The relationship theory- practice and the teaching-learning process in a Collective Health Nursing Course

Abstracts

Este estudo tomou como objeto a articulação teoria-prática da disciplina Fundamentos e Práticas da Enfermagem em Saúde Coletiva, do curso de graduação em enfermagem da EEUSP, e como objetivos: identificar a apreensão dos conceitos da disciplina e verificar sua aplicação nas práticas de enfermagem entre esses estudantes de graduação. Utilizou questionário com questões fechadas e abertas para apreensão empírica do objeto, através de análise de conteúdo. Os resultados indicam que a dimensão teórica apenas em parte possibilitou sínteses capazes de fomentar práticas sociais coerentes com o arcabouço teórico-conceitual da Saúde Coletiva. Para superar essa dificuldade faz-se necessário explicitar as diferentes abordagens teórico-metodológicas que fundamentam as práticas e que o educador direcione o educando para elaboração de sínteses, com a finalidade de formar enfermeiros comprometidos com a interpretação da saúde-doença como processo social e da saúde como direito social e, portanto, com a transformação das práticas reiterativas do modelo hegemônico.

Ensino; Enfermagem; Enfermagem em saúde pública; Educação em enfermagem

ORIGINAL ARTICLE

The relationship theory- practice and the teaching-learning process in a Collective Health Nursing Course

Articulación teoría-práctica y proceso enseñanza-aprendizaje en un Curso de Enfermería en Salud Colectiva

Célia Maria Sivalli Campos^I; Cássia Baldini Soares^II; Carla Andréa Trapé^III; Bárbara Ribeiro Buffette Silva^IV; Tatiana Cristina Silva^V

^IPh.D., Professor. School of Nursing, University of São Paulo. Doctorate in Nursing. São Paulo, SP, Brazil. [e-mail]

^IIAssociate Professor. School of Nursing, University of São Paulo. Doctorate in Education. São Paulo, SP, Brazil. [e-mail]

^IIINurse at Jd. Boa Vista Primary Health Care Center. Master in Collective Health Nursing and Doctorate in Nursing. São Paulo, SP, Brazil. [e-mail]

^IVUndrgraduate student. School of Nursing, University of São Paulo. Holder of a scientific initiation grant, of the teaching with research modality, University of São Paulo Undergraduate Studies Department. São Paulo, SP, Brazil. [e-mail]

^VUndrgraduate student. School of Nursing, University of São Paulo. Holder of a scientific initiation grant, of the teaching with research modality, University of São Paulo Undergraduate Studies. São Paulo, SP, Brazil. [e-mail]

Correspondence addressed to

ABSTRACT

This study focused on the relationship theory-practice of the discipline Fundamentals and Practices of Collective Health Nursing, offered to undergraduate students of the Nursing School, University of São Paulo, Brazil. The objectives were: to identify and understand the concepts studied in the discipline and to identify its application in nursing practices among these students Data were collected using a questionnaire and analyzed by content analysis. Results: theoretical dimension only partly allowed students to make syntheses potent to develop social practices consistent with the conceptual framework of Collective Health. To overcome this difficulty - and prepare nurses committed to the interpretation of health and disease as a social process and health as social right and, therefore, the transformation of reiterative practices of the hegemonic model -, it is necessary to clarify the different theoretical and methodological approaches underpinning the practices, having teachers directing students to articulate theory and practice.

Key words: Teaching. Nursing. Public health nursing. Education, nursing.

RESUMEN

Este estudio tuvo como objeto la articulación teoría-práctica del curso Fundamentos y Prácticas de Enfermería en Salud Colectiva, para alumnos de graduación de la Escuela de Enfermería de la Universidad de Sao Paulo. Se buscó identificar la aprehensión de los conceptos del curso y evaluar su aplicación en las prácticas de enfermería. Se utilizó un cuestionario para aprehender empíricamente el objeto. Las informaciones fueron analizadas con análisis de contenido. Resultados: la dimensión teórica, apenas en parte, posibilitó una síntesis capaz de fomentar prácticas sociales coherentes con la estructura teórica-conceptual de Salud Colectiva. Para superar esa dificultad es necesario explicar los diferentes enfoques teórico-metodológicos que fundamentan las prácticas y que el educador conduzca al educando en la elaboración de síntesis. De esta manera, formar enfermeros comprometidos con la interpretación de salud-enfermedad como proceso social, con la salud como derecho social y con la transformación de las prácticas reiterativas del modelo hegemónico.

Descriptores: Enseñanza. Enfermería. Enfermería en salud pública. Educación en enfermería.

INTRODUCTION

The Collective Health Nursing (CHN) Department at the University of São Paulo School of Nursing (EEUSP, abbreviation in Portuguese) was created during the movement for establishing the Collective Health field. The theoretical and methodological frameworks of collective health were historical and culturally inspired and became the central support for the practice of teaching and research aimed at the development of policies to change health and health care conditions in Brazil.

The theoretical-methodological framework supporting Collective Health was sought to make a radical criticism to the functionalist approach sustaining the multi-factor explanation of the health-disease process, hegemonic in Public Health. Inspired in an inter-disciplinary epistemology, collective health sought sources especially in Social Sciences of historical and structural character, capable of making a conceptual relationship of the forms that social groups reproduce the explanation of the health-disease process⁽¹⁾ and propose practices that are consistent with that interpretation.

The referred inter-discipline character, though indispensible - due to the multiple facets and complexity of Collective Health - is fragile in health workers' education, which reinforces biomedical courses in detriment to their intersection with social sciences⁽²⁾ and makes the theory-practice relationship more difficult.

To understand any social phenomenon, including those related to the health-disease process, it is necessary to know its many dimensions, which are part of the courses and of the relationships between courses in the curricula that are the bases of health workers' education^(3-4), particularly in the preparation of nurses⁽⁴⁾.

It is important to educate health workers to use innovating practices and care models when facing the challenge of developing the Unique Health System (UHS), o SUS, having the theory-practice relationship as one of the guidelines for educational practice⁽⁴⁾. However, the initiatives to implement curricular changes to answer that need remain scarce⁽³⁾. Particularly in nursing education, innovative educational practices usually integrate contents to produce more comprehensive knowledge, which, in turn, is what has the power to understand health as a whole⁽⁵⁾.

The CHN department has developed undergraduate courses with the purpose to prepare nurses who are capable of performing a social practice that considers the social determinants of the health-disease process in the course of changing health work. One of the referred courses is Collective Health Nursing Fundamentals and Practices (referred to as ENS 235), which has the purpose to provide students with the necessary tools to identify the health needs of social groups that together form the territory covered by a Primary Health Care Center (PHC), recognizing health as a socially determined process and as a social right.

The referred course consists of classes that present Collective Health concepts, which provide students for the activities they will perform during practical classes at PHC.

In this class, the teaching-learning process is supported by the development of an investigation about the characteristics regarding the social reproduction of families in the area covered by a PHC. This permits students to understand the problem of the situation they find and to implement a health education project that would be able to achieve two goals: first, to answer some of the identified health needs; and, second -as an instrument of the teaching-learning process- make it possible to create practices consistent with these needs, overcoming reiterative practices primarily reproduced according to the programmatic logic.

OBJECTIVES

The objectives of this study were to identify EEUSP undergraduate students' understating of Collective Health concepts and verify how those students use those concepts in nursing practice.

THEORETICAL CONSIDERATIONS

Praxis is a strong category to explain the connection/discussion between accumulated knowledge (students' understanding of Collective Health concepts) and its use in nursing practices; it refers to an activity adjusted to objectives, guided by the consciousness (theoretical activity) to change a certain object based on an intentional project⁽⁶⁾.

The form how consciousness is present in the subject's practice assigns different levels of praxis, hence it is possible to differentiate creative praxis from reiterative praxis. Reiterative praxis is a practice that follows a previously established law, with analogue products. Creative praxis, considering it originates in a conscious project, does not fully adapt to a previously established law and produces a new and original product⁽⁶⁾.

From that perspective, the production of new knowledge is determined by practical purposes; however, the practical problem that mobilized it - the object of this process - requires knowledge

about something new that must be known. In other words, without knowledge it is impossible to explore the unknown [...]. Therefore, the proposition of experimentation or problem-posing as the starting point for knowledge development requires, first, specific basic conceptual knowledge. Otherwise, the process of decoding the identified data might not overcome immediate knowledge that is restricted to empirical thinking⁽⁷⁾.

It is an error to favor immediate knowledge (empirical) over concept-based knowledge, under the false idea that theory (an abstraction) is deprived of objectivity⁽⁸⁾. There is no practice without theory, and no theory deprived of practice. In this theory-practice movement

theoretical knowledge is filled with empirical contents, which, in turn, consist of truly human knowledge, through their theoretical-abstract mediations [...] If, on one hand, abstractions and concepts move away from the object, on the other hand, nothing is more appropriate to become closer to its essentiality, considering that true knowledge is not obtained by live contemplation or immediate contact. [...] the genetic code (thought concrete) will never be immediately learnt by observing blood (apparent concrete) [...]⁽⁷⁾.

METHOD

The population of this descriptive study consisted of nursing undergraduate students from EEUSP, 70 of which were attending the course in 2007, in addition to 72 who had attended the same course in 2005 or 2006.

After receiving and invitation and being informed about the study objectives, participants agreed to take part in the study at their own will and signed the Free and Informed Consent Form.

The project was approved by the Research Ethics Committee at EEUSP (register number 620/2007).

Data collection was performed by means of a questionnaire addressing the students' understanding of Collective Health concepts (each participant was asked to state all the concepts taught in the course that they could remember). Students attending the course were also asked how they could use, in their further practices, the collective health concepts they had stated. Students that had taken the course in the previous years were asked how they used the concepts they stated in other courses, especially in areas of nursing care practice. The questions also addressed the strengths of the course ENS 235 to make the theory-practice relationship of these concepts effective.

The obtained data were submitted to content analysis⁽⁸⁾, which permitted to analyze the frequency of the answers to the closed questions, as well as the elaboration of the statement meanings, presented in the open questions, under two themes: sedimentation of concepts and syntheses that promote the theory-practice relationship.

RESULTS

Of the 70 students attending the course in 2007, 45 (64%) answered the questionnaire, against 36 (50%) of the72 students who addressed the course in 2005 or 2006. The other students who did not answer were either absent on the day or chose to not participate in the study.

Table 1 lists the concepts stated by the respondents, 40 (88.9%) of which were attending the course and 26 (72.2%) of those who attended in the previous years.

Among those who stated concepts, the most frequently remembered was the social determination of the health-disease process, by 33 (82.5%) of the students attending the course as well as 24 (92.3%) of those who had attended the course in the previous years, as shown in Table 2.

Sedimentation of concepts

The course's potential for the sedimentation of concepts was also investigated. Most students who attended the course in the previous years - 26 (92.8%) - reported the course's strength, which proposes to combine concepts and practical classes at PHC, where the concepts are brought closer to real objective situations - a strategy that students consider fundamental to integrate the concepts, as described in the following example:

The course was fundamental for the sedimentation of the concepts, as it made their discussion possible, that is, it started from concepts we already knew and developed them. Later, with the internships, it was possible to observe the contents in practices and see how they were established in this area.

A smaller number of those who had already attended the course, 15 (53.5%), stated limitations to emphasize the learning of the concepts: insufficient hour load, disagreement among the professors teaching the course, lack of integration between theoretical and practical classes.

On the other hand, among the students attending the course, 26 (57.7%) gave generic answers that the practical classes were important to implement theory in practice. However, 10 students (22.2%) described how that contribution occurred, as shown below:

I saw many problems in practice, I saw that the UHS is perfect only in theory and there is very much to be done. Seeing other's errors and transmitting what we learned in theory to other professionals is of great help in the sedimentation of theory. In addition, being able to confirm and observe that the social determination of the disease process is, in fact, present in the everyday practice in the inquiries, helped the sedimentation of concepts and allowed for a better view of the social determination.

Only five (11.1%) students attending the course reported difficulty in establishing the theory-practice relationship, 40 (88.8%) informed having little or no difficulty. Among the difficulties stated, 19 (57.5%) also added the ineffectiveness of the course to promote the relationship between concepts and practical activities, as shown in the excerpts below:

I cannot answer, I considered the course very abstract, I know it is, but I did not sympathize with this type of terms, thought they are very important. I think it lacked interaction between theory and practice. It appears as one thing only, first we studied theory and then when we go to practice, we forget the theory.

I think there should be a professional to make the transition from theory to practice. I think it would be easier to learn.

Syntheses that promote the theory-practice relationship

Considering that social determination of the health-disease process was the most frequently memorized concept, it was expected that students would associate the reading of determinant and conditioning factors of the health-disease process in the performed practices. However, among the students who had attended the course in the previous years, only part (36%) described using the concept in some practical activity in other undergraduate courses, as described in the example below:

I observed that the health-disease process does not depend only on the individual, but also on the population of which it is part and on the life conditions of that population; which is the collective health concept that I used. In practice I asked the patient where he or she lived, his or her family, neighborhood, etc.

As for the students who were attending the course during the studied period, there was a higher percentage (62%) of those who stated and exemplified how to associate concepts presented in the course to nursing practice.

I believe that keeping the concept of territory in mind, recognizing the several epidemiological profiles, realizing the social characteristics, the potentials of wearing and strengthening, and, finally, all the contents addressed in the course prepared me for my future professional practice as a nurse, for when I put a bandage on a patient, provide nursing consultation, administer medications and/or perform educational activities. Of course this preparation is not complete, but the course can help me guide myself.

The difficulty to understand the concepts was noticed, on one had because of the number of students that did not state any of the concepts taught in the course, and on the other hand because of the difficulty, presented by students who stated concepts, to exemplify their use in nursing practice.

DISCUSSION

The present study results showed that the respondents memorized concepts, but were more often remembered among student attending the course, probably because the students answered the questionnaire on the last day in the course, which means it was easier for them to recover the concepts from their memories.

The concept most frequently remembered by the students was the social determination of the health-disease process. As this is one of the fundamental concepts developed in the course, it was expected that students would associated this concept to activities performed in the practical courses, exemplifying its use in health practice, especially nursing practice. However, the expected rate of mentioning this relationship was not proportional to the rate of the memorization of the concept.

It should, however, be emphasized that if on one hand more students attending the course were able to describe how the Collective Health concepts could be used in their future practices, among students who had already attended the course there was a higher percentage of reference to the relationship between the concept of social determination of the health-disease process and the practices, showing there was greater understanding of this concept among those students.

This result is consistent with the definitions of understanding a concept as a process, the students who attended the course in the previous years had higher theoretical-practical chances of elaborating syntheses, confirming the idea that understanding the concepts does not occur in a single theoretical-practical teaching experience, which is a situation that occurred with students attending the course during the data collection period.

However, of the 4305 required course hours that compose the nursing curriculum, the ENS department courses add to 825 hours, that is 19.2% of the whole curriculum, distributed among 6 of the 44 required courses in the nursing undergraduate curriculum.

Therefore, it can be inferred that in the EEUSP undergraduate curriculum, the area for teaching-learning Collective Health concepts, and thus the opportunities for the students to use these concepts in nursing practice, are reduced to the chances offered by the ENS department courses. It should be noted that the concepts taught in the course, partly originated in the theoretical sphere that established the Collective Health field, do not originate from the dominant theory, which is based on clinical and epidemiological knowledge, according to a classificatory functionalist view.

However, the curriculum is a reproducer of values. In modern times knowledge has been fragmented under the justification of the need for in-depth knowledge. Nevertheless, after in-depth knowledge of the parts, there has not been a recomposition of the object of knowledge, in a necessary movement to process the synthesis, and this assigns a value to limiting knowledge to the restriction of the specialty, an intolerance to the interference of values and the dichotomist distinction between subject and object⁽⁹⁾. Therefore, hegemonically, knowledge remains based on classification and fragmentation.

To overcome the difficulty of the theory-practice relationship brought by the students, derived from the functionalism that also fragments teaching into courses, we propose the context of creative praxis, which has the strength to support the creation of a curriculum that favors the theory-practice relationship and interdisciplinary integration.

Social practice presupposes theoretical and practical domains, and, therefore, when the subject of knowledge has a thought of the reality, meaning to interfere, the quality of his or her intervention will depend on the conceptual knowledge he or she has, that is, thought (as an expression of the capacity to know) is not a spontaneous good that is activated automatically when an individual is exposed to reality. It is developed as an achievement of the social being, in teaching processes, whose framework results from human history seen as wealth by the praxical action of individuals who appropriate themselves of these historical conquests⁽⁷⁾.

Teaching a complex object, as demanded by Collective Health, requires, in addition to interdisciplinary integration, an educational process that combines theoretical and practical dimensions and the directive presence of the educator when elaborating syntheses.

The need for more integration among courses and departments has been discussed in the undergoing curricular reform process at EEUSP, which proposed theoretical-practical courses that combine interdepartmental contents⁽¹⁰⁾.

However, the simple juxtaposition of interdepartmental contexts per se will not make it possible for students to overcome the reported dichotomy. To do this it is necessary to actually integrate them, that is, clarify the different theoretical-methodological approaches that are the basis for making the practice operational, allowing students to identify and understand the contradictions between the concepts presented in the course and the actions developed at the health service centers that configure as practice field of these students, hegemonically founded on functionalist frameworks.

CONCLUSION

The analysis of the results in this study showed that EEUSP undergraduate students have difficulties to understand Collective Health concepts. Although the students attending the course during the data collection period were able to reproduce theoretical contents and have a perspective of their use in a future practice, despite their not having understood those concepts, students who had attended the course did not show they understood the concepts, which led us to infer that this possibility of reproducing the theoretical dimension was not transformed into synthesis throughout the years of undergraduate study.

The results, especially those of students attending the course, suggested a disagreement between theoretical concepts and their use in practical classes. Students evaluated the need for someone to make this connection in practical activities.

For students to be able to make the theory-practice synthesis, educator directivity is indispensible, through the analysis, that in the educator-student relationship the educator is the one who knows the theoretical category and for this reason is able to see and analyze the practice distortions, as well as the possibilities and forms of overcoming them.

To formulate this criticism and overcome the perception of the powerlessness to establish practices consistent with the Collective Health theoretical-methodological framework, it is indispensible for educators to direct students towards elaborating syntheses, with the purpose of forming nurses committed to the interpretation of health-disease as a social process and health as a social right; thus changing reiterative practices of the hegemonic model.

Finally, it should be stressed that there is a limitation in this study, inherent to the methodological design, as there was a single evaluation performed at the end of the course.

As recommended before, it is expected that studies on teaching-learning be based on the presuppositions of formative evaluation, which follows procedurally the everyday experiences of students in the theoretical-practical activities⁽⁵⁾.

REFERENCES

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Correspondência:

Célia Maria Sivalli Campos

Av. Dr. Enéas de Carvalho Aguiar, 419 - Cerqueira César

CEP 05403-000 - São Paulo, SP, Brasil

Publication Dates

• Publication in this collection
  07 Apr 2010
• Date of issue
  Dec 2009

History

• Received
  15 Sept 2009
• Accepted
  01 Dec 2009