Nursing education in Brazil: a historical perspective

Abstracts

Descreve-se o processo de expansão do ensino superior em Enfermagem brasileiro, destacando a diversidade e heterogeneidade desse sistema. Observa-se que o ensino nessa área teve um crescimento muito acelerado e desorganizado a partir da década de noventa. Tal crescimento evidenciou a diversidade e heterogeneidade das instituições de ensino, aspectos que repercutem também no perfil do docente, especialmente na titulação e no regime de trabalho, que variam de acordo com sua inserção institucional. Defende-se que esses efeitos irão repercutir, em última instância, na docência e, portanto, na própria formação inicial, na qualificação do profissional de enfermagem e, consequentemente, na assistência de enfermagem oferecida aos usuários dos diferentes serviços de saúde. Conclui-se pela necessidade da identificação do perfil profissional e dos distintos processos de trabalho docente, contextualizado no cenário atual de políticas públicas voltadas para o sistema de ensino superior no Brasil.

Educação superior; Educação em enfermagem; Docentes

REFLECTION

Nursing higher education in Brazil: a historical view^*

La formación superior de Enfermería en Brasil: una visión histórica

Valéria Marli Leonello^I; Manoel Vieira de Miranda Neto^II; Maria Amélia de Campos Oliveira^III

^IRN. Master in Nursing by the Nursing Graduate Program, School of Nursing, University of São Paulo. São Paulo, SP, Braszl. [e-mail]

IIRN. Resident of the Program for Multiprofessional Residency in Family and Community Health , federal University of São Carlos. São Carlos, SP, Brazil. [e-mail]

^IIIRN. Full Professor of the Collective Health Nursing Department, School of Nursing, University of São Paulo. São Paulo, SP, Brazil. [e-mail]

^{Correspondence addressed to}

ABSTRACT

This article describes the process of the expansion of higher education in Brazilian nursing, highlighting the diversity and heterogeneity of the system. It is observed that teaching in this area developed in a very fast and disorganized fashion, as of the nineties. This growth resulted in great diversity and variety of educational institutions, which are aspects that also affect the profile of the faculty, particularly their title and working arrangements, which vary according to their institutional placement. It is argued that these aspects will, eventually, affect the faculty, and, thus, in the early nursing training, in the qualification of nurses, and, therefore, in the nursing care offered to users of different health services. In conclusion, it is necessary to identify the professional profile and the particular working processes, contextualized in the current setting of the public policies for higher education in Brazil.

Descriptors: Education higher; Education nursing; Faculty

RESUMEN

Se describe el proceso de expansión de enseñanza superior en Enfermería brasileño, destacando la diversidad y heterogeneidad del sistema. Se observa que la enseñanza en el área creció acelerada y desorganizadamente a partir de la década del '90. Dicho crecimiento evidenció la diversidad y heterogeneidad de las instituciones de enseñanza, aspectos que repercuten también en el perfil del docente, especialmente en la graduación y en el régimen laboral, que varían acorde a su inserción institucional. Se destaca que tales efectos repercutirán, en última instancia, en la docencia y en la propia formación inicial, en la calificación del profesional de enfermería y, consecuentemente, en la atención de enfermería ofrecida a usuarios de diferentes servicios de salud. Se concluye en la necesidad de identificación del perfil profesional y de los distintos procesos de trabajo docente, contextualizados en el escenario actual de políticas públicas orientadas al sistema de enseñanza superior en Brasil.

Descriptores: Educación superior; Educación en enfermería; Docentes

THE DEVELOPMENT OF BRAZILIAN HIGHER EDUCATION: THE COMPLEXITY AND DIVERSITY OF THE SYSTEM

The higher education system within a country has great influence over society, in all its aspects; at the same time, it is influenced and determined by historical-social conditions. Its strategic position in the development of the country does not only derive from processes of technological innovation, production and diffusion of the science and culture, but also from its impacts on the education and qualification of the work force and on the processes of modernization and societal improvement.

In studying the development of higher education in Brazil, it is necessary to consider the aspects that distinguish it from other systems in the educational field. First of all, its late arrival is noteworthy, since the first institutions of higher education in Brazil were built after the arrival of the Portuguese royal family in 1808, much later than the catholic universities in neighboring countries in Latin America, which were already under development in the XVI century⁽¹⁾.

Another aspect is the decentralization that took place following the Proclamation of the Republic, in 1889, which allowed the creation of new places of learning, both by the government and through private initiatives, starting the process of diversification of the higher education system in the country⁽¹⁾.

In the period between the 1930's and 1945, the first universities were founded and a competition began between public and private institutions, which consisted essentially of confessional institutions. Dating from this period, the Statute of the Brazilian Universities (1931) defined a university model that was adopted by the entire Brazilian system of higher education, placing the other institutions in a subordinate position⁽²⁾.

From 1945 to 1960, the higher education system continued to expand slowly. During this period, the network of federal universities was established and the Pontifical Catholic University of Rio de Janeiro was founded. The state university system from São Paulo also expanded, and other state and municipal institutions were built throughout the country, totaling 18 public universities and 10 private universities, mostly religious⁽²⁾.

During the military regime, in an intensely repressive political context, the university model was reformed. The reform, which took place in 1968, focused mainly on federal institutions, reiterating the adoption of a single model to organize the entire Brazilian system of higher educational, attributing a secondary and transitory position to all other establishments⁽¹⁾.

Although the legislation does not recognize this diversification, the increase in the demand for higher education in this period and the consequent expansion in numbers of institutions are more than enough evidence to support this aspect. Data indicate that, from the early 1960's through the 1970's, the growth rate in the number of enrollments in higher education courses was 540%^(1-2). This expansion occurred differently in the public and the private institutions. Public higher education institutions (HEI) had a growth of 260% in the number of enrollments, whereas in the private sector this growth was 512%; in other words, nearly twice the growth than in the public sector⁽²⁾.

This growth resulted from the increase in the demand for higher education led by students who came mainly from the urban middle class, enriched by the economic prosperity of the time, the so-called Brazilian miracle. At that point in time, higher education began to assume greater visibility and importance for certain societal groups as a strategy to obtain better material or symbolic positions⁽¹⁾. As a result, an intense growth of higher education then began in the country.

According to research⁽²⁾, in the United States the growing demand for higher education by the emerging middle class was absorbed by the creation of community colleges([¹]). In Brazil, in the absence of a similar alternative, the public sector was soon incapable of meeting the high demand. The private sector, thus far made up of religious or community schools, expanded and gained a new segment with a more entrepreneurial character; that is, institutions that offered low-cost courses with lower academic requirements.

The Brazilian public university headed in another direction. As of the 1950's, it began to receive incentives for the development of research and the betterment of its teaching staff, offering a teaching system focused on quality, but aimed at a small proportion of the population. Catholic and community establishments followed the teaching model adopted by the public system more closely, with a greater inclination towards teaching rather than research.

In the 1980's, a decade characterized by the process of renewed political democracy, Brazilian higher education went through a stage of stagnation, both in the public and in the private sector. This phenomenon occurred because of the economic crisis experienced during this period, but also due to the small number of graduating students coming out of high schools as a consequence of the structural problems at this teaching level, such as the low proportion of enrolments, the high number of students needing to repeat grades and school truancy. Therefore, a small percentage of the population completed high school and, consequently, higher education. Despite this stagnation, at the end of the decade, the private sector showed a positive growth index due to the expansion of private for-profit universities, low investment in the qualification of their teaching staff, and failure to invest in the research area⁽²⁾.

Despite this, in the 1990's the rhythm of growth recovered, especially in the private sector. This growth did not occur in a homogeneous manner in the country, being concentrated mainly in the southeast region. In addition, there was a strong process of diversification of institutions, with the creation of HEI with different organizational profiles and academic inclinations⁽¹⁾.

In 1996, the approval of the Law of Directives and National Educational Bases allowed for flexibility of curriculum and the expansion of courses and vacancies in higher education, among other aspects. This Law recognized the heterogeneity of the system, admitting HEI with different academic formats(4)([²]).

In 2003, an interministerial work group was created, which proposed two alternatives for higher education in Brazil: an emergency program of support for higher education, especially federal universities, and a broader university reform. Two major programs were proposed: Prouni and Reuni.

Prouni (University for All Program) grants scholarships to egressed students from public or private schools with a maximum family income per capita of three minimum wages. These students can obtain scholarships to private HEI that, in return, receive fiscal exemption for some taxes. This program was begun in 2005, and by 2010 it had already offered 919,000 scholarships⁽⁷⁾.

Reuni (Program of Restructuring and Expansion of the Federal Universities), instituted in 2007, aims at broadening the access and permanence of students in higher education, encouraging the growth of the public sector through the expansion of the federal universities. According to the Ministry of Education, since the beginning of the program 14 new universities and over 100 new campuses were created, increasing the number of vacancies and courses available to students⁽⁸⁾.

Data from the last census regarding higher education, performed in 2009, show that higher education in that year was represented by 2,314 higher education institutions, namely 1,966 colleges (85%), 186 universities (8%), 127 university centers (5.5%) and 35 technological education centers and institutes (1.5%). Regarding the institution category, the private HEI represented 89.5% of the higher education system, with a total of 2,069 institutions. Of the 245 public HEI (10.5% of the total), 38.5% were federal, 34% were state and 27.5% were municipal institutions⁽⁹⁾.

The state of São Paulo had 556 HEI; in other words, 24% of all HEI in the country. Similar to the national scenario, nearly 90.5% of the HEI in São Paulo were private (503 institutions) and only 9.5% were public (53 institutions). In 2009, the higher education system of São Paulo consisted of 468 colleges (84%), followed by 48 university centers (8.5%), 39 universities (7%) and one federal technological education center (CEFET) (0.5%)⁽⁹⁾.

It is important to highlight that the expansion and diversification of this system does not show only in the numbers, but also in the inclination and activities developed within this series of institutions. In the public institutions, for instance, there is a greater concentration on the production of research, which is perceived as an institutional order⁽¹⁾. Public universities, even regional ones, endure pressure to produce research, although in most of them, the academic ethos of the professor is focused on the students. This is the case in federal universities, where most of the professors work full time, with a smaller proportion of professors with doctoral degrees. Public HEI also currently face the challenge of increasing the number of vacancies and offering new courses, especially in the evenings, changing the profile of the student and the traditional education offered by these institutions.

Among the private HEI, there are at least two major types: those considered elite, aimed at a small proportion of the population with high purchasing power, and those that meet most of the demand for higher education, mass private institutions, which currently contain most of the vacancies available in higher education.

Although diversity is a characteristic of Brazilian higher education, with academic establishments having significantly different institutional formats, academic practices and inclinations, this phenomenon has been little observed and analyzed⁽¹⁾.

These differences among the institutions that compose the current Brazilian system of higher education seem to prevent a single model that would represent all the complexity and multiplicity of the institutions. Its is necessary to recognize these differences and that the main challenge for Brazilian higher education today is to build a policy aimed at all parts of the system, and not only one⁽¹⁾. The authors believe that one of the actions necessary in this process is a general and integrated plan consisting of strategies that reach the system as a whole.

NURSING HIGHER EDUCATION IN BRAZIL: MAIN CHARACTERISTICS

The first initiative to systematize nursing education in the country occurred in 1890, 82 years after the creation of the first higher education schools in Brazil, with the creation of the Professional School of Nurses in the National Asylum of the Insane, in the municipality of Rio de Janeiro. The main purpose of this school, which was different from the engineering, law and medicine schools created at the same time, was to prepare nursing professionals instead of a local elite, at low cost, in order to take care of mentally ill patients, since the charity sisters who were responsible for this function had left the hospital due to a misunderstanding regarding the direction of the Asylum⁽¹⁰⁾.

This school, later named as School Alfredo Pinto, was inspired by the French way of nursing, although it was not administrated by a nurse until 1943. In 1916, the Practical School of Nurses of the Brazilian Red Cross was created to train volunteer first aid experts and, in 1920, this same school created the course for health surveillance agents⁽¹¹⁾. New nursing schools and courses were created with the same purpose; in other words, to meet the urgent public health needs of the country at that historical moment⁽¹²⁾.

The origin of the modern education of nurses in Brazil was entirely related to the need of the State to control epidemic and endemic diseases that put the population at risk from urban centers and the Brazilian commercial relationships with the countries that consumed its products⁽¹³⁾.

The initial milestone was the creation, in 1923, of the Professional School of Nursing of the National Department of Public Health (DNSP), through a mission of North-American nurses led by Ethel Parsons. In 1926, the school was renamed as the Anna Nery School of Nursing. Today, it is called the School of Nursing of the Federal University of Rio de Janeiro. Its original purpose was to educate nurses who would work with the population, disseminating sanitary education. The curriculum was directed at preventive activities and contents, with an emphasis on health educational interventions. It was created according to Nightingalean standards, and it is considered the first modern nursing school in the country^(11,14).

The mission of North-American nurses, throughout the period of their permanence in Rio de Janeiro, contributed significantly to the project of doctrinaire inculcation and technological importation in the areas of health and education, in the core of capitalism, in a conjuncture of strong American influence⁽¹⁵⁾.

Over the years, the process of political and economical expansion evidenced the need to increase the qualified work force in healthcare, thus increasing the need for new healthcare workers. The evolution of higher education programs in nursing, however, was only expressed as of the 1940's, after the strengthening of industrialization and the economic acceleration of the country⁽¹¹⁾.

Until 1947, there were only 16 higher education programs in nursing in Brazil. In the period from 1947 to 1964, a moment of great expansion of nursing education, the number of courses increased to 39, a growth of 43.75% in seventeen years⁽¹⁶⁾.

A remarkable fact in this period was the approval of law 775, in 1949, through which the State stimulated an increase in the number of schools, making mandatory the inclusion of nursing programs at every university or headquarters of a medical school. This law also proposed an education strongly bonded to hospital qualification, centered on the clinical model, in harmony with the work market at the time⁽¹⁰⁾.

This, the growth of higher education in nursing was intrinsically connected to the increase in the number of hospitals, as a strategy designed to meet the demand for nurses in these locations. By 1956, the number of nursing schools in Brazil had doubled, reaching a total of 33 schools⁽¹⁷⁾.

Following the pattern of the higher education system in the country, the late 1950's and the early 1960's were marked by a decrease in the expansion of nursing schools, and in 1964, there were 39 nursing programs in Brazil⁽¹⁶⁾.

The University Reform of 1968 had a significant impact on the recovery of the growth of nursing higher education, stimulating an increase in the number of vacancies and the establishment of new schools. Whereas in the period from 1960 until the middle of the 1970's only two nursing schools were created, implanted in universities and bonded to the federal government, the following period, from 1975 to 1977, registered the creation of 22 new nursing programs, 19 of them in universities: 14 in federal universities, two in state universities and three in private universities. Three other programs were created as isolated units: one associated with the federal government, one associated with the Catholic Church and one in a private college. These courses were the result of a program connected to the Ministry of Culture and Education, which increased and stimulated the creation of nursing schools inside universities, due to the lack of nurses in the country⁽¹⁸⁾.

From 1978 to 1980, 16 new courses were created, 12 in the southeast region and four in the south region. From 1980 to 1990, the number of nursing education establishments had shown great growth, with a total of 102 programs, distributed throughout all the regions of Brazil. Of this total, 57 courses (56%) were bonded to federal, state or municipal governments and 45 (44%) to private institutions⁽¹⁸⁾.

From 1991 to 1994, the number of programs increased from 106 to 415; in other words, there was a growth of 291.5%. From 1994 to 1996, the year of approval of the Law of Directives and National Educational Bases, only five nursing programs were created, whereas from 1997 to 2004, 304 new programs appeared, an expansion of 286.79%⁽¹⁶⁾.

This expansion was greatly concentrated in the southeast and south regions, in which the industrial development induced the demand for qualified services. The diversification of the establishments is also another remarkable consequence of the expansion of nursing education as of 1991. Regarding the academic organization, for instance, there was a higher growth of private establishments in relation to public institutions⁽¹⁶⁾.

The programs in the private network went from 45 in 1991 to 322 in 1994; that is, a growth of 615.55%. Meanwhile, the public network experienced a growth of 52.45%, growing from 61 courses in 1991 to 93 in 1994⁽¹⁶⁾.

This growth in the private network was even higher after 1997, as a consequence of the autonomy given to the HEI and the flexibility of the curriculum, resulting from the 1996 Law of Directives and National Educational Bases. The flexibility present in the Law contributed to the increase in private programs from 45 in 1996 to 322 in 2004, an expansion of 837.77%⁽¹⁶⁾.

Data from the Brazilian educational census from 2009 reveal that, of the 3,381 higher education courses existing in the area of health and social well-being, 752 were nursing courses, which represented approximately 18% of the total programs in this area of education⁽⁹⁾.

Regarding the administrative category, 148 (19.5%) were public, 68 were associated with federal IES, 62 with state IES and 18 with municipal institutions. The private network had 604 programs, or 80.5% of the total, 489 in private IES and 115 in community, Catholic or philanthropic IES⁽⁹⁾. As for the academic organization, of the 752 existing nursing courses, 330 (44%) were in universities, 322 (43%) in colleges, schools or isolated institutions and 100 (13%) in university centers⁽⁹⁾.

The numbers presented reveal that nursing education went through a period of great and unorganized expansion up until 1994, and increasingly after 1996, with the publication of the Law of Directives and Bases. They also demonstrate that this education is hegemonically concentrated in private HEI. Regarding the academic organization, although the university model is still prevalent, there are courses distributed in other institutional formats, such as colleges and university centers, similar to what has occurred in the country with the entire higher education system.

FINAL CONSIDERATIONS

This overview orients the reflection regarding two great questions, the first one concerning the limitation imposed by the classification between academic and administrative organization. Higher education institutions that share the same academic and administrative organization may present very different work processes. Therefore, other classifications are necessary in order to reveal the multiple facets of this diversification.

The second question concerns the effects of the diversification on the profile and work processes of the teaching staff, and in the strategies they adopt to overcome the institutional impositions to which they are subjected⁽¹⁹⁾. Considering that the work process of the teaching staff is closely related to the education of the nurses who are going to work in the health services, it becomes necessary to study the different work process and profiles of the teaching staff found in the different institutional contexts, so as to evaluate their repercussions on the education of the work force in nursing.

REFERENCES

Disponível em: http://www.scielo.br/pdf/spp/v14n1/9801.pdf

2. Durham ER. O ensino superior no Brasil: público e privado. Documento de Trabalho nº3/03. São Paulo: Núcleo de Pesquisas sobre Ensino Superior – NUPES, Universidade de São Paulo; 2003.

3. Mhlaba SL. Community colleges e o sistema educacional norte-americano. Bol Téc Senac R Educ Prof [Internet]. 2007 [citado 2011 out. 25];33(2):57-69. Disponível em: http://www.senac.br/BTS/332/artigo-5.pdf

4. Brasil. Lei n. 9.394 de 20 de dezembro de 1996. Estabelece as diretrizes e bases para a educação nacional [Internet]. Brasília; 1996 [citado 2011 out. 25]. Disponível em: http://www.planalto.gov.br/ccivil_03/LEIS/l9394.htm

5. Brasil. Decreto n. 2.207, de 15 de abril de 1997. Regulamenta, para o Sistema Federal de Ensino, as disposições contidas nos arts. 19, 20, 45, 46 e § 1º, 52, parágrafo único, 54 e 88 da Lei nº 9.394, de 20 de dezembro de 1996, e dá outras providências [Internet]. Brasília; 1997 [citado 2011 out. 25]. Disponível em: http://www.planalto.gov.br/ccivil_03/decreto/D2207.htm

6. Brasil. Decreto n. 5.773, de 9 de maio de 2006. Dispõe sobre o exercício das funções de regulação, supervisão e avaliação de instituições de educação superior e cursos superiores de graduação e seqüenciais no sistema federal de ensino [Internet]. Brasília; 2006 [citado 2011 out. 25].

Disponível em: http://www.planalto.gov.br/ccivil_03/_Ato2004-2006/2006/Decreto/D5773.htm#art79

7. Brasil. Ministério da Educação. Prouni [Internet]. Brasília; 2005 [citado 2011 out. 25]. Disponível em: http://prouniportal.mec.gov.br/index.php?option=com_content&view=article&id=124&Itemid=140

8. Brasil. Ministério da Educação. Reuni [Internet]. Brasília; 2007 [citado 2011 out. 25]. Disponível em: http://reuni.mec.gov.br/index.php?option=com_content&view=article&id=25&Itemid=28

9. Brasil. Ministério da Educação; Instituto Nacional de Pesquisas e Estudos Educacionais Anísio Teixeira (INEP). Censo da Educação Superior 2009 [Internet]. Brasília; 2010 [citado 2011 out. 25]. Disponível em: http://portal.inep.gov.br/web/censo-da-educacao-superior/censo-da-educacao-superior

10. Saupe R, organizador. Educação em enfermagem: da realidade construída à possibilidade em construção. Florianópolis: Ed. UFSC; 1998. Ação e reflexão na formação do enfermeiro através dos tempos; p. 29-73.

11. Germano R. Educação e ideologia da enfermagem no Brasil. São Paulo: Cortez; 1983. Breve histórico do ensino de enfermagem no Brasil; p. 21-57.

12. Galleguillos TGB, Oliveira MAC. A institucionalização e o desenvolvimento da enfermagem no Brasil frente às políticas de saúde. Rev Bras Enferm. 2001;54(3):466-74.

13. Oliveira MAC. Da intenção ao gesto: a dialética da formação de enfermagem em saúde coletiva [tese livre-docência]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2004.

14. Rizzoto MLF. História da enfermagem e sua relação com a saúde pública. Goiânia: AB; 1999.

15. Santos TCF, Barreira IA, Fonte AS, Oliveira AB. American participation in the creation of a nurse model in Brazilian society in the 1920's. Rev Esc Enferm USP [Internet]. 2011 [cited 2011 Sept 12];45(4):966-73. Available from: http://www.scielo.br/pdf/reeusp/v45n4/en_v45n4a25.pdf

16. Teixeira E, Vale EG, Fernandes JD, Sordi, MRL. Enfermagem. In: Haddad AE, organizador. A trajetória dos cursos de graduação na área da saúde: 1991-2004. Brasília: INEP; 2006. p.142-68.

17. Medeiros M, Tipple ACV, Munari DB. A expansão das escolas de enfermagem no Brasil na primeira metade do século XX. Rev Eletr Enferm [Internet]. 1999 [citado 2009 jun. 20]; 1(1). Disponível: http://www.revistas.ufg.br/index.php/fen/article/view/666/736

18. Baptista SS, Barreira IA. Repercussões da Reforma Universitária de 1968 nas Escolas de Enfermagem Brasileira. Acta Paul Enferm. 1999;12(3):46-50.

19. Pereira WR. Higher Education in Nursing: between symbolic domination and political emancipation. Rev Esc Enferm USP [Internet]. 2011 [cited 2011 Sept 12];45(4):981-8. Available from: http://www.scielo.br/pdf/reeusp/v45n4/en_v45n4a27.pdf

Received: 11/03/2011

Approved: 11/29/2011

Correspondence addressed to:

Maria Amélia de Campos Oliveira

Av. Dr. Enéas Aguiar, 419 – Cerqueira Cesar

CEP 05403-000 – São Paulo, SP, Brazil

*

Study presented at the Round Table "O Ensino e a Pesquisa de Enfermagem em Saúde Coletiva frente à Consolidação do SUS", 2º Simpósio Internacional de Políticas e Práticas em Saúde Coletiva na Perspectiva da Enfermagem – SINPESC, School of Nursing, University of São Paulo, São Paulo, Oct. 9th – 11th, 2011.

1

The North American higher education system is organized through different institutional formats: universities, which award professional degrees, doctor's degrees and develop researches; state colleges, which award bachelor's degrees, master's degrees and send students to universities and, finally, community colleges, which award certificates and degrees, sending their egressed students either to state colleges and universities, or to the work market

⁽³⁾.

2

The decree 2.207 from 1997 established that teaching institutions could be organized by administrative (public or private) and academic nature (universities, university centers, integrated colleges, colleges, higher education schools or institutes, and technological centers)

⁽⁵⁾. This decree was revoked until the current decree 5.773 was approved in 2006, which maintains the same administrative organization and updates the academic organization in: colleges, university centers and universities. Technological centers are classified as professional education, and may offer higher education, through technologic graduation courses

⁽⁶⁾.

Publication Dates

• Publication in this collection
  04 May 2012
• Date of issue
  Dec 2011

History

• Received
  03 Nov 2011
• Accepted
  29 Nov 2011