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Print version ISSN 0104-1169
Rev. Latino-Am. Enfermagem vol.14 no.5 Ribeirão Preto Sept./Oct. 2006
Nursing education: seeking critical-reflexive education and professional competencies
Kênia Lara SilvaI; Roseni Rosângela de SenaII
IRN, M.Sc. in Nursing, Faculty, Pontifícia Universidade Católica de Minas Gerais, e-mail: firstname.lastname@example.org
IIRN, PhD in Nursing, Adjunct Professor (Retired), Minas Gerais Federal University
The study describes changes that are noted in students during training and which contribute to define a professional profile. We carried out a descriptive-exploratory study with a qualitative approach, based on dialectics as a theoretical-methodological framework. The data was obtained from documented analysis and through focal groups with teachers, students and service nurses. The results show the student's position as an active subject in the teaching-learning process, through a movement of transformation of academic structures. A correlation was found between the movement that seeks students' greater political, active and critical participation as a way of determining and guiding the profile of the generalist nurse and greater social insertion. We conclude that, despite efforts, training guidelines and the definition of the professional profile in the study settings is directed at the demands of the labor market, and that competency-based training is still incipient.
Descriptors: education; nursing professional competence; problem-based learning
Teaching-learning experiences are determined by the political, social, cultural and economic context they are inserted in. The modern world requires professionals to have a multivalent training, oriented towards the globalizing view of reality and a permanent attitude of learning to learn(1).
The deregulation of national economies, imposed by the international division of work, commends the adoption of privatization programs in the public sector, including in health and education. These transformations change work relations which, in combination with technological innovations, impose new relations in the labor world and, consequently, new requirements in terms of workers' profile(2).
In the health sector, transformations occur in work organization, entailing repercussions for technological incorporation, associated with changes in the Brazilian population's epidemiological profile and demographic pattern. In this context, modifications should be acknowledged which derive from the implantation of new technological and care models, posing demands in terms of professional profile.
In Brazil, these modifications occur in the framework of the process to consolidate the Single Health System - SUS, including efforts to take form in ethical, theoretical, organizational and operative principles related to health, defined as a right of all citizens and a duty of the State, which is responsible for assuring social and economic public policies that guarantee the population's physical, mental and social well-being.
The theories and principles guiding the SUS are addressed in Decree 8.080(3), especially: universal health service access at all care levels; care integrality; preservation of people's autonomy in defense of their physical and moral integrity; equality of health care, without any kind of prejudices or privileges; political-administrative decentralization, with one single management in each government sphere; regionalization and hierarchization of the health service network; problem-solving capacity of services at all care levels.
In the attempt to consolidate the SUS, efforts have been made to construct a model that gives social responses to health problems and needs, in view of Brazil's heterogeneity and political, economic and cultural diversity.
Health workers' training, inserted in the context of professional training, must be guided by the definition of competency areas (knowledge, skills and attitudes) that allow for multiprofessional action and interaction. General guidelines for health professional education in the 21st century state that competency development should be oriented towards the search for health care integrality, contributing to the formation of professionals who join decision-making, communication, leadership, management and permanent education aptitudes(4).
In order to cope with rapidly emerging and modifying demands in health professional training, there is a need for changes in the teaching-learning process, adapting it to contemporary reality and to the complexity and unforeseeability characteristic of health work.
Preparing professionals for the labor world requires the development of knowledge, ideas, abilities and, also, dispositions, attitudes, interests and behaviors. These should adapt to the possibilities and demands of work modes and the way they are organized(5).
In this perspective, significant mobilization efforts have been made to transform professional training models, seeking to integrate the university with segments of civil society and communities, in a partnership that raises the potential of alternatives for pedagogical and organizational changes and institutional interactions. This is necessary for the academy to demonstrate its relevance in the social context and to allow for student training based on concrete, real problems.
Attempts to revert traditional teaching models demonstrate that different actors must participate in the definition of a professional profile: graduates, faculty, students, service professionals, health service managers, members of class organizations and civil society, in a movement that guides training and the definition of the professional profile, based on competency areas.
Defining competencies is a hard task. It is important to move from the analysis of practices to a reasonable inventory of competencies considered essential, which constitute the body of the profession(6).
A competency is defined as the aptitude to cope with a series of analogue situations, correctly, rapidly, pertinently and creatively mobilizing several cognitive resources: knowledge; skills; micro-competencies; information; values; attitudes; and perception, assessment and reasoning schemes(7).
In terms of health professionals, besides this concept, the need should be added to incorporate a prospective analysis of professional practices, in contexts of technological innovations, changes in health services and in the population's epidemiological profile and demographic pattern.
In the context of these transformations, the notion of competency emerges to reorder the understanding of the work/education relation, deviating the focus from employments and tasks to a reference framework centered on human praxis and increasing the potential of worker emancipation actions(8-9).
Applying the notion of competency implies institutionalizing new forms of educating / training workers and managing organizations and the labor market internally, in view of economic-productive, social-historical, cultural and political mediations in the determination of the teaching-learning process(8-9).
Thus, we defend that the nursing training model should be anchored in the reference framework of critical-reflexive pedagogy(1,10-11), contributing to the construction of professional competencies that allow for actions focused on integral care.
This study presents partial results of the research "UNI Project as the scenario for new experiences in the transformation of nursing education"* realized by researchers from the Study and Research Group on Nursing Teaching and Practice - NUPEPE at Minas Gerais Federal University between 2000 and 2003. In this research, we attempted to analyze the change process in nursing education experienced by nursing courses at Brazilian institutions that developed the UNI Project.
The UNI Project - A New Initiative in Health Professional Education, a political-pedagogical program that had been encouraging innovations in health professional formation since the early 1990's, in partnership with health services and the community, was developed in Brazil by the following higher education institutions: Londrina State University, Marília Medical School, Bahia Federal University and Rio Grande do Norte Federal University.
The Project presented a proposal to teaching and service institutions and their actors, to give up the existing paradigm in capitalist society, in which professionals are educated to attend to needs related to profit and capital accumulation, and prioritize human needs, the population's health needs and the improvement of sanitary environments, assuming the commitment to train professionals who are willing to work towards quality of life as a whole, without abandoning the valuation of the dialectic construction of the health-disease process(12).
We decided to adopt a qualitative approach, based on dialectics(13) as a theoretical-methodological reference framework, which reveals a belief in the movement process that permanently exists in society, as well as in the historical, cultural and social construction of health professionals' education processes and in the capacity to transform and overcome contradictions through new practices.
In order to capture reality, we used primary data, collected through the realization of a three-hour focus group(14) in each scenario. In total, 27 faculty, eight students and eight service professionals participated. Their discourse was recorded, transcribed and then submitted to Discourse Analysis(13,15). Secondary data were obtained from reports and documents made available by the research institutions, which helped us to understand the change process in nursing training at each of the four institutions. In the results section, discourse is identified by the letter C and a number (1, 2, 3 or 4), which randomly indicate the research scenarios.
Before starting data collection in the field, the research project was approved by the Ethics and Research Committee at Minas Gerais Federal University - COEP/UFMG, in accordance with Resolution 196/96 by the National Research Ethics Commission. Participants' testimonies were only recorded after they agreed to participate and signed the Free and Informed Consent Term.
This study describes the changes manifested and/or perceived during the student training process and which can be demonstrated as elements contributing to the definition of a professional profile. We attempted to describe the change movement in nursing training, indicating shared points in subjects' thinking and practice in each scenario, which supported the construction of the empirical category: "From critical student to generalist nurse" and how this movement has contributed to the definition of the professional competency area.
RESULTS AND DISCUSSION
The focus group participants' discourse in the four scenarios revealed, at these institutions, the student's position as an active subject in the teaching-learning process, with room to take positions and propose changes. This condition has been facilitated by academic structure transformations, by the construction of a political-pedagogical project based on critical and reflexive reference frameworks, the adoption of active teaching methodologies, the expansion and diversification of teaching-learning scenarios and attempts to adopt formative assessment.
Focus group participants indicated that the changes in the teaching model contributed to the construction of a political-pedagogical project in which students are considered as active subjects in the construction of their own knowledge (C1), thus becoming critical, inquiring, innovative subjects with more mature attitudes (C3).
Participants affirmed that, during training, attempts have been made to construct the profile of a reflexive professional, who knows the ethical, political, historical, ideological and cultural determinants of the profession (C4), in line with the Ministry of Education's guidelines for nursing education(4).
Discourse in the four scenarios contained quotations that disclose the movement seeking students' greater political, active and critical participation, as a factor that determines and guides a generalist nursing profile with greater social insertion.
This consideration is remarkable for the reorganization of teaching and health care processes, as professional training exerts positive effects, to a greater or lesser extent, on health service practice, in consonance with the established teaching-learning process.
The changes described in discourse about students' attitude reflect labor market requirements. This market stimulated the construction of a profile for future professionals to attend to a new dynamics in health work (C3), requiring professionals to be able to act in the progressive health care network, mobilizing knowledge in individual and collective preventive and curative actions, in order to guarantee health care quality (C4).
In scenario 1, participants indicated that changes in teaching occurred to attend to nurses' training needs to work in the Family Health Program. Subjects' discourse in this scenario displayed constant concern about inverting the hospital and disease-centered model, to construct a health model based on social health production.
The Family Health Program is a strategy to reorganize basic care in Brazil, whose actions are directed to the needs of families within its territory, as a geopolitical space, in a continuous, tailor-made and active way; emphasizing health promotion and problem prevention, but without ignoring the curative-rehabilitating focus, with a high problem-solving level; at low direct and indirect economic or social costs and articulated with other sectors determining health.
In scenario 3, participants affirmed that the change in the care model, through the implantation of the Family Health Program, started to require pedagogical practices that emphasize integral health care, which influenced the change in the political-pedagogical project, incorporating new concepts and new teaching practices to accompany this tendency.
Participants in scenario 4 mentioned their concern about implementing a training process to contribute to social changes, related to education and nurses' insertion in the labor market. They affirmed that, to accompany this "pattern", i.e. the Family Health Program, the course has been guided by the principle of introducing the student into real practice scenarios of current health models, prioritizing health surveillance actions.
Discourse analysis reveals that training and professional profile definition in the study scenarios are directed at labor market requirements, while training based on competency areas is in an initial stage. These areas go beyond the transitory and momentary requirements of a market and affirm the construction of a set of abilities and attitudes that will allow professionals to act in different and unforeseeable daily work situations.
Therefore, the nursing training process should occur in view of context dynamics and future needs in health and education, to which professional training should be oriented by means of a competency area-based education, in which market demands are taken into consideration. However, this factor should not be the priority element in the definition of the professional profile, preparing nursing professionals not only to attend to labor market demands, but mainly to transform the conditions imposed by this market.
Focus group participants mentioned that professional training is excessively privileging knowledge of social areas, to the detriment of knowledge about technical areas. They indicate that trained nurses are professionals who are very critical with respect to social problems, but do not master the technical knowledge and instruments needed to develop nursing practice (C3).
This finding goes against the premises of the training model in force until that time, which privileged curative and individual action, based on the hospital-centered biomedical model and strongly characterized by a technicist orientation. However, participants perceived that social and political issues are emphasized to the detriment of technical skills development of "health clinic". Therefore, we believe that the model is still fragmented and does not allow students to develop themselves simultaneously in technical-scientific and political-social competency areas, mobilizing them to guarantee integrality in their training and health care process.
This reveals the need to restructure the training process, adopting an integral view of the health-disease process and of receiving care and, thus, overcoming the fragmentation between biology / social, curative / preventive, clinical / epidemiologic, subjectivity / sociability in the construction of a teaching-learning process that makes future professionals develop specific professional competencies, combining soft-hard, like clinical technology, and soft technologies like bonding, welcoming and accountability(16).
The analysis of documents from the four scenarios allows us to affirm that the professional profile expressed in the political-pedagogical project was designed on the basis of an analysis of the labor market, of the population's demands and health needs and future projections about nurses' insertion into health service production scenarios, oriented towards the consolidation of the Single Health System. However, schools continue structuring their curricula by contents and objectives, which is characteristic of traditional teaching models. This difference seems noteworthy in the possibility to construct proposals that go beyond the understanding that it is necessary to attend to the labor market and strengthen the modus operandi of schools and pedagogical practices, sustained by the pedagogical conception of transmission and conditioning.
Therefore, the teaching-learning process must be assumed on the basis of a critical-reflexive pedagogical conception that guides methodological options directed at changing the centralism of the teaching-learning process in the teacher, in order to transfer it, make it accountable and establish a new meaning in the student(11,17).
The change and redefinition of nurses' professional profile has been established on the basis of opportunities students are offered during the course, to act in multiprofessional activities, using the interdisciplinary focus in work teams active in new teaching-learning scenarios (C4).
Various proposals are being applied in nursing education, such as curricular integration, teacher-care integration, competency-based curriculum, aimed at training professionals who are committed to health policies and at developing specific competencies and skills to exert an impact(18).
These experiences have been the fruit of nursing education programs' dissatisfaction and fragility at all levels. This fragility can be understood as a lack of theoretical bases for action, attested by the traditional lack of reflection about why and what for, by the obsession to innovate for the mere sake of innovation, in short, by education processes with little adherence to reality, where the dichotomy between theory and practice is still remarkable and where the conception of the health and disease process subordinated to biological sciences and individual care is perpetually reproduced(18).
Focus group participants also manifested that the financial support of the UNI Project contributed to the exercise of research methodology among students (C3). The documentary analysis also reveals that support was directed at strategic-institutional plans, constructed by the teaching / service partnership to design change processes.
Documentary data from the four scenarios affirmed that the approximation between teaching and research is part of mechanisms to try and integrate basic and professional teaching and articulate theory and practice, contributing to the definition of a professional profile that integrates knowledge from different disciplines and destructures the dichotomy between teaching and care practice.
In line with this analysis, practice analysis and research are training methods that allow for the construction of professionalism, through the development of a meta-competency: knowing how to analyze(7).
This seems to be a differentiating element in the search for critical-reflexive training, in which learning is the fundamental attribute in the relations between the subjects involved in interactions in the teaching-learning process, through students' active participation, the problematization of reality and the theory/practice articulation, in a permanent movement of learning to learn.
In this perspective, students can construct knowledge based on problems from concrete reality, articulating knowledge from different areas, based on interdisciplinarity and on the integration of contents and actions. This training has the potential to support actions in the complexity and unforeseeability that are characteristic of daily health work.
The analysis of focus group participants' discourse reveals that the teaching / work relation stimulates transformations in teaching which are nourished by the reorganization of the health care model, in the search for care integrality. Participants revealed that the relation between teaching and service has been a positive experience for all actors, allowing for the training of professionals who are in line with the reality of health service and with the population's health demands and needs, considering the complexity and transformations of health work.
The research results disclosed that adopting a critical-reflexive focus in the training process can affect the health and nursing work process, being able to affirm care delivery by subjects with values, culture and ideology, committed to solving the population's and health services' concrete health problems. Therefore, this movement should not only be guided by technical and instrumental rationality, but basically by new possibilities for communication, organization as well as intersubjective and care relations.
Thus, we need to think about ways to flexibilize the teaching system, constructing processes that help to structure proposals that are more adapted to requirements in the modern and future world of uncertainties. This more flexible teaching system should be manifested by the introduction of new contents but, mainly, it should give a meaning to students as subjects who need to be capable of thinking creatively, have self-esteem, can face professional changes and construct their own network of beliefs and values.
This indicates the need to reorient professional nursing training towards solving concrete and real problems, as an alternative to develop the capacity to create, recreate and project new things from the perspective of creative practice, allowing for subjects' development in their multiple dimensions: social, historical, cultural and holistic.
Thus, we consider that nursing education should distinguish itself by the search for integral care, constructed during training, on the basis of critical-reflexive references in the definition of professional nursing competencies.
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Recebido em: 25.11.2004
Aprovado em: 12.7.2006
* Research project funded by the Minas Gerais State Research Support Foundation - FAPEMIG