Nursing education oriented to the principles of the Unified Health System: perception of graduates^*

ABSTRACT

Objective:

To identify how nursing undergraduate students from a public university in southern Brazil perceive their educational process in line with the principles of the Brazilian Unified Health System (SUS).

Methods:

This is a qualitative research, based on Freire's studies. Data were collected in the first half of 2012 through individual interviews and analysed according to content analysis.

Results:

Training geared towards reality, with an emphasis on SUS, stands out as a category. Nursing training is in line with the National Nursing Curriculum Guidelines and SUS principles; students feel prepared to work in primary care, and their training is generalist, humanist, critical and reflective.

Conclusion:

The nursing training process is in line with the current health public policy, although presenting weaknesses that must be rethought, such as interdisciplinary and transversality of SUS related content.

Keywords:
Nursing Training; Brazilian Unified Health System; Curriculum

RESUMO

Objetivo:

Identificar como os formandos de graduação em enfermagem de uma Universidade Pública da Região Sul do Brasil percebem o seu processo de formação em consonância com os princípios do Sistema Único de Saúde (SUS).

Métodos:

Pesquisa qualitativa, ancorado no referencial de Freire. Os dados foram coletados no primeiro semestre de 2012, por meio de entrevistas individuais e analisadas de acordo com análise de conteúdo.

Resultados:

Destaca-se como categoria que a formação está dirigida à realidade, com ênfase no SUS. A formação do enfermeiro está de acordo com as Diretrizes Curriculares Nacionais/Enfermagem e os princípios do SUS; os alunos sentem-se preparados para trabalhar na atenção básica, sendo que sua formação é generalista, humanista, crítica e reflexiva.

Conclusão:

O processo de formação do enfermeiro encontra-se de acordo com a política de saúde vigente, porém apresenta fragilidades que devem ser repensadas, como a interdisciplinaridade e a transversalidade dos conteúdos relacionados ao SUS.

Palavras-chave:
Educação em Enfermagem; Sistema Único de Saúde; Currículo

RESUMEN

Objetivo:

Identificar como los alumnos del último año de grado en enfermería de una universidad pública del sur de Brasil perciben su proceso de formación en línea con los principios del Sistema Único de Salud (SUS).

Métodos:

Investigación de carácter cualitativo, anclado por el referencial de Freire. Los datos fueron obtenidos en el primer semestre de 2012 y se analizaron de acuerdo con el análisis de contenido.

Resultados:

Para los alumnos la formación está dirigida a la realidad, con un énfasis en el SUS. La titulación académica de enfermería está según las directrices del Plan de Estudios Nacional de Enfermería y con los principios del SUS. Los estudiantes se sienten preparados para trabajar en la atención primaria, siendo que su formación es generalista, humanista, crítico y reflexiva.

Conclusión:

El proceso de formación del enfermero está de acuerdo con la política de salud actual, sin embargo presenta debilidades que deben ser repensados, como la interdisciplinariedad y la integración de los contenidos relacionados con el SUS.

Palabras clave:
Educación en Enfermería; Sistema Único de Salud; Currículo

INTRODUCTION

The Brazilian Health Reform began during the military dictatorship and within a context of struggle for the country's democratization. The health model at the time was highly segmented and fragmented, excluding the poorest population from both the formal labour market and access to public healthcare services, focusing the health care system in physicians' offices and private hospitals. The depletion of this model coincides with the beginning of the Brazilian sanitary movement, which arose driven by two "feelings": the criticism of the current model and the construction of a new health system for the country¹.

In 1986, the 8^th National Health Conference, with the full participation of workers, government, users and some health service providers, meant a milestone in health policy changes and expanded the concept of health that goes beyond the absence of disease; in its entirety is full citizenship guaranteed to all Brazilians².

In view of the construction of this new public health model, and under the 1988 Constitution, Brazil expanded rights in health, consolidating, in Article 196 of the Federal Constitution, the principle that "health is everyone's right and the duty of the State", guided by the principles of universality, comprehensiveness of care, preserving autonomy, equality of health care, right to information, dissemination of information, use of epidemiology to establish priorities, community participation³. Even though this right's fulfilment is still to be ensured, the Unified Health System (SUS) implementation process has shown increasing access to services for the population and, moreover, contributed to incorporating the right to health as a condition for citizenship in public culture¹.

The change in the healthcare model also pointed to a necessary change in the profile of future health workers, through the adoption of strategies directed to the field of professional training and development, built on the principles and guidelines of the Public Health System, and based on a broader health concept; on the use of methodologies that consider health work as a structural axis; on multidisciplinary and transdisciplinary work; on the integration of education and health services; and on the improvement of comprehensive health care for the population. In other words, a new healthcare model; a new training model⁴.

Therefore, higher education institutions are being challenged to break paradigms regarding professional training and need to implement actions that redirect the training process. These paradigm shifts, transformations, achievements and challenges show that many advances towards respecting SUS principles occurred, and also influenced the reconstruction of the courses' pedagogical projects, which should be in line with the sanitary reform and SUS principles.

Thus, the professional training process constitutes the development of a critical citizen, able to cope with the rapid knowledge changes and their effects in the workplace, and also allowing the construction of an academic and professional profile that leads, through perspectives and contemporary approaches, to the enhancement of skills and abilities that can support the development of a critical-reflective professional, transformer of social reality and agent of change in the perspective of reorganizing practices in primary care⁵.

Liberating and critical education can only take place from the time the student experiences reality, so that they can build concepts and knowledge, i.e. they can only be critical if they know, understand or comprehend reality to be able to reflect on it, and from this reflection appropriate a critical character concerning it⁶.

Thus, the student will be using a process that stems from observation and reflection and culminates in transformative action. They must realise critically that, in order to change, they need the ability to intervene in reality, a very complex task, but also generator of new knowledge. Hence, the student is not the object of history, but its subject⁷.

This education guided by reality, knowledge construction and reality transformation is in accordance with the National Nursing Course Guidelines.

Given this, the nurses training process, in contemporary times, constitutes a major challenge, which is to train professionals with technical and political expertise, endowed with knowledge, reasoning, perception and sensitivity to issues of life and society, being able to intervene in situations of uncertainty and complexity⁷. It is necessary to have clarity from the beginning of the training process that "those who teach learn and re-learn by teaching, and those who are taught teach themselves and teach by being taught"⁶.

In view of this background of transformations, this study aimed to identify how nursing students perceive training aligned with SUS principles.

METHODS

This is a qualitative, descriptive and exploratory study. The study setting was a southern Brazilian public university's Nursing Course. Participants were 11 female nursing students, aged between 21 and 30, enrolled in the course's final year. The total number of students was defined by the data saturation criterion.

Data were collected through semi-structured script interviews scheduled in advance, according to participants availability, and individually conducted by the researcher where the course is given or at the students' internship. The average duration of the interviews was 30 minutes.

The interviews were recorded digitally, transcribed immediately after collection and then read and analysed according to content analysis, which was organized around three major chronological poles: pre-analysis; material analysis; treatment of results, inference and interpretation⁸.

1. Pre-analysis is the organization itself. At this stage, the researcher came into direct contact with the material, performing readings and inquiries, clipping passages from the recordings to remove the main interview points from the students' responses. At this stage, the interview clippings were grouped into a table using Microsoft Word.

2. The second stage was material analysis. This was a long and fastidious phase, consisting essentially of coding operations and administrating techniques on the corpus. At this stage, the researcher explored every line in detail in order to find main ideas contained in the students' speech.

3. The third stage consisted of processing the obtained data corresponding to a transformation of the raw text data, enabling the obtaining of a representation of the content, or its expression. A new reading of the material was carried out at this stage, and it was grouped into subcategories.

4. Inference and interpretation: In this phase, the treatment of the results was performed, inter-relating them with the theoretical framework and literature.

After rereading the theoretical framework, the category 'The Process of Training in the Perception of Undergraduates' and the subcategory 'Training is Directed to Reality and Emphasizing SUS' emerged.

Data collection was performed after approval by the Ethics Committee in Research with Human Beings/UFSC through Opinion Nº 1942/2011, fulfilling the requirements of Resolution 196/96 of the National Council of Ethics in Research. The invitation was made in verbal form on the first day of the 2012-1 semester, and subsequently reiterated by e-mail. After explaining to the participants the study's purpose, they signed the Free and Informed Consent Form. The data collection period was April and May 2012, and the average duration of interviews was 30 minutes. Anonymity was guaranteed through the use of alphanumeric codes: S1 (student followed by serial number).

RESULTS

The results were grouped from the category 'Training is Directed to Reality and Emphasizing SUS'.

This student believes that the nursing course is geared towards professional training with emphasis on the Unified Health System, as depicted in the following quote:

[...] As we have SUS since the first phase, you know SUS, how it works. Some stages are more geared towards it, especially the sixth stage, and in other stages you always talk about SUS - this topic is always discussed. I find this training important because it prepares you for public hospitals, as I told you everything that relates to health is directly linked to SUS - it's a differential (S10).

In this way, we see that during training, the course is concerned with this so that it is in line with the 2001 National Curriculum Guidelines. The testimony below strengthens the study and corroborates this perception:

[...] Another important thing is that during all the training you see examples that SUS works, you embrace the cause. It makes you believe that it is really right, you see good examples, and that cause you to want to make a difference and follow these good examples (S1).

During training, we realized that student are inserted into reality so that they can understand the process and then discuss it, to make this connection between theory and practice. This connection appears in the speech of students because they perceive this insertion into reality, as shown by the following statement:

[...] Since the first phase, SUS is already inserted; we go to the field; I note that it is discussed at all stages, teachers talk about family health strategy, SUS history. I believe that students are coming out of university with a good sense of SUS and how nurses can be inserted (S2).

The students also highlight the changes in training, this new view of SUS, as expressed in the following quote:

[...] We performed a job once [...] when we studied collective health. It was really cool, because we went to the real world identifying all the work that SUS does and then you identify yourself as a SUS professional; first they show you as a user, your rights, what is SUS, what it does, what it covers, then they insert you not only as a user, but as a professional (S6).

For students, nurses are professionals who work in the health team and have direct contact with those who seek health services. Therefore, they are also responsible for the consolidation of SUS principles. The students show how they are inserted within the health services during the course and the importance of SUS content:

[...] In the first phase we have the introduction to SUS, the history of SUS, nursing within SUS, and in the second phase also. Also in the fifth phase because we go to basic units for women's health. The sixth stage is totally SUS; being entirely in a basic unit in the sixth stage, we had more contact with SUS. In the seventh stage as well, but as a manager - more administrative work, and in the eighth stage I chose to stay in the basic unit as well (S5).

Under the Ministries of Education and Health of Brazil's Reorientation of Professional Training in Health Programme, it is noteworthy that, throughout the training, students did not perceive and did not participate in programmes such as the Pro-saúde [Pro-health - National Programme for Reorientation of Vocational Training in Health] and Pet-saúde [Pet-health - Labour Education Programme for Health], since the institution of higher education in which this study took place participates in these initiatives. The students demonstrated, in their statements, a lack of knowledge and interest about these programmes, as specified below:

[...] I've never participated in the Pet, because I already had another research grant, but we didn't have much information regarding the Pet and the Pro-health is very shallow. We had no discussion about it in class (S7).

Another issue raised by the students was interdisciplinarity during training. The statement below shows that the students recognize the importance of interdisciplinarity and its fragility during their training:

[...] What is missing is the issue of SUS interdisciplinarity. I think they strengthen this issue of nursing in SUS a lot; the importance of the nurse. But I think there is a lack of work on the other courses (S6).

I believe that this kind of interdisciplinary approach is still incipient in the training, as the students reported in their statements. This is the difficulty for the construction of an interdisciplinary proposal in nursing. The training of human resources to work in primary care and in all public networks is included in the government training reorientation programmes proposal. The students talk about their training, and feel greater security in working in primary care and in SUS, as reported below:

[...] And I feel much more prepared for primary care than hospital care. The university prepares me more for SUS and primary care (S8).

Based on the investigated results, it can be observed that the process of nursing training is directed to the Unified Health System, and is in line with the national curriculum guidelines, as evidenced in the course's political and pedagogical project. The curriculum axis is constituted from health promotion in the process of human living, in the various scenarios of health work. Only by inserting the students into reality will they become aware of themselves and the world; they appropriate reality, reflect on it and after admiring it, they transform it according to their actions.

DISCUSSION

The nursing training process has undergone changes over the years. Since 1890, when the training focused on preparing professionals to work in hospices, it passed through the creation of the School of Nurses in 1922; the creation of the Ana Nery School in 1926, and finally underwent changes with the implementation of the Curriculum Guidelines for Nursing, in 2001.

Thus, the trajectory of the training and the profile of the graduates have always been linked to the prevailing political, economic and social model in the country. This path, however, did not occur in a linear way; it faced challenges that were overcome in the short-term limits of each historical societal moment⁹.

Given these changes, the training of nurse practitioners is guided by the DCN/ENF [National Curriculum Guidelines for Nursing Courses], which, in its sole paragraph, says: "The training of the nurse must meet the social health needs, with emphasis on the Unified Health System (SUS) and ensure comprehensive care and the quality and humanization of care"¹⁰.

Authors state that the nursing course has increased prospects for public healthcare as a labour market and, therefore, opportunities for society transformation¹¹. A study with nurses identified that for their first activity as professionals, 52.5% was in public service, followed by 44% in private employment and only 2% as self-employed¹².

Rethinking the role of the educator in training, from the interaction with the community, may be a crucial point in order to raise student's awareness about the real understanding of SUS. The theory/practice schism is aggravating the quality of training. Therefore, thinking about the transformation of health practices is needed to improve the population's quality of life. When working only in practice, the individual becomes an activist; by articulating theory and practice, the individual seeks to exercise praxis, that is, the reflected and transformative practice¹³.

In the academic training, students need to know/recognize SUS, aiming to be closer to the population within the system reality, with sensitivity to act in the diversity and complexity of the population health problems¹³.

The change in training is required, but in order for such training to break values and paradigms, it must approach the real needs of users and system. This requires hard, slow, complex and conflicting institutional, professional and personal changes. The significance of the training and the qualification of care must be present in the educational processes for health professionals¹⁴.

Within this perspective, we observe that the training of health professionals was strongly marked by the paternalistic vision, under the strong influence of conservative, fragmented and reductionist approaches, in which the curative knowledge was favoured at the expense of proactive practices targeting the protection and promotion of health. Accordingly, in pursuit of technical efficiency, the transmission of knowledge was centred on lectures, in which the student had little or no possibility of inclusion and participation. Besides the emphasis on technical competence, traditional approaches separated reason and emotion, science and ethics, objective and subjective. The teaching-learning process was focused primarily in the person of the teacher and classroom space, with little chance to practice questioning¹⁵.

However, for nurses to contribute to the effective implementation of SUS governing principles, it is necessary for these professionals to know, understand and incorporate such principles in their daily practice, regardless of their area of operation and the various levels of healthcare complexity. Such understanding should start in the nursing education process and should continue in their daily work, since the concepts will reformulate as new situations and knowledge emerge¹⁶.

Recognizing this need, some interministerial actions (Health and Education) has fostered the creation of new experiences in health education. The training of human resources to work in primary care and in all public networks is included in the government training reorientation programmes proposal.

Among these actions is the Pró-saúde (Pro-Health) Project, which consists of a proposal for a teaching-service integration, aimed at vocational training reorientation, ensuring a comprehensive approach to the health/disease process with emphasis on primary care, promoting changes in the processes of knowledge generation, teaching and learning, and providing services to the population¹⁷. As well as the Pro-health, the Pet-saúde (Pet-health) project constitutes an instrument for achieving work initiation programmes, internships and experiences, aimed at students in the area, according to SUS needs¹⁸. Its central axis is the teaching-service integration, with the subsequent integration of students in the actual scenario of practice, which is the SUS network, with emphasis on primary care, from the beginning of their training¹⁹.

The interdisciplinary approach is a potentially creative proposal that can generate resizing of knowledge and practices, by promoting the transposition of disciplinary boundaries and establishing a mutual dialogue of knowledge²⁰. This is recognized by the curriculum guidelines for undergraduate courses in general, when recommending the need for educating subjects who can think, analyse/reflect and who are committed to ethics and society¹³.

This way, it is necessary that education contribute to the formation of critical, creative and reflective practitioners, so the desired changes in the health care model can be achieved. Therefore, it is necessary for the students to develop critical awareness, which is the ability to critically reflect on reality; and through this awareness, the student is able to transform it²¹. For this, students need to distance themselves to think about the object, and admire it, which means focusing their views and thoughts, and from this act, analyse and sharpen curiosity, remain inquisitive and build ways of acting by perceiving this attitude as a necessity. This process is only achieved with a consciousness that is critical, creative and indicative of the scope of awareness^22,23.

Awareness is proposed as a way for human beings to approach preparation for action against their dehumanization. For this, the individual must admire reality in a detached way, then come back to it and re-enter themselves, transforming it. This act, then, will be their praxis²¹.

CONCLUSION

The nurses training process in this study course is in line with DCN/ENF and SUS principles, but it has some weaknesses that should be reconsidered, as the interdisciplinarity and cross-cutting of SUS related content. Nevertheless, the students realize that their training is geared towards the Unified Health System, feel prepared to work in primary care, and demonstrate that their training is generalist, humanist, critical and reflexive.

The training is guided by pedagogical projects aimed at dialogic and participatory methodologies, committed to the construction of knowledge, and to provide students with the knowledge, know-how and know-how-to-be, committed to the changes in society to act with autonomy, efficiency and effectiveness in health services.

We also noticed that the government reorientation programmes for teaching and service integration, such as the Pro-health and Pet-health, are part of the training for some students and are recognized as enriching experiences, but still require institutionalization.

The students also reported the importance of SUS related content, as well as its gradual inclusion in curricular experiences in primary care, from the earliest stages of the course. This fact confirms the importance of this approach for the training of professionals in order to contribute to the consolidation of the Unified Health-System (SUS), in Brazil.

This study has shown that students recognize that their training is focused on the public health system and conforms to the DCN/ENF. However, more innovative pedagogical proposals that align training with SUS principles need to be discussed, and new ways can also be rediscovered for better understanding. We should further reflect on the possibility of institutionalizing the formative experiences offered by the government reorientation programmes such as the Pro-Health and Pet-Health, in order to effectively integrate the training course for students, thus contributing to strengthening interdisciplinary experiences - weakness pointed out by students in this study.

• *
  This study is part of the dissertation - Nursing education oriented to the Unified Health System in a critical and creative perspective: vision of the master's graduates in nursing developed during the Postgraduate Program in Nursing at Universidade Federal de Santa Catarina, Brazil, in 2012.

REFERÊNCIAS

• ¹
  Silva SF. Sistema Único de Saúde 20 anos: avanços e dilemas de um processo em construção. Saúde em Debate. 2009 jan-abr; 33(81):38-46.
• ²
  Lucchese R, Vera V, Pereira WR. As políticas públicas de saúde - SUS - como referência para o processo ensino-aprendizagem do enfermeiro. Rev Eletr Enferm [online]. 2010, 12(3):562-6 [acesso 2012 out 12]; Disponível em: http://www.fen.ufg.br/revista/v12/n3/v12n3a21.htm
  » http://www.fen.ufg.br/revista/v12/n3/v12n3a21.htm
• ³
  Minayo MCS. Pesquisa social: teoria, método e criatividade. 29ª ed. Petrópolis (RJ): Vozes; 2010.
• ⁴
  Brasil. Lei n. 8080, de 19 de setembro de 1990: Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes. Brasília: Ministério da Saúde, 1990.
• ⁵
  Fernandes JD, Silva RMO, Teixeira GA, Florencio RMS, Silva LS, Rebouças LCC. Aderência de Cursos de Graduação em Enfermagem às Diretrizes Curriculares Nacionais na Perspectiva do Sistema único de Saúde. Esc Anna Nery. 2013; 17(1):82-9.
• ⁶
  Freire P. Pedagogia da autonomia: saberes necessários à prática educativa. 43ª ed. São Paulo: Paz e Terra; 2011.
• ⁷
  Lima MM, Almeida AB, Giovannetti MO, Backes VMS, Kloh D. Produção do conhecimento acerca da formação do enfermeiro: um estudo bibliométrico. Rev Bras Enferm. 2012 mai-jun; 65(3):522-8.
• ⁸
  Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2011.
• ⁹
  Silva MG, Fernandes JD, Teixeira GAS, Silva RMO. Processo de formação da(o) enfermeira(o) na contemporaneidade: desafios e perspectivas. Texto Contexto Enferm. 2010; 19(1):176-84.
• ¹⁰
  Ministério da Educação e Cultura (BR). Câmara de Educação Superior. Parecer CNE/CES n. 1133/2001: Diretrizes Curriculares Nacionais dos Cursos de Graduação em Enfermagem, Medicina e Nutrição. Diário Oficial da União, 3 out. 2001. Seção 1E. p. 131.
• ¹¹
  Erdmann AL, Stein Backes D, Alves A, Albino AT, Farias F, Guerini IC, et al. Formando Empreendedores na Enfermagem: Promovendo Competências e Aptidões Sócio políticas. Enferm Global, 2009; (16):1-10.
• ¹²
  Ministério da Saúde (BR) . Organização Pan-Americana da Saúde, Universidade Estadual do Rio de Janeiro. Empregabilidade e trabalho dos enfermeiros no Brasil - Relatório Final. Rio de Janeiro: MS; 2006.
• ¹³
  Valença CN. Corações e mentes desvendam o Sistema Único de Saúde visões e vivências de estudantes de enfermagem [dissertação]. Natal (RN): Universidade Federal do Rio Grande do Norte, Programa de Pós-Graduação em Enfermagem; 2011.
• ¹⁴
  Batista KBC, Gonçalves OSJ. Formação dos profissionais de saúde para o SUS: significado e cuidado. Saúde Soc. 2011; 20(4):884-99.
• ¹⁵
  Chiesa AM, Nascimento DDG, Braccialli LAD, Oliveira MAC, Ciampone MHT. Formação de profissionais da saúde: aprendizagem significativa à luz da promoção da saúde. Cogitare Enferm. 2007; 12(2):236-40.
• ¹⁶
  Backes DS, Marinho M, Costenaro RS, Nunes S, Rupolo I. Repensando o ser enfermeiro docente na perspectiva do pensamento complexo. Rev Bras Enferm. 2010; 63(3):421-6.
• ¹⁷
  Lima MM. Integralidade no processo de formação do enfermeiro [dissertação]. Florianópolis (SC): Universidade Federal de Santa Catarina, Programa de Pós-Graduação em Enfermagem; 2010.
• ¹⁸
  Ministério da Saúde (BR). Ministério da Educação. Programa Nacional de Reorientação da Formação Profissional em Saúde - Pró-Saúde: objetivos, implementação e desenvolvimento potencial. Brasília (DF): Ministério da Saúde; 2009.
• ¹⁹
  Ministério da Saúde (BR). Portaria interministerial n.1.802, de 26 de agosto de 2008. Institui o Programa de Educação pelo Trabalho para a Saúde - PET-Saúde. Brasília (DF): Ministério da Saúde; 2008.
• ²⁰
  Ministério da Saúde (BR). Ministério da Educação. Programa Nacional de Reorientação da Formação Profissional em Saúde - Pró-Saúde. Brasília (DF): Ministério da Saúde; 2007.
• ²¹
  Heidemann IBS, Boehs AE, Wosny AM, Stulp KP. Incorporação teórico-conceitual e metodológica do educador Paulo Freire na pesquisa. Rev Bras Enferm. 2010; 63(3):416-20.
• ²²
  Freire P. Pedagogia do oprimido. Rio de Janeiro: Paz e Terra; 2005.
• ²³
  Waterkemper R. Formação da atitude crítica e criativa do acadêmico de enfermagem na disciplina de fundamentos para o cuidado profissional: um estudo de caso [tese]. Florianópolis (SC): Universidade Federal de Santa Catarina, Programa de Pós Graduação em Enfermagem; 2012.

Publication Dates

• Publication in this collection
  Apr-Jun 2016

History

• Received
  29 June 2015
• Accepted
  04 Mar 2016