning methodologies, other challenges must be overcome by the students, allowing them to occupy the place of subjects in the construction of knowledge, with the professor as facilitator and guiding the process⁽⁵⁾.

The role of the professor is questioning, and students becoming critical researchers in dialogue with the counselor who is also a critical researcher. Education should put professors and students in a dialogical position. The educator is no longer the one who only teaches, but what while teaching, is taught in dialogue, both become subjects and grow together in the process, thus educate themselves in communion mediated by the world⁽⁵⁵⁾.

Taking into account the speed with which knowledge is produced, one of the fundamental objectives of learning in the undergraduate course should be to learn to learn. This also requires the application of criticism during the learning process⁽⁵⁾.

For this to be possible, it is necessary an education that leads people to be subject and this becomes subject by a reflection on their reality and real environment. The more you actually emerge in the real environment, the closer you are to be ready to intervene in reality in order to change it. This education that develops consciousness and criticism in which people choose and decides, frees them⁽⁵⁶⁾.

In this regard, it is important to emphasize the ontological vocation of people to be subject and not object. People are not empty beings, but are situated in time and space; they live in a time and in a social context. Therefore, to validate education must consider the vocation of man to be subject and its conditions of place, time and context⁽⁵⁶⁾.

2. Curricular structure aspects and the Nursing training

Some articles^{(11,15,19,21,29)} point out that the fragmentation of the nurse's professional practice begins during their undergraduate course. Undergraduates experience teaching with separate courses and content that result in the fragmentation of learning. This reflects negatively on nurses' professional practice. Through article⁽²¹⁾, it was possible to identify that, although the NCPs guide education through content integration, there are difficulties in operationalizing this integration.

Several mobilizations were promoted by the Associação Brasileira de Enfermagem (Brazilian Nursing Association) with a view to the construction of the National Curricular Parameters approved in 2001. The proposal was to bring together the education and health sectors and to think about the training of professionals to work in the Brazilian Unified Health System (SUS).

NCP of Nursing should guide Institutions of Higher Education in the training of citizens and professional nurses, in the definition of curricular components and in the construction of Course Teaching Projects (PPC) that should contain the philosophical, conceptual, political and methodological bases that define the essential skills to the training of nurses⁽⁵⁷⁾.

The training institutions, in turn, must demonstrate the social relevance present in their educational projects that impart meanings in the production of knowledge and vocational training, fulfilling their public functions⁽⁷⁾.

Therefore, the new model of training of health professionals implies the construction of an integrated curriculum⁽⁵³⁾ with adequate articulation between the determinants of health and disease, seeking, both in the theoretical knowledge approach and in its care application, to keep adequate to the biological and social articulation of the health-disease process⁽⁵⁾. This new training model requires innovative educational practices, which encourage the protagonism of the student (and in this case, we are talking about those aligned with the critical currents of education), in order to contribute to the training of professionals with learning capacity, considering the speed with which the current knowledge is produced in order to guarantee integrality in quality assistance, with efficiency and resolution. It is also necessary to "train professionals as social individuals with ethical, political and technical skills endowed with knowledge, reasoning, criticism, responsibility and sensitivity for the issues of life and society, enabling them to intervene in contexts of uncertainty and complexities".

The articles^{(14-15,17-18,21-22,28-29,34-37,41-42,44-45)} also state that contents related to public health policies that lead to reflections about of the strengthening of the Brazilian Unified Health System have been inserted in the curricula. This evidences the recognition that health education in the country must transcend the hegemonic conception, which considers the hospital as a center of learning focused on biological aspects, for a model based on the real health needs of socio-historically constructed users and for the responsibility of professionals for the health problems of the populations of the territories under their operation⁽⁵⁸⁾.

In this sense, the training should address aspects of SUS's thinking and knowledge, aiming at the transformation of professional practices, the organization of work and its capacity to welcome and care for the health needs of people, groups and populations⁽⁷⁾.

3. Shared management in Health training

Health training needs, in addition to the articulation of knowledge, the participation of the actors involved in the training process.

The articles^{(14,20,25,30,34,37)} cite the importance of the theoretical-practical articulation in diversified scenarios and state that it has been happening. However, some articles^{(22,30,40,42,44,47)} still expose weaknesses in practice scenarios, especially regarding the lack of spaces. Health training needs, in addition to the articulation of knowledge, the participation of the actors involved in the training process.

A responsible shared network is needed for the training of health professionals, composed of teaching-service-management-social control, that is, the quadrilateral of training. The service is not restricted only to the mastery of technical skills, but to the production of meanings of acts of caring for health problems or improving the quality of life of populations⁽⁷⁾.

Also, for training and a professional practice in keeping with health realities in the country, aimed at meeting SUS demands, it is necessary for students to have experiences between theory and practice in diversified scenarios. These, in turn, should allow the student to recognize and understand the network of care of which they will be part as nurses.

It is in reality that individuals create and recreate, and it is in this process that people become aware. The more people reveal reality, the more they deepen the object, which cannot exist outside of praxis and without the action-reflection-action. This is the way of being or transforming the world that characterizes people. It implies that these take the role of individuals who shape and reshape the world⁽⁵⁶⁾.

Health education training is central and represents the constitution aimed at the population, their health needs, so that the social management of public health policies should be considered⁽⁷⁾. The student's interaction with population and with health professionals should occur from the beginning of the training process, providing work on real problems and taking on increasing responsibilities⁽⁵⁾. This requires a diversification of the scenarios in which practical learning is developed during training, including educational and community facilities, which are part of the relevant territories and spaces for health promotion.

For this to happen, it is necessary to articulate the social sectors responsible for health education. This articulation between teaching-service is an important aspect in health training as it emerges from different exchanges of experiences and mutual learning. Permanent Education occurs and is strengthened through the exchange of experiences between those involved in training processes.

The articles^{(14-15,28,36,46-47,51)} state that the need for articulation already demonstrates the distance between teaching-service that should be co-responsible for the training process of health professionals. However, they point out that the articulation does not happen due to numerous obstacles present mainly at work, in which professionals do not take responsibility for the training of new professionals as their own.

As teaching and service get closer, what is intended that students should have an expressive participation in the care network, building the learning process from reality, directing the reorientation of the work process to an analytical health system with quality⁽⁵⁹⁾.

Permanent Education in health permeates several of the sub-themes already mentioned. It takes place through active teaching-learning methodologies, involving professors, students, professionals and communities. In addition, it occurs in the scenarios of practice, which enable reflection on reality, and the moments of theoretical-practical classes are opportunities that must be recognized by the individuals for Permanent Education to happen.

Learning and teaching is part of human existence as well as the process of redoing, knowing and teaching what is learned, and learning what is taught, improving every day. Human beings, through the consciousness of their incompleteness, remain in constant search, inquiring, curious and moved in a constant process of training⁽⁸⁾.

Permanent Education understands that the practice scenario informs and recreates the necessary theory, recreating the practice itself, proposing to reflect on the care and management practices. It should be a work-oriented education, but an education that thinks about the work and the production of the world through a critical reflection⁽⁷⁾.

Education of health professionals should be understood as a permanent process in professional life, through the establishment of partnerships between educational institutions, management and health services, the community, bodies and other sectors of society⁽⁵⁾.

Limitations of the study

In conclusion, we recognize the limitations of this study, which relate to the inclusion and exclusion criteria of the studies themselves, and the fact that we have researched two databases, which represents only part of the universe of studies. We recommend further studies in order to deepen the debate on the subject. We suggest mainly to the professors who work in the area, allowing reflection on the themes addressed.

Contributions to the area of nursing, health or public policy

The construction of this Review of Literature contributes to show the need to incorporate the principles and directives of the Brazilian Unified Health System (SUS) in nursing education so that the training is consistent with the professional practice, pointing to the challenges that emerge from this incorporation.

FINAL CONSIDERATIONS

One of the themes that emerged about nursing education with an impact on professional practice refers to the educational processes and the role of professors and students. They encourage professors to create innovative methods, to transcend traditional methods, and to encourage them to become learners of the process as well. To the students, take on the role of protagonists and subjects, together to construct innovative teaching and learning methodologies.

Regarding the curricular structure in nursing education, it is proposed that nursing education be based on content integration and transcend the individual and curative clinical model for a model based on the Brazilian Unified Health System (SUS) in all its aspects. The curricular structure should lead the student to understand health beyond the health-disease process so that he/she undertakes to construct it as a social project.

Finally, the shared management of health training challenges the responsibility for nursing education to reach other sectors, in addition to health and education, so that the theoretical-practical articulation is possible. And, that this process is fruitful territory for the development of the permanent education in health.

The Review of Literature confirms that the training of professionals has decisive influences on the practice of professionals, and can contribute to a reproduction of the biological, clinical and individual model or to a model based on integrality that considers the socio-historical and cultural needs of individuals. Therefore, the theme must continue to be the subject of discussions and debates among all sectors.

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Publication Dates

• Publication in this collection
  Jul-Aug 2018

History

• Received
  14 Sept 2016
• Accepted
  16 Oct 2017