Perceptions of nursing undergraduate students concerning the human dimension in the learning process

Abstracts

Os objetivos deste estudo foram identificar e interpretar as percepções apresentadas por alunos de um Curso de Graduação de Enfermagem após o estágio de Saúde Mental. Foram gravadas 12 entrevistas com acadêmicos de Enfermagem da Faculdade da Fundação ABC - Santo André, São Paulo, Brasil, em agosto de 2004, utilizando-se de roteiro semi-estruturado. Por meio da Análise de Conteúdo, modalidade temática, foram identificadas quatro categorias: 1. saúde mental: proporcionando a compreensão do outro; 2. respeito pelo humano: a importância de ouvir; 3. saúde mental: contribuindo para uma visão contextualizada do paciente e 4. graduação em enfermagem: "sinais e sintomas" indesejáveis da profissão. A análise e a discussão dessas categorias representaram o vislumbramento da possibilidade de um ensino pautado na condição humana. Dessa forma, defende-se, aqui, a idéia de que novos estudos devam ser realizados, mas já considerando que a disciplina Saúde Mental deve ser valorizada nos Projetos Políticos Pedagógicos dos Cursos de Graduação em Enfermagem.

saúde mental; educação; enfermagem; empatia

Los objetivos de este estudio fueron identificar e interpretar las percepciones de los alumnos de Graduación de Enfermería posteriores a las prácticas de Salud Mental. Fueron grabadas 12 entrevistas con alumnos de Enfermería de la Facultad de la Fundación ABC - Santo André, São Paulo, Brasil, en agosto de 2004, utilizándose para ello, una guía semi-estructurada. El Análisis de Contenido, en su modalidad temática fue empleada para la identificación de cuatro categorías temáticas: 1. salud mental: proporcionando la comprensión del otro; 2. respeto por lo humano: la importancia de escuchar; 3. salud mental: contribución en la visión en el contexto del paciente y 4. graduación en enfermería: "signos y síntomas" indeseados por la profesión. Del análisis y la discusión de esas categorías se vislumbró la posibilidad de una enseñanza basada en la condición humana. De esa forma, se defiende la idea de que nuevos estudios deben realizarse, tendiendo en consideración que el curso de Salud Mental debe ser valorizado dentro de los Proyectos Políticos Pedagógicos dentro de la Graduación en Enfermería.

salud mental; educación; enfermería; empatía

ORIGINAL ARTICLE

Perceptions of nursing undergraduate students concerning the human dimension in the learning process

Simone de Oliveira Camillo^I; Ana Lúcia da Silva^II; Alan Jefferson do Nascimento^III

^IM. Sc., Professor at the ABC Foundation Medical School, e-mail: [e-mail]

^IIPhD, Faculty member at the Graduate Program in Sciences of the Coordination of Disease Control of the State Secretary of São Paulo, e-mail: [e-mail]

^IIIRN, e-mail: [e-mail]

ABSTRACT

This study aimed to identify and interpret the perceptions presented by undergraduate students of a Nursing course after internship in Mental Health. Twelve nursing undergraduate students at the Nursing School of ABC Foundation - Santo André, São Paulo, Brazil were interviewed. These interviews using a semi-structure script were performed and recorded in August 2004. Through Content Analysis, thematic modality, four categories were identified, 1. mental health: providing understanding of the other; 2. respect for the human being: the importance of listening, 3. mental health: contributing for a contextualized view of the patient and 4. nursing graduation: undesirable "signs and symptoms" of the profession. The analysis and the discussion of these categories suggest the possibility of teaching based on the human condition. Thus, we support the idea of new research been carried out, considering that the Mental Health discipline must be valued in the Political and Pedagogical projects of the Nursing Undergraduate Courses.

Descriptors: mental health; education; nursing; empathy

INTRODUCTION

The teaching-learning process of undergraduate Nursing courses in Brazil is usually focused on biotechnological matters and the study of the physical procedures related to the ill person. Therefore, the interpersonal relations that permeate the health care process, as well as the importance given to other human beings' feelings and the responsibility of caring not only become a great challenge but also one of the most difficult tasks, besides the fact that these issues often are not valued as they should be⁽¹⁾.

Thus, students and faculty constantly experience great anxiety and dissatisfaction when they face the interpersonal relationships of the care process, exactly because they do not know how to deal with certain situations and the resulting feelings. These situations essentially involve not only the physical aspect, but also fear, sorrow, insecurity, contradictions between other emotional aspects of the patient, the student and the faculty member him/herself^(1-2).

In this sense, seeking to expand spaces for academic learning, the subject Mental Health in Nursing was added to the pedagogical project in the undergraduate Nursing course taught at the ABC Foundation Medical School. This knowledge is essential to prepare students from the beginning of the course in order to acquire experience and skills to talk to people, hear histories, recognize and express feelings and, certainly, to have better conditions to deliver care to the patient, developing his/her own grandness as a person and professional. Thus, the Interpersonal Relationship subject addresses the foundations of human relations. In the fifth and sixth semester, its content is deepened in the Mental Health subject, which aims to look at emotional reactions, feelings focused on the self and the other and the interrelationships established in the teaching-learning process between student, patient and professor, by means of discussed expositions and group work. This has stimulated both students and professors to discuss not only theoretical concepts and situations experienced in other subjects, but also feelings, values, prejudices and other emotional aspects involved in the care process.

Hence, it is relevant to know the perceptions of undergraduate Nursing students at the ABC Foundation Medical School in São Paulo (SP), Brazil, after their Mental Health internship. Did they start to value emotional aspects in the same way as technical aspects? Did their academic and personal lives changes after the Mental Health practice? Thus, we expect to contribute to the improvement of the teaching-learning process, stressing the idea that the human being is not composed only by the biological aspect, but also by the psychological, social, cultural and spiritual aspects.

The Biomedical model and Nursing

For a better understanding of the valuation of both technical aspects and studies of physical procedures related to the ill, we need to understand the influence of the Cartesian paradigm in the health area and consequently, in the Nursing universe.

The major change in the history of occidental health occurred with the Cartesian revolution. Before, most therapists looked at the interaction between body and soul and treated their patients in the context of their own social and spiritual environment. Descartes' philosophy profoundly altered this situation. His rigid division between body and mind made therapists concentrate on the body and neglect the psychological, social and environmental aspects of the disease. Descartes himself, although he introduced the separation between body and mind, considered the interaction between both as an essential aspect of human nature and was perfectly aware of its implications for science^{( 3)}.

On the other hand, advancements in biology during the XIX century were accompanied by advancements in material technology. New diagnostic instruments were invented, such as the stethoscope and blood pressure verification devices. Surgical technology became more sophisticated. At the same time, attention was gradually transferred from the patient to the illness. This gave rise to the specialization tendency that would reach its summit in the XX century⁽³⁾.

Thus, we can say that the biomedical model was influenced by the Cartesian paradigm and that, today, it constitutes the conceptual framework of the health-illness process. In this model, the human body is considered a machine that can be analyzed in terms of its pieces. The illness is seen as an organic malfunction, which is studied from the viewpoint of cellular and molecular biology. The health professionals' role is to intervene physically or chemically in this malfunctioning mechanism.

The fact this model sees the individual as a predominantly physical being affected or has affected the practice of nurses, who are more centered on the physical needs of the ill. Thus, nursing as well often acts mechanically, valuing much more technical and biological aspects to the detriment of psychological, emotional, social and spiritual aspects. The care that allows for the expression of the person's development in a biopsychosocial context, considering that person's needs, resources, values, beliefs and myths, is not contemplated in this model. There is little concern about what the ill person thinks and feels, contrasting with the great value attributed to techniques, especially the most sophisticated ones. Health professionals' education, while restricted to the biomedical model, is not able to consider the experience of suffering as part of its professional relation.

Regarding undergraduate Nursing education, one very disseminated principle in educational institutions considers excellence in care quality as care delivery to the individual as an integral being (biopsychosocial, cultural and spiritual). However, actions are below expectations, since what is prioritized is the technical aspect.

The discussion is not about the need to develop nursing students' technical competence, who will have the guarantee of safe and effective professional work. Nonetheless, it is important to pay attention to the development of abilities not only in terms of performance but also in terms of thoughts and feelings. If the nurse's main function is to deliver care to human beings, human complexity needs to be emphasized, focusing on understanding, respect for the other, so as not to fragmentize the human condition⁽⁴⁾. Moreover, for Nursing students to implement care practices and conducts, they need to experience care in their personal lives and educational environment. In addition to having an environment of trust and respect, they need to be given opportunities to develop critical thinking⁽⁵⁾.

Hence, this research aimed to: identify and interpret undergraduate Nursing students' perceptions after their internship in Mental Health.

METHOD

Study type

This is a qualitative research. Qualitative research identifies characteristics and meanings of human experiences, which the subjects describe at several levels of abstraction, without allowing for ambiguities and contradictions across the interviewees' reports.

Scenario and participants

This study was carried out on ABC Foundation Medical School campus, a philanthropic and private educational institution located in Santo André, in the Grande ABC region of São Paulo State, Brazil.

The 22 students in the sixth term of the undergraduate Nursing course who had finished their Mental Health internship in the fifth term were invited, but only twelve agreed to participate in the research. The decision to interview sixth-term students was due the fact that they had recently concluded their internship in the Mental Health in Nursing subject. Thus, we believed these students' contribution would be more effective, since their perceptions about their learning in the Mental Health internship would be more vivid in their memory.

Data Collection

Authorization from the educational institution was obtained. After the favorable review by the Ethics Committee for Research involving Human Beings, students received orientation about the Free and Informed Consent Term. They were also informed that their names would not be revealed in research data presentations.

In total, three interviews were recorded with the participants' agreement and authorization, aimed at improving the data collection instrument. These were not included in this analysis.

The students were contacted individually and those who accepted to participate were interviewed at their convenience, outside class hours. Data were collected in August 2004 through semistructured interviews. This kind of interview values the researcher's presence, who offers possible perspectives to make the interviewees achieve the necessary freedom and spontaneity, thus enriching the investigation. The guiding questions were: 1. What were your perceptions about the internship in the Mental Health in Nursing subject?; 2. Do you think that the way you see the relationships with patients, the multiprofessional team, professors, fellow students and personal relations changed in any way? Why?; 3. In what way did Mental Health in Nursing practice contribute to your education?; 4. Regarding your academic education, do you think the emotional aspects are valued as much as the technical aspects? Why? 5. Do you think the internship in the Mental Health in Nursing subject changed your way of life?

Data Analysis

The interviews were analyzed by means of Content Analysis, that is: "… a set of communication analysis techniques that aims, through systematic procedures and description of the message content, to obtain indices, whether quantitative or not, that permit inference of knowledge about the conditions in which these messages were produced/received" ⁽⁶⁾. We added the thematic modality to reach both revealed and latent meanings obtained through in-depth interviews, with subjects who live in the academic universe. This modality is an assertion about a certain issue, which can be expressed in a simple sentence, a set of sentences or a paragraph. It incorporates, more or less intensely, the personal aspect the respondent attributes about the meaning of a word and/or about the connotations attributed to a concept, involving not only rational, but also ideological, affective and emotional components.

Six steps were adopted for a consistent construction of categories^(6-7):

First, after the verbatim transcription of the recorded interviews, the texts were read through free-floating attention. Next, based on this free-floating attention, three more readings were performed, intercalating listening to the recorded material with reading of the transcribed material. This attentive posture permits following the chain of associations in each interview and interviewee. Free-floating attention permits the association, as freely as possible, of any discourse element. In free-floating reading, impressions and orientations are internalized, even before any actual analysis or knowledge of the text;

Second, through a new re-reading, words and phrases were underlined from the original texts in order to identify convergent and divergent elements among interviews;

Third, after the identification of convergences and divergences, the underlined words and phrases were cut from the original texts. This procedure was performed in each of the interviews;

Fourth, after cutting words and phrases, we aimed to identify convergences and divergences per interview and between interviews, in order to elaborate categories;

Fifth, after the construction of categories, data discussion followed.

RESULTS AND DISCUSSION

Table 1 identifies the categories found:

Mental Health: providing for understanding of the other

Comprehension is the act, the ability to understand in all senses. Preparing for the human comprehension is one of the missions of education, so that we can acquire intellectual solidarity in humanity⁽⁴⁾. One of the purposes of the Mental Health subject is to provide students with a reflection on the comprehension of the human dimension. The phrases below show the students' perceptions:

I found it very interesting because I didn't have the slightest idea of what it was about, I got a psychological view (Josefa).

In the beginning I got lost, but then I got familiarized with the internship and saw its importance, because I learned to make the therapeutic relationship (Maria)

I started to respect my colleagues and professors more (Camila)

It can be noticed that, through the internship in Mental Health, the students Josefa, Maria and Camila felt stimulated and interested, as they perceived the importance of having a psychological view of the human being, as well as the importance of improving their interpersonal relationships. This is demonstrated by the satisfaction of having learned to develop the therapeutic relationship. As people start to understand the subjectivity of the other and improve their interpersonal relationships, they also perceive the importance of respect in relationships, which is undoubtedly a fundamental element in the understanding of the other. Comprehension necessarily includes a process of empathy, identification and projection. It is always inter-subjective and demands openness, sympathy and generosity⁽⁴⁾.

This process of empathy, identification and projection is highlighted in the participants' discourse:

This internship was very interesting because there was involvement with the patient and we've created a bond (Manolo)

Through this experience, I've learned to see the subjective side of people (Rafaela)

I've learned a lot because it changed the way I see people and understand that they also have feelings (Roseli)

Not understanding oneself is an important source of not understanding the other. When we start to comprehend ourselves, we get connected with our subjectivity. Through the mental practice of a permanent self-exam, we find that we are all fallible, fragile, insufficient, needy beings. We find that everyone needs mutual comprehension⁽⁴⁾. The human being needs to comprehend (him)herself and the other, because when we understand ourselves and the other, the relationship becomes more spontaneous and effective⁽⁸⁾.

The following sentence shows that the student allowed herself the mental practice of the self-exam, one of the purposes of the Mental Health subject:

It changed my way of life a lot, as I was different before the practical internship and now I try to be a different person, worrying about the patient's feelings, because it is very important, and even essential for his(er) recovery (Sônia).

Understanding the other requires awareness of human complexity. Therefore, it is important to be open to the other and try to be tolerant, that is, to be capable of accepting the expression of diverging ideas, convictions and choices. As we get tuned with the other at a high level of empathy, we become comprehensive⁽⁸⁾. The world needs, in all senses, mutual comprehension. Thus, preparing for comprehension is essential at all educational levels and ages⁽⁴⁾.

In the study area, the Mental Health subject offers its fundamental contribution as it provides the worthy task of comprehending the other.

Human Respect: the importance of listening

To listen is to abdicate. It is the highest form of altruism, with all its meanings of love and attention to the other. Perhaps that is why most people hardly listen or simply do not listen at all⁽⁹⁾.

Our tendency to fragment is stronger than the need to integrate. We do not know how to listen. When someone talks, instead of listening until the end to what the person has to say, we soon start to compare what is being said with our own ideas and previous reference frameworks. This mental process is called the agree-disagree automatism⁽¹⁰⁾. To listen up to the end, without agreeing or disagreeing, is an extremely difficult task for all of us. This agree-disagree automatism functions as follows: when our interlocutor starts to talk, we immediately assume one of two attitudes: a) "I know what he(she) is going to say and I agree, thus, I am not going to lose my time listening to him(her)"; b) I know what he(she) is going to say and I disagree, thus, I have no reason to keep listening to him(her)". In both cases, the result is the same: we deny to whom is talking to us the possibility to say something new. In practice, this can correspond to the denial of our own existence⁽¹⁰⁾.

While we listen, it is important to be aware of how we feel. We need to be attentive to our reactions to what we are listening to, because communication is fundamentally determined by the perception of who receives it, and not exclusively by what is expressed by who is talking⁽¹⁰⁾.

The students Manoela, Isabel and Goreti learned that the importance of listening is related to the respect and human comprehension, as illustrated by the following phrases:

There was a significant change because I've learned to listen to people better, to value more the human being... To really listen… (Manoela)

Listening first and talking later...We always want to talk...In this internship I've perceived how important it is to welcome people, listening…(Isabel).

We need to listen more to the patients and be more considerate with them…If we listened more, perhaps the patients would recover better, due to their satisfaction of really having someone who actually gives them the importance they deserve (Goreti)

There are some ways to listen, because we are, sometimes, better listeners in certain situations than in others. Interest guides our behavior, we listen better when we our attention is stimulated. This stimulus varies according to our interest, and we listen better whenever we need to understand issues of our interest, when our curiosity is aroused and when someone refers to any issue that affects us personally⁽⁹⁾.

The expansion of our view regarding the importance of listening to the other pertains to our own subjectivity, which favors professional and interpersonal exchanges, facilitating coping with conflicts and sharing experiences, which in fact constitutes the matrix of identity for humanized care.

Mental Health: contributing to a contextualized view of the patient

One of the principles largely disseminated in the Nursing area is that of global care delivery. However, the delivered care has not attended to expectations, since what is prioritized is the technical aspect. The need to develop nursing students' technical competency is not questioned. Nevertheless, the development of abilities cannot be limited to issues focused on actions, but on thinking and feeling as well. Comprehension of the other and respect for the other in his(her) complexity need to be emphasized, since the human being is at the same time a biological, psychological, cultural and social being. In this sense, the importance of the Mental Health subject was documented as follows:

The Mental Health subject contributed because I got more human... more tolerant and more understanding (Manolo).

The Mental Health subject contributed because there was a notion of mental health and prevention by means of mental health, seeing the patient as a whole…seeing everything…Not only the disease or body, but really seeing the person (Isabel).

In the health area, technology cannot annul the human being. Being considerate with the other, valuing the human dimension, delivering care within a complex view and creating a help relationship with empathy turn humanization into the base of professional Nursing practice. We know that our goal is to move towards humanization and, when we attempt to humanize our work, we become more humanized. In order to reach this goal, the student needs to have knowledge about care humanization, about personal values regarding the respect for human beings or the values that can be added to one's conduct and acquire the necessary in order to know how to act therapeutically. Care delivery is nursing's reason of being and, consequently, its ethics^(5,8).

Therefore, students need to be guided towards reflections about what the "human being" is in order to be able to practice complex care, that is, not only in the biological but also in the full biopsychosocial dimension.

Undergraduate Nursing: undesirable "signs and symptoms"

Nursing in Brazil, not very differently from other countries, started to devaluate human care in response to an ideology of cure. Today, curative actions occupy the majority of activities, using increasingly sophisticated material technologies. In the light of this reality, students comment on the work of nursing professionals, based on their participation in undergraduate nursing internships. Let us look at the following extracts:

People act forgetting the emotional side. Many of them only think of the technical aspect, how to apply a dressing… The patient is more than a wound, than a disease (Roseli).

I perceive... when I observe the professionals who work at the hospital, I see that they do not put in practice what they have learned, that is, to value the emotional aspect (Carmen).

It is a very mechanical profession. Everything is technique… Everything has a schedule, everything happens in a hurry. The emotional aspect is of secondary importance (Manoela).

Higher education institutions can no longer accept professional education merely focused on the specific technical performance of one's activity area. Their concern should focus on training professionals who are citizens, scientifically and technically competent, but, above all, with a broad view of the human dimension. The frequent difficulty in seeing the human dimension is evidenced as follows:

Many times, the patient is sad because (s)he is hospitalized and we do not stop to talk to the person, only execute our task and go away (Ivone).

The profession is more mechanical than emotional. I see people's cold behavior. I do not want to be like this (Rafaela).

As they prepare professionals who deal with people's health and life, undergraduate courses need to rethink pedagogical practice and formation, which are still inspired in the mechanical model nowadays. One of the precepts of this model is to divide the object of study or the difficulties that emerge in how many parts as necessary to solve them, which provokes the division of knowledge in areas increasingly more specialized^{(5, 11)}.

Until the Cartesian revolution, therapists in general treated their patients as beings composed of body and soul, within a social and spiritual context. However, in the biomedical model, the division between body and mind reduced the human body to a machine whose function depends on its biological mechanism's state of operation. Since then, sciences have investigated biological functioning down to the molecular level, while the influences of factors like the psycho-emotional and the social-environmental in the health-illness process are no longer considered⁽⁵⁾, as shown in the following phrases:

The curriculum does not permit a better valorization of the emotional aspect, because we are more charged for the technical aspect (Isabel).

There is a prioritization of technical values, while emotional aspects are being forgotten…We are evaluated by the way we carry out the procedures and by the way we rationalize… By the scientific knowledge… Then, we forget the patient's emotional aspect (Josefa).

The possibility of a more humane education needs to be taken into account, acknowledging the importance of the psycho-emotional and environmental aspects in the health-disease process and in the relationship between professionals and clients. This education will certainly not be the object of one or some subjects in human sciences, but of the philosophy that must guide the development of the course, involving all professors and students⁽⁵⁾.

After this discussion, we hope that undergraduate nursing courses become increasingly based on contact with people's emotional dimensions, on decreasing the dichotomy between so-called physical and psychological problems, on stimulating students to perceive and deal with their own emotional background, on preparing them to acquire experience and ability to talk to people, to listen to stories, to recognize and express feelings and, definitely, on obtaining better conditions to deliver care to the patient through the development of the student's own grandness as a person and professional. Future nurses do not constitute themselves only as technical and skilled elements but, above all, as human beings⁽¹²⁾.

The presented categories possess common elements, relationships and permutability. They open up paths for a better verification and analysis of undergraduate nursing students' perceptions after their internship in Mental Health. Therefore, we do not intent to exhaust the topic under study. On the contrary, we hope that new points of view will contribute to the improvement of this study.

CONCLUDING REMARKS

It is important to recall that the realization of this study was motivated by the need to investigate undergraduate nursing students' perceptions after their internship in Mental Health, taking a closer look to find out if, after the internship, emotional aspects were valued to the same extent as technical aspects.

Participants could freely express themselves through the semistructured interviews. There was a guiding script and the content of the interviews permitted the recognition of categories. These categories were discussed and interpreted as to their meanings as guiding sources for a humanized teaching-learning process in an undergraduate nursing course.

Through the categories, we could grasp the students' perceptions after the mental health nursing practice, and we registered that students reported and understood that the human being is not composed only of the biological, but also of psychological, social, cultural and spiritual aspects.

The mental health subject in the field of study in question offers its fundamental contribution to the extent that it promotes the comprehension of the other through empathy, identification, projection, the mental practice of self-exam and the importance of listening as a form of respect for the other. It is one of the missions of education to prepare for human comprehension, so that we can acquire a condition of intellectual solidarity in humanity.

Recebido em: 10.8.2005

Aprovado em: 16.11.2006

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Publication Dates

• Publication in this collection
  29 May 2007
• Date of issue
  Apr 2007

History

• Accepted
  16 Nov 2006
• Received
  10 Aug 2005