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Rev. esc. enferm. USP vol.45 no.5 São Paulo Oct. 2011
Conceptions of performance evaluation in a competence-centered curriculum*
Concepciones de evaluación de desempeño en un currículo orientado por competencia
Luzmarina Aparecida Doretto BraccialliI; Maria Amélia Campos de OliveiraII
in Nursing. School of Nursing, University of São Paulo. Professor at
Faculdade de Medicina de Marília. Marília, SP, Brazil. firstname.lastname@example.org
IIFull Professor of the Department of Collective Health Nursing, School of Nursing, University of São Paulo. São Paulo, SP, Brazil. email@example.com
The objective of this study was to identify faculty conceptions on evaluation in the Professional Practice Evaluation Exercise (PPEE). An analysis was performed on 155 evaluation instruments answered by the faculty, and video-recordings of four PPEE answered by 1st and 3rd year students. Data analysis was performed using the Meaning Interpretation Method. The expressions expressed by the faculty on their conceptions of evaluation were close to the dialogic competence approach, valuing product as much as process, which help reduce the negative effects of an evaluation. Changes on conceptions of evaluation require a process of institutional construction, with an active participation of the academic community, taking into consideration their existing conceptions and seeking to reach consensus.
DESCRIPTORS: Education, nursing; Professional practice; Professional competence; Evaluation; Curriculum.
El objetivo de este estudio fue identificar concepciones de evaluación de los docentes en el Ejercicio de Evaluación de la Práctica Profesional (EAPP). Fueron analizados 155 instrumentos de evaluación rellenados por los docentes, y se filmaron los EAPP de cuatro estudiantes de primero y tercer año. Para el análisis de los datos, se utilizó el Método de Interpretación de los Sentidos. Las concepciones de evaluación expresadas por los docentes se aproximaron al abordaje de competencia dialógica, valorizando tanto producto como proceso, lo que contribuye a la disminución de los efectos negativos de la evaluación. Cambios en las concepciones de evaluación requieren de un proceso de construcción institucional con participación activa de la comunidad académica, considerando las concepciones existentes y buscando generar consensos.
DESCRIPTORES: Educación en enfermería; Práctica profesional; Competencia profesional; Evaluación; Curriculum.
In the 20th century, the development of health professionals, especially nurses, suffered deep influence from the flexnerian model. When working for the Carnegie Foundation, Abraham Flexner published a report on medicine education in the United States of America. The Flexner Report, as it became known, completed 100 years of existence in 2010. It had great repercussion in the development of medical and other health professionals, not only in the USA but also in countries that followed the North-American education model. Most of all, the model influenced public health systems structure in many countries.
Today, the flexnerian term is used to refer to medicine aimed at the individual and to biologism, mechanicism, specialization, and the excessive technification of health work. In education, the main characteristics of this model are its emphasis on basic sciences and the separation between basic and clinical education, which, on the other hand, is directed towards individual care, centered on faculty(1). It is a model that uses the teaching-hospital as a laboratory for professional practice, which caused changes in health education, and thus became the dominant paradigm to explain phenomena of the health-disease process.
In Brazil, modern nursing education was initiated when the sanitary campaign model was in full effect. The first nursing school in Brazil, established in 1923, in association with the National Public Health Department, had the mission to prepare professionals to help improve the hygienic-sanitary condition in Brazil in a time when the country struggled with several epidemics that harmed the coffee agriculture and exporting economy(2-3).
After several decades of relative continuity, in the 1980's, Brazilian Nursing was influenced by the Sanitary Reform movement, which resulted in the promulgation of the 1988 Constitution and on the proposition of the Unified Health System (SUS, acronym for Sistema Único de Saúde), whose principles are health universality, comprehensive and decentralization, and community participation.
During the two decades following the implementation of the SUS, the challenge posed to nursing education was to prepare professionals to work technically, socially and politically in the construction of the Brazilian health system, thus consolidating the Sanitary Reform.
Therefore, nursing education was the object of discussion in several forums, but the search for a nursing education policy was a process led by the Brazilian Nursing Association (ABEn), through the Brazilian Nursing Congresses (CBEn) and the National Seminars on Nursing Education Guidelines (SENADEn)(4).
These movements to change the development of the nursing work force were stimulated by the passing, in 1996, of Law 9.394 on the Basic Tenets and Guidelines of National Education. Since then, several higher education nursing schools have changed their curricula, despite a number of economic and political difficulties in the fields of health and education. Those changes have permitted schools to increase strength and knowledge to advance towards an education that is committed to the SUS principles(4).
In collaboration with the educational system, the Ministry of Health is also engaged in implementing the National Curricular Guidelines that were adopted to formulate the political-pedagogical projects in health courses, defining the philosophical, conceptual, political and methodological foundations guiding the process. In nursing, the National Curricular Guidelines aim at offering nurses a generalist, analytical and reflexive preparation, with technical-scientific, ethical-political, social and educational competency(5).
The Marilia Faculty of Medicine (FAMEMA- Faculdade de Medicina de Marília) has participated of those changes since the 1990s, when it joined the Project UNI - A New Initiative in the Education of Health Professionals (in Portuguese: Uma Nova Iniciativa na Formação de Profissionais de Saúde). In 2003, it took part in the Program for Encouraging Curricular Changes in Medicine Education (in Portuguese: Programa de Incentivo a Mudanças Curriculares nos Cursos de Medicina - PROMED) and, in 2005, of the National Program for the Reorientation in the Education of Health Professionals (in Portuguese: Programa Nacional de Reorientação na Formação de Profissional em Saúde - PRÓ-SAÚDE). The participation of FAMEMA in those projects reaffirms its conception of curriculum as a social construction that involves contradictions and conflicts between different subjects that establish the limits and possibilities to advance the implementation of an education model that favors the development of competency and to implement new experiences, practices and knowledge that trigger the process of change in health services and significantly improve the quality of life of the community(6-7).
In 2003, the FAMEMA academic community developed a new Political Pedagogical Project (PPP) for the Nursing Course, made effective through an integrated, competency-based curriculum. The word integration expresses the unity that must exist among the different class subjects and the forms of knowledge, which characterize crossdisciplinarity. The pedagogical movements towards crossdisciplinarity appeared from the progressive demands of ideological and political groups for a more democratic society(8).
The integrated curriculum is characterized by the effective integration of teaching and professional practice, improving collective work, associating theory and practice, making progress in the construction of theories and in the search for specific solutions for different situations, adapted to the local reality and cultural standards of a certain social structure(9).
One reason to implement the integrated curriculum is that it is not limited to the memorization of contents. The teaching-learning process aims at everyday practice, to evaluate limitation and find the means to solve real life problems. This is a counter-hegemonic process that is not feasible by the force of law. The official curriculum it that which is determined by the Institution, but the concrete social subjects involved in the teaching-learning processes are the ones who make it effective. An integrated curriculum offers the necessary conditions to motivate learning, so that it is meaningful to the personal and professional lives of students; it offers more liberty to select the study topics, and to perform research related to the context.
There are many sociological arguments for an integrated curriculum, one of which is the need to humanize the knowledge which is provided in schools(8). Another argument concerns the views that people have of the reality, considering them as subject of history, and promoting a more active, analytical and accountable stance among students. This curricular proposal is founded on Dewey's thoughts and on the psychology of Piaget and Vygotsky.
In the curricular structure of the FAMEMA Nursing Course, the new meaning of evaluation is one of the structuring axes of the educational process. The aim was to elaborate a proposal based on a concept of evaluation that was coherent with the curricular principles, with a view to achieve the performance that was expected for the different course years.
In the political and pedagogical proposal of the FAMEMA Nursing Course, the importance of evaluation originates from its ability to promote a reflection on the learning and teaching process, identifying its strengths and weaknesses, and pointing at its permanent reconstruction. It is a change of paradigm towards a differentiated university pedagogy that is committed to an innovative view of health, humans, and Nursing.
Evaluation in a competency-based curriculum
Evaluation is a social, intersubjective practice with many values. It is a continuing, systematized activity that questions meanings and phenomena, and is inherent to the teaching-learning process(10). It cannot be restricted to static instruments and explanations that are inadequate for the present context, neither can it be considered an instrument to measure what has been done. O the contrary, it is actually a dynamic communication process in which the evaluators are mutually constructed. As an instrument that consolidates education, the evaluation must be an ethical practice aimed at social responsibility in the benefit of education, with scientificity, in processes that produce knowledge and develop subjects with moral, social and political autonomy(10). Evaluation, therefore, is a complex, multi-reference, polysemic and heterogeneous battlefield where disciplines, values, social practices and different academic, political and social positions are confronted(11).
In a competency-based curriculum, the evaluation is part of the pedagogical work in the many teaching-learning scenarios. Although it is only one of the many academic terms, culturally, evaluation has been highlighted and has often had an excessive central position. When competency evaluations are restricted to the cognitive aspects (to know) and or skills and abilities, they become reduced and fragmented(12). A fragmented evaluative process in undergraduate courses can be accounted for an unsuccessful professional practice due to the lack of preparation of the graduates or the incompatibility between their values and the ethical posture and the social responsibility required in their profession.
The proposed curriculum of the FAMEMA Nursing Course gives evaluation a relevant role. To assign meaning and significance in the Nursing Course curriculum proposition, fit was necessary to guarantee the coherence between the diagnostic (that identify where the student is in the educational process), formative (performed during the teaching-learning process) and summative (which define the student's development), and associate them with the expected professional profile and the philosophical and pedagogical frameworks outlined by the Institution. Its procedural, dynamic, co-participative features and its integration to the teaching-learning process are centered on students and on the educational units, with the purpose to implement and verify students' performance, which is the visible part of competency.
In the competency-based, integrated curriculum, competency is understood as the ability to mobilize a group of resources and cognitive, affective and psychomotor attributes, i.e., knowledge, abilities, information, relationships, values, posture, culture, ethical principles, and skills to solve different situations adequate and efficiently.
It should be recalled that there is no conclusive definition for competency, and it does not always appear with the same meaning in the education and work environments. Its meaning should be constructed in each institution or professional location. Competency accompanies the learning subject in the many situations that occur during their development. It is an attribute that can only be verified in action, in a certain situation. In educational practice, competency evaluation is no longer centered in class subjects and is verified using specific situations and tasks(12-14).
Several strategies are adopted at FAMEMA to perform diagnostic, formative and summative evaluations. The present study focuses on the Professional Practice Evaluation Exercise (EAPP - Exercício de Avaliação da Prática Profissional). Over the four-years period of the Course, students develop their activities at the Professional Practice Unit (UPP - Unidades de Prática Profissional), at the Primary Care area of Family Health Units (USF - Unidades Saúde da Família) and at Hospital Care. To develop these activities, the Professional Practice Laboratory is used (LPP - Laboratório de Prática Profissional).
At the LPP, actors are trained by professionals to interpret patient roles. The clinical histories played by the actors are extracted from real situations, most from student portfolios, and reproduce situations in which the performance expected and developed at the UPP are also explored at the Systematized Educational Units.
The activities at the LPP are performed at two moments. In the 1st meeting, students assisted the simulated patient (actor) while being observed by the faculty of Semiology, Communication and from the UPP. The faculty took notes on the performance that needed more attention, students made a provisional syntheses, elect learning issues, search from several sources and, in the following meeting (support moment), work on the new synthesis and on the evaluative process (self-evaluation, peer evaluation and process evaluation).
The EAPP consists of a recent activity in the Nursing Course, as it is being performed since 2003, with process assessments, in a continuous and systematic movement, in a way that individual development can be monitored and educational activities can be planned according to the needs. In the different course years, students must progressively acquire autonomy and knowledge, while it is the role of faculty to work as facilitators and encouragers of their accomplishments and their professional and personal development.
The evaluation at the EAPP has a privileged area in the PPP of the Course, i.e., one of constructing and reconstructing professional practice, which involves the students' creativity, sensitivity and availability of students and faculty to work on the construction of subjects who can intervene in a certain reality with the possibility of change. However, this practice is now exempt from contradictions. There are few studies that address the conception that FAMEMA faculty have of evaluation and if it is in line with the planned curriculum and the curriculum that is effectively developed by faculty in their many activities.
The present investigation has the objective to identify and problematize the evaluation conceptions of the FAMEMA Nursing Course faculty involved in student performance evaluation at the EAPP, with the purpose to verify how they perform the evaluative process in practice.
This study was performed with a qualitative perspective approach, which is understood as a group of interpretative practices that aim at investigating the meanings that FAMEMA faculty assign to the phenomena and to the group of relationships in which they are involved. This approach is based on the principles of hermeneutics-dialectics, which aims at understanding and contextualizing the meanings underlying the statements and actions of the investigated subjects(15-18).
Faculty, students and actors playing the roles of patients involved in the Nursing Course EAPP were invited to participate in this study. The following qualitative sample principles were considered: (a) choosing subjects whose attributes are in line with what is being studied; (b) the number of subjects must be sufficient for the repetition of information to occur; (c) it must be possible to include subjects successively until it is possible to have a dense discussion on the issues being evaluated. Therefore, when composing the sample, we did not aim at numerical representation but at deepening the topic being studied(18).
The field of study was the FAMEMA Nursing Course, located in the Marília. The sources used for data collection were the evaluation instruments filled in by the Nursing Course faculty during 2007, with a total 155. In addition, four individual EAPP were video recorded, which permitted to register the students' performance during their interaction with the simulated patient, as well as the following evaluation by the faculty. In the first course-year, the EAPP activity recorded in the adult health area, and in the third, the EAPP activity was in children's, women's and adult health, individually. The material from the recordings of the EAPP activities was transcribed, resulting in texts that, along with the performance evaluation instruments filled in by the faculty, was submitted to discourse analysis. This process was initiated with a thorough reading to understand the meanings present in the communication. To do that, the Meaning Interpretation Method whose principle is the search for internal logic of facts, reports and observations, aiming to place them in the context in which they were produced(15-18).
The research was initiated only after being approved by the Research Ethics Board at the Marília Faculty of Medicine, which reviewed and approved the project, under review number 594/07. The subjects were guaranteed about their rights and anonymity, according to ethical principles.
RESULTS AND DISCUSSION
Characterization of the studied group
The studied group was composed of four FAMEMA Nursing students and eight professors, seven of which were faculty at the university and one was a professional working in the hospital network. Most students (75%) were female, aged between 18 and 22 years. One student was in the first year and three were in the third year.
All professors were regular employees at FAMEMA, some worked full-time while others worked part-time. Only one collaborating professor had a contract as a clinical nurse and who received gratification to work as a professor. Two professors also became responsible for the coordination of the educational units. All professors (100%) were female, and between 34 and 48 years old. Most were nurses (87.5%). As to their graduate degrees, some had specialization (37.5%), or a Master's (50%) or Doctorate (12.5%) degree. The professors' time working in primary and hospital care ranged between 3 and 19 years, with an average 11 years.
In the EAPP, which were performed individually, the freshmen took 55 minutes to complete the activity, and the professor's evaluation took 41 minutes. The activity performed by junior students took from 57 to 64 minutes, with an average 60.7 minutes, and the professors' evaluation took from 10 to 33 minutes, with an average 20.3 minutes.
Description of the faculty's performance in the student learning evaluation
Before initiating the activity, the professors carefully explained the task. In fact, they suggested how to distribute the time they had, and left students free to decide whether they wanted to follow the suggestion or not. They also informed about biosafety measures and how to handle the materials during the activity. Students were also allowed to ask any questions they had before beginning the activity, and were asked if they wanted to be notified 10 to 15 minutes before the activity time was up.
During the activities with the freshman student, the professors appeared to be concerned with the space they were taking up in the room, and, because they were worried about disrupting the student, they changed places. In the evaluation, they problematized the situation, giving the student the opportunity to think and reflect before answering. They asked the reason why the student performed a procedure in one way or another, and expected a justification using scientific principles. They mentioned noticing the lack of a guide in the clinical history, considering the student went back a few times to ask something that had already been addressed. As to the complaint and the duration, they asked the student how to use traditional history to evaluate the patient's health needs.
You started by the lifestyle, but it is more interesting to start [...] we call it complaint and duration, but we have to change it into health needs. To start approaching someone by addressing what he or she sees as things that have been disturbing his or her health, what he or she could [do] in case [there was] anything he or she felt could improve his or her health. Start from that need, interrelate the aspects of the anamnesis. Because, when you address these points, you are just collecting data, but with no definition (SP1a).
Next, they called the students attention to the health needs framework used in the course. When discussing on the perspective using the health needs evaluation as the guideline of the clinical history, the professors emphasized that those needs should also be considered from the patient's perspective, rather than only considering the professional's view. The proposal was to discuss patient autonomy with the student. They reinforced that their role as faculty was to observe the student's performance, with a view to her learning.
When the professors discussed with the freshman about the forms to collect data, they outlined the need to listen more to what the patient had to say and to explore the issues deeper. They considered that the freshman was worried only about completing all the steps recommended for the clinical history, without articulating them properly. They reinforced that the student often reached her conclusions before the patient said anything, supposing that things would follow a certain order. They suggested ways to perform the clinical history avoid making judgments.
Give the patient some space, let her tell you the reason. Actually, you even induced her. If she says she doesn't brush her teeth, it's no problem. Now, if you do [say it], she can even feel like she's being judged. It is part of the strategy to make a question and let the patient speak, you give that option, [or] she can interpret it pejoratively (SP1a).
The evaluations with junior students addressed the confidence, tranquility, skills and the extent to which they were able to discuss on biologic, social, psychological and cultural dimensions involved in the care, as well as prevention and promotion actions. The professors had already evaluated the posture of these students in previous evaluations, so they were able to evaluate the students' progress.
Another aspect that I found interesting is that you did not limit the talk to the biological aspects; you also focused a lot on the psychological and social attributes. I think that is essential, you managed to characterize the biological aspect but you looked beyond that. Because you investigated a lot about the preoccupation issue. There were several pieces of information that, if you had not problematized, they would surely not appear. Your physical evaluation was perfect (SP3a).
The professors concluded that the students approached the patients appropriately and established a good interpersonal relationship, as they were empathetic and developed clear and adequate communication, thus promoting bonding. They also outlined the professional confidentiality. As to the biosafety measures, they considered that one of the students should adopt a more ergonomic posture, because the student stayed in a curved position for too long, and this could cause health problems.
In the freshman student evaluation, the professors outlined that, although the student's attitude did not compromise professional bonding, it could have caused problems. They also mentioned that the student also revealed his values and prejudices while collecting the data, which could also harm the bond that was being established while performing the clinical history.
You said: You are lazy. Another thing you asked was: Are you lazy to go to the bathroom? So you have to be careful. You are investigating the patient's judgment of value, which can also compromise the bonding. You are at the patient's house and you are saying that he is lazy to brush his teeth. Perhaps you are not judging, but to the patient it can sound something like this: -You think I am lazy. Just be careful about this, you need attention (SP1a).
In the self-evaluation, the student argued that he had to make a strong effort to use clear language, adequate for the patient's understanding, so she would not be confused about what was being said. The professors reinforced that the student's effort was valuable and she managed to express himself clearly. As to the verbal communication, they warned about avoiding using words in the diminutive form, which can be understood by the patient as contempt and harm the bond between them.
Also regarding the freshman student, the professors consider he initiated the activity showing too much insecurity, but improved and developed the task on an adequate rhythm. They identified some weaknesses in formulating the problem and elaborating the intervention plan, and asked him how he would re-elaborate those items and which elements should be considered as essential in the task.
The professors instructed the student to develop a care plan for the experienced situation and took advantage of the evaluation to explain what how he should evaluate a certain body segment, but as a way to problematize the evaluation. They tranquilized the student as to his performance and encouraged him to continue just as he is. By doing so, they revealed they see learning as a process, and professors know the student does not need to be ready for the evaluation and that, with time, he will learn.
The professors demonstrated they understood that freshmen students are in the beginning of their learning process and that evaluation time is stressful, especially regarding professional practice evaluation, which involves knowledge, skills and posture in action.
Especially in the beginning, [you] were very nervous and often forgot a few things (SE1a).
When professional practice situations are presented to students, they often become very tense, but professors usually take advantage of that moment to discuss about care with the student, explaining that because they will become health professionals in the future, they should think about their actions from every perspective. Students also appeared to be stressed during their self-evaluation, and that stress appeared as a determinant of their performance
I confess I was really nervous in the morning, but it turned out great (SE3m).
It was observed that the EAPP offered the necessary conditions to provide motivation for a meaningful learning in the personal and professional lives of students and professors. As to the pedagogical conception, it permitted students to learn with what they do or discover and not only with what the professor does or teaches(19).
The evaluation was focused on students as subjects of the process of knowledge development and appropriation, thus expressing a view of the world, human being and of nursing that is more progressive, analytical, reflexive and democratic. However, what actually determined this tendency in professional development is the way it is worked in the classroom, in the interaction between faculty, students, health professionals and health service users. Evaluation is committed to an education that is not limited to promoting improvement within the school, but also committed to the reconstruction of the social area, which is the reason why it should be in harmony with the political-pedagogical project constructed by the school community(20).
The evaluation also proved to be a process that is negotiated and responsive between faculty and students, and it develops based on the concerns, worries or controversies regarding the object of evaluation(21).
The student-performance evaluation at the EAPP is based on the dialogic matrix of competency. The faculty valued the comprehensiveness of care, emphasizing on the combination of attributes (knowledge, values and skills), considering the social context of patients, their level of autonomy, their relationship with the patient, the bonds that were established, and verbal and non-verbal communication. When planning the care, the students not only addressed the biological but also the psychological, social and cultural aspects, besides the involvement of the multiprofessional team in actions of promotion, prevention, treatment and rehabilitation, at the different levels of care. The professors performed students' evaluation using dialogue and problematizing strategies, with tips of how to perform in individual care, in every task proposed for the experienced situation.
The meanings of evaluation and their principles expressed in the EAPP
The performance of faculty and students in the EAPP permitted to identify the meanings of the evaluation and its principles in the FAMEMA Nursing Course. As it is a practical activity, the EAPP permit to look "inside" the evaluation process.
Students, depending on their moment in the development process, present different levels of appropriation of cognitive, psychomotor and affective resources throughout the long development pathway and their performance in the EAPP showed how they manage those resources in the time of action.
It was also observed there was consistency of meanings in relation to the evaluation process between professors, though different approaches in relation to the evaluation and competency framework were also identified.
The integrated competency-centered curriculum adopted by the FAMEMA Nursing Course includes the EAPP as a strategy that reinforce the strength of the evaluation. However, it demands faculty and students to break with the original paradigm of evaluations. In the traditional evaluation model, emphasis is on cognition: those are the famous tests, in which knowing is essential.
The EAPP is the form of evaluation that allows seeing what escapes the traditional evaluation, i.e., posture, intersubjective relationships and the view of the world. In the FAMEMA Nursing Course, it is an evaluation strategy used integrated and associated with different areas of knowledge.
It was possible to identify the presence of the Australian competency matrix that expresses the integration between theory and practice, considering the context, culture of the working place, values and ethics(12-14,22). In the Australian current, competency is used in the singular form, expressing a synthesis of the professional profile or a judgment attributed to someone in relation to their professional practice, according to the context and excellence standards(12).
In this perspective of competency, the curriculum aims at integrating general and professional knowledge and working experience, promoting the interaction between knowledge, skills, and attitudes in a certain social context. This model requires an active teaching, leaning and evaluation process, using active methodologies in a teaching-learning process using active methodologies, in a teaching-learning process that assign meaning to knowledge, associating them with the real problems of the working world(12).
Work-centered education can contribute to overcome the current health practices through reflexive action. The dialogue between development and work allows students to mobilize their knowledge and construct their performance in action, in a pertinent and timely way to solve problems and meet the health needs found in the practice scenarios.
In this competency framework, the evaluation process is dialogic and requires the participation of all subjects involved. It values process as much as results and allows for verifying the learning that is used in real and simulated situations. Competency, therefore, is the mental structure or schematics responsible for the dynamic interaction between the individuals' previous knowledge - constructed with experience - and the formal knowledge.
The meanings that FAMEMA Nursing students and faculty assign in the EAPP were close to the dialogic competency approach in which the construction of learning occurs by means of a process of action, reflection and action, developed in the dialogue between education and the working world, valuing product as much as process. This approach is more in line with the Australian matrix, which is based on the social-constructivist framework and similar to the critical theory.
In this conception, faculty work as mediators of the teaching-learning process, thus reducing the negative effects of evaluation. The evaluation performed at the EAPP was coherent with the philosophical and pedagogical foundations of the political-pedagogical project of the Course, the National Curricular Guidelines, the mission of the school, and the expected professional profile of nurses.
Nevertheless, as every historical process, the FAMEMA Nursing Course shows advancements and regressions, in a dialectic movement that involves countless social subjects, with different views of the world. Overcoming the hegemonic practices of health and education requires permanent investments in the dialogue between the worlds of work and education, through a process of action-reflection-action that would allow students to mobilize and construct their performance in action, reflecting on the professional practice in health and their potentials to answer the health needs of the population.
It is acknowledged that there is a need to change conceptions regarding evaluation, but they cannot be guaranteed by regimental rules. Rather, changes require a process of institutional construction, with the active participation of the academic community, and taking into consideration the existing conceptions and aims at reaching possible consensus. In this paradigm, there is a possibility for health education to break with the flexnerian model of education and health care, and making health care comprehensiveness the structuring axis of new education proposals
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Received: 08/24/2009 *
Extracted from the dissertation "Os sentidos da avaliação do desempenho
do estudante em um currículo integrado orientado por competência",
School of Nursing, University of São Paulo, 2009.
* Extracted from the dissertation "Os sentidos da avaliação do desempenho do estudante em um currículo integrado orientado por competência", School of Nursing, University of São Paulo, 2009.