Integrality and higher education aimed at the Brazilian Unified Health System from the perspective of physical therapy undergraduate students

Integridad y formación para el Sistema Único de Saúde em la perspectiva de estudiantes universitários de Fisioterapia

Abstracts

In recent years, there has been the need to reorganize the curriculum of undergraduate courses in the health science field in order to educate professionals to be able to practice the principles of the Brazilian Unified Health System from the perspective of integrality. From a qualitative research perspective, this study aimed to identify the perceptions and opinions of physical therapy undergraduate students regarding comprehensive health care and about the principle of comprehensive health care in their education. Three focus groups were conducted with students in their senior year of the undergraduate course in physical therapy enrolled in three universities in the Federal District. After analyzing the content, results show that despite government efforts and changes in the curriculum proposals, it was observed that undergraduate education in physical therapy still does not favor the Brazilian Unified Health System and its guiding principles, in particular comprehensive health care. It is necessary to invest in reflective spaces that articulate university (faculty and students), health services, management authorities, municipal policies and social movements in order to yield new teaching and learning possibilities that will contribute to the transformation of the university education aimed at the Brazilian Health System.

Physical Therapy Modalities; Education, Higher; Public Health

En los últimos años, ha habido una necesidad de reorganización de los planes de estudio de los cursos superiores del área de salud buscando formar a profesionales capaces de llevar a cabo los principios del Sistema Único de Salud (SUS), en la perspectiva de la integralidad. En la vertiente de la investigación cualitativa, este estudio tuvo como objetivo identificar las percepciones y opiniones de estudiantes de pregrado de Fisioterapia en cuanto a la integralidad de la asistencia y acerca de la inclusión de este principio en su formación universitaria. Se realizaron 3 grupos de enfoque (GEs) con 30 estudiantes del último año del curso de pregrado de fisioterapia inscritos en tres instituciones de educación superior (IESs) en el Distrito Federal (DF). Después del análisis de contenido, los datos mostraron que, a pesar de los esfuerzos del gobierno y cambios en las propuestas curriculares, se observa que la educación en Fisioterapia todavía no privilegia el SUS y sus principios y ejes orientadores, especialmente la integralidad. Es necesario invertir en espacios críticos y reflexivos que articulan la universidad (docentes y estudiantes), los servicios de salud, los niveles de gestión y las políticas municipales y los movimientos sociales, con el fin de producir nuevas posibilidades de enseñanza-aprendizaje que contribuyan a la transformación de la formación para el SUS.

Modalidades de Fisioterapia; Educación Superio; Salud Pública

Nos últimos anos, constata-se a necessidade de reorganização dos currículos dos cursos superiores da área da saúde buscando formar profissionais capazes de efetivar os princípios do Sistema Único de Saúde (SUS), na perspectiva da integralidade. Na vertente da pesquisa qualitativa, este estudo teve como objetivo identificar as percepções e opiniões de estudantes de graduação em Fisioterapia em relação à integralidade da assistência e acerca da inclusão desse princípio em sua formação universitária. Foram realizados 3 grupos focais (GFs) com 30 estudantes do último ano do curso de graduação em Fisioterapia matriculados em 3 instituições de ensino superior (IESs) no Distrito Federal (DF). Após análise de conteúdo, os dados apontam que, apesar dos esforços governamentais e das mudanças nas propostas curriculares, observa-se que o ensino em Fisioterapia ainda não privilegia o SUS e seus princípios e eixos norteadores, em especial a integralidade. Faz-se necessário o investimento em espaços críticos e reflexivos que articulem universidade (docentes e discentes), serviços de saúde, instâncias gestoras e políticas municipais e movimentos sociais, a fim de produzir novas possibilidades de ensino-aprendizagem que contribuam para a transformação da formação para o SUS.

Modalidades de Fisioterapia; Educação Superior; Saúde Pública

INTRODUCTION

In the past few years, it was possible to observe the need to reorganize the curriculum of higher education courses in the health field in order to consider not only the professional curricular guidelines, but also the needs and realities of the Unified Health System (SUS) with regard to epidemiological, demographic, cultural, social and economic diversities. Such an effort aims at providing integral health actions to all layers of society, at all levels of complexity, aiming at health promotion, protection and recovery of individuals and groups¹.

For Ceccim and Feuerweker², it is possible to promote integral health actions, in different contexts at different realities, if education is based on the principle of integrality. For the authors, the configuration of an integrated curriculum (in which educational orientation can articulate the triad practice-work-care) requires the use of active methodologies, considering its potential to turn the student into an active subject in the learning process, based on the principle of autonomy, therefore breaking the traditional teaching model in which knowledge is centered on the image of the professor, and the student is a mere passive spectator of the process.

Camargo³ points out that "integrality" cannot even be called a concept; however, it is a convenient identity for the combination of a set of cognitive and political tendencies that are somehow related, but not completely articulated. In the same direction, the Federal Constitution and the Organic Law of Health (LOS) determine that integrality is one of the doctrinaire principles of SUS, and should be conceived as an articulated set of health actions and services, be it preventive or curative, in each case, in all levels of complexity^{4 , 5}.

Integrality also allows the identification of subjects as totalities, even if these cannot be completely reached, but considering all of the dimensions that can intervene⁶. From this perspective, it extrapolates the hierarchized and regionalized organizational structure of health care aiming at the quality of individual and public attention assured to users of the health system, since they are perceived as historical, social and political subjects articulated in their family context with the environment and the society in which they are inserted⁷.

This new model of attention requires an updated pedagogical and educational approach, which establishes the action of problematizing as a teaching-learning strategy. This new approach favors the construction of knowledge by means of significant experiences, thus enabling the articulation of several contents (which are offered as a problem to the students) that are necessary to solve situations in complex contexts⁸.

However, health education in Brazil is apparently not addressed to the perspective of integrality. The profile of graduated professionals is still strongly leaning towards early specialization, with dichotomized curriculums in basic and professionalization cycles, besides the massive use of hospital environment as a priority scenario for practices, thus continuing to dissociate the realities in the services and the health of the population⁹.

It is important to consider that the origin and evolution of Physical Therapy are historically characterized by the work in rehabilitation¹⁰. The focus on the post-war rehabilitation model connected the physical therapy practice to the biomedical and Cartesian model, in which disease is seen as an abstract condition, regardless of the social behavior or the personality of the individual, and in which being healthy is the same as not being sick. Therefore, it is a reductionist view of the human body regarding its structures and biological processes, centered on healing and rehabilitating the body¹¹.

In the process of building and implementing SUS, Brazilian physical therapists, as well as other professionals in different fields of knowledge, were faced with new demands that required them to expand the focus of intervention, thus extending their work beyond the scope of rehabilitation, in order to produce practices to prevent diseases and promote health. For that objective to be reached, it was necessary to rethink and reformulate the higher education for Brazilian health professionals.

In this sense, in 2001, the Ministry of Education and Culture (MEC) presented the National Curriculum Guidelines for undergraduate health courses and stated the need for education that considered the principles and guidelines of SUS, thus valuing team work and integral health care. Afterwards, undergraduate health courses released their specific curriculum guidelines, by reviewing their higher education projects with the objective of adapting them and enabling the

formation of professionals with autonomy and discretion to ensure the integrality of attention, as well as the quality and humanization of care provided to individuals, families and communities (p. 4)⁵.

The Curriculum Guidelines of the undergraduate Physical Therapy course were created in 2002, and establish that the undergraduate student should experience generalist, humanist education, thus developing a critical point of view problematizing the social nature of the health-disease process, however, without losing the scientific and intellectual rigor that is a characteristic of the profession⁵.

However, usually, the profile of the Physical Therapy professional is far from expectations. Studies indicate the detachment of higher education processes in Physical Therapy from the principles and the reality of SUS^{12 - 14}. Besides, there is also more emphasis on technical contents and biomedical disciplines, with little room for discussions about the interface of the field of human and social sciences.

The characteristic of hegemonic traditional teaching, which is still adopted by many Physical Therapy courses, is to educate professionals with a curative-rehabilitating-private profile, aiming at the healing process by applying technological techniques and resources, whose practical environment involves hospitals and private rehabilitation clinics¹². Therefore, the education of the Brazilian physical therapist has been addressed to damage control, thus restricting the practice of rehabilitation, with little focus on integrality.

From this perspective, this study aimed at analyzing the perception and opinions of undergraduate Physical Therapy students with regard to the integrality of care and the inclusion of this principle in their university education.

METHODOLOGY

Since this study aims at extending the debate about the graduation of physical therapists and its implications for their work in SUS, from the perspective of undergraduate students, it was chosen to conduct a qualitative study because of its potential to obtain senses, conceptions, values, beliefs and opinions, considering the sociocultural dimensions of the different subjects¹⁵.

For data construction, the focus group (FGs) method was adopted, which, according to Gatti¹⁶, refers to a research strategy in which people that were previously selected by intentionality criteria gather together to discuss and debate a specific theme, of the researchers' interest, based on their personal experiences. This methodology is applied to understand the processes of building reality, knowing representations, beliefs, attitudes, habits and values, from different perspectives.

FGs are conducted by a coordinator whose role is to moderate the discussion and heat up the debate about the research themes. In this sense, it is essential that this person plays both the role of mediator and facilitator of the group, thus favoring interaction and intervening in order to deepen the discussions about the theme¹⁶. Some authors also suggest the presence of an observer, who would also be a member of the research team, and whose role would be to observe the process of group interaction, thus identifying silences, speech monopoly, reactions to the debate, among others, besides assisting the coordinator in group moderation¹⁶.

As mentioned by Gatti¹⁶, it is necessary that the FGs be constituted by subjects who have had personal experiences with the study problem established by the researchers, thus favoring the debate about the theme of interest. From this perspective, three FGs were conducted with senior undergraduate Physical Therapy students enrolled in three higher education institutions located in the Federal District. Senior students were chosen considering that, among the students, this group is expected to have more knowledge about the undergraduate course and to have attended more disciplines, internships and other activities carried out by the institutions.

Institutions were selected based on the following inclusion criteria: being a higher education institution recognized by the National Institute of Educational Studies and Research Anísio Teixeira (INEP), from MEC; providing the undergraduate Physical Therapy course; obtaining grade 3 or more, in a scale from 0 to 5, in the course concept (CC) from the last INEP evaluation. The inclusion criteria of subjects in the FGs were: being regularly enrolled in the Physical Therapy undergraduate course; attending the senior year; being interested and available to participate in the study.

After previous contact and the authorization of higher education institutions, the coordinators of the Physical Therapy courses were contacted and a visit was scheduled to present the objectives of the study. After the authorization, all of the students who met the inclusion criteria of the study were invited to participate. Invitations were made personally, by one member of the research team during the mandatory disciplines of the senior year. Therefore, the groups were composed of all of the students who met the inclusion criteria and were interested to participate, attending the date established for the conduction of the FG.

The FGs took place in the classrooms of higher education institutions from October to December, 2012, counting on an average of 10 participants each, with mean duration of 80 minutes. At first, the moderator, the observer, and the research team were introduced, followed by a brief exposure of the objectives of the study and the conduction of the FG. Information was given about the rules of the activity, and an authorization was requested to make audio recordings of the discussion. Participants also signed the informed consent form.

Afterwards, the students introduced themselves with the objective of integrating the group and adapting them to the FG technique. In the third stage, the subject of discussion was introduced by means of a program, composed of a script of open questions to trigger the debate, developed for this purpose. The program was structured as a script of previously established topics, based on the following themes: perception of the students about the principle of integrality; participants' opinions about the inclusion of this principle in their higher education course. The initial triggering question was "For you, what does integrality mean?".

FGs were recorded, and the audios were fully transcribed and, afterwards, submitted to content analysis¹⁷. The systematization of content analysis led to the flowing and comprehensive reading of the interviews; construction of thematic categories and significance units; data interpretation and construction of results.

As emphasized by Gatti¹⁶, there are several possibilities to analyze the material produced by the FGs, for instance, individuals talks (identifying the opinion of each participant) or group speeches (debates and common notions that, even if emitted by one subject, reflect the group's opinion). Considering the homogeneity aspect of the group of students with regard to the theme proposed in this study, it was chosen to analyze the agreements established by the group. In order to ensure anonymity, the names of participants and institutions were omitted in the description of results. Each focus group was called FG, followed by the number that identified the institution, therefore: FG1, FG2 and FG3.

The research project was submitted to and approved by the Research Ethics Committee of Fundação de Ensino e Pesquisa Ciências da Saúde (FEPECS) from the Secretariat of Health of the Federal District, report n. 251.187.

RESULTS AND DISCUSSION

There was important participation of the group members in the discussions about the proposed themes; even though they were part of different groups, it was possible to identify similarities in the speech of students concerning the approximation of integrality with Physical Therapy.

Integrality as an attribute of the physical therapist's practice

The integral perspective of care requires an also integral conception of health, considering not only the biological aspects, but also the psychological, environmental and social conditions of the individual¹⁸. The integral approach requires that health professionals, when meeting with patients, can overcome the reductionisms of biomedical care (fragmented and centered on the disease), thus perceiving the subjects in their totality. Therefore, integrality starts to mean more than a constitutional principle, but the expression of a "set of values that should guide all health practices, assuring them with quality" (p. 778)¹⁹.

In response to the introduction of the integrality theme, the following lines reflect the understanding of the students about the subject:

It is not only about looking at this pain, it is about having a biopsychosocial view of the patient... the physical and the psychological aspects of that patient at that time, and the social aspects, his reintegration in society. (FG1)

I think it would be the patient as a whole, in his integrality, about all of his need. (FG2)

For Gonze and Silva²⁰, integral care depends, among other things, on the approach of factors related to well-being and quality of life of people. From the students' statements, it is possible to observe that they recognize the fact that segmented vision is insufficient (focusing on the disease, its signs and symptoms) for the promotion of care, and that such a view makes it difficult to conduct a broader analysis of health, which is necessary for integral care.

Bedin and Scarparo²¹ defend that the idea of integrality extrapolates the mere refusal of reductionist actions, thus suggesting the need of implication with the context. Franco and Merhy²² add the importance of the subjective matters that are present in the relationships between the subjects who integrate the production of care.

For the students, it is necessary to consider the individual aspects of people, their specific characteristics, and the context of life in which they are inserted. According to the participants, the contextualized analysis is essential to turn practices based on integrality into something concrete, once such aspects interfere directly on the health condition and on the conception the person has of it:

his history, knowing who he is, how old he is, his profession, social condition, associated pathology... (FG1)

You get to a Physical Therapy clinic feeling pain on the right knee, and the physical therapist will treat your right knee... Actually, we see the whole, and in the end we take the examination just to add what was really missing. (FG3)

According to the report of the participants, usually the health need of one person may not be the same one programmed by a health service or professional in the conception of its care action. In order to meet the real health needs of a person or population, it is necessary to know how to listen to them:

sometimes a patient arrives in orthopedics with a foot problem, and we do the whole orthopedic treatment to discover his problem was caused by diabetes. (FG2)

In that case, developing hearing skills is essential to understand the real needs that led the person to look for care. For Pinheiro²³, "integrality is present in the meeting, in talking" (p. 290), moment when the health professional needs to carefully try to recognize, besides the explicit demands, other needs of the citizen.

Therefore, the reception and the bonds between users, health professionals and the service are strategies adopted to improve the access and develop integral practices. In this sense, reception presents itself as a humanized and welcoming relationship that workers and service have to establish with the different types of users²³.

Even though reception and bonding practices are not identified by these names, students gave examples of such actions:

When the patient comes, maybe when he comes with that disease, he didn't come with that problem, he wants to feel better, I see many patients coming here to talk... They don't have only the disease, they have problems at home, with their family, with their jobs, or at that time they cannot find a job and have to feed their families. (FG2)

It is possible to observe that the trusting relationship established between the subjects involved in the health care process becomes more consolidated while they build relationships regarding health practices. In this sense, the search for clinical and sanitary accountability and intervention in health problems will only be effectively reached if it is possible to recognize the role played by the reception and the bonding aspects of health²³.

Integrality in the formation of the physical therapist (from the perspective of the students)

The characteristic of traditional hegemonic teaching model, which is still adopted by many Physical Therapy courses, is to educate professionals with a curative-rehabilitating-private profile (inheritance from the creation of the profession), who aims at the healing process by applying technological techniques and resources, whose practical environment are hospitals and private clinics¹². This educational model, strongly associated by the recommendations in the Flexner Report, emphasizes the disease instead of the subject, and the fragmentation of knowledge by means of disciplines that do not communicate with each other.

This dichotomized context of teaching, which separates theory from practice, is identified in the speech of some students:

in the first semesters, there are theoretical lessons, and from the seventh, in total, eight, right? The internships begin, there is practice too. (FG1)

The lack of articulation between disciplines, which are still rigidly fragmented, denounces the difficulty (or negligence) found by the courses to change or restructure their curriculums. Matters related to the universe of Public Health (SUS) are carefully separated in specific disciplines to deal with each of these subjects, and, once they are analyzed, these contents are not approached anymore:

there were two disciplines, Public Health and Public Policies... It approached the functioning (of SUS), history, policies, legislation... (FG1)

When students speak, it is possible to observe some isolated attempts to promote the integral approach in the education of physical therapists from the analyzed courses. Some examples were: the case of a shared medical care, conducted between two professional specialties (Physical Therapy and Psychology) simultaneously, involving the same subject, in order to provide the best results by means of the interdisciplinarity of practices; integration of curriculums by the offer of common disciplines (such as the ones of Public Health) to several health courses, thus enabling the interchange of knowledge; and the experience of extension projects with interdisciplinary approach:

I even took part in a program for diabetics and there were many courses, like Psychology, Physical Therapy, many courses to treat the diabetic patient. (FG2)

Now they are doing just that, they are gathering the people of Psychology to go up to Physical Therapy and see the care. So someone is assisting the kid while I'm doing Physical Therapy, so I work with him and so does the psychologist. (FG3)

These isolated initiatives lead us to believe there is little preparation (or no preparation at all) in terms of school ability and institutional incentive to conduct and implement innovative pedagogical strategies, able to break with the traditional educational model and to establish the integrality model.

For Aguilar-da-Silva²⁴, Physical Therapy is going through a crisis of paradigms (biomedical versus integrality) in which the conceptual change became a consequence of dissatisfaction and insufficiency of teaching models that were previously prevalent. According to the National Curriculum Guidelines (NCG), curriculums whose pedagogical model were filled with a fragmented view, addressed to a technical and specialized formation, must give room to the integrality model, based on the generalist education, on curricular flexibility, on the integrality of care, and on interdisciplinary work. In that direction, NCGs also guide the use of active teaching and learning methodologies, thus enabling Physical Therapy teaching addressed to the current health system.

The approximation of Physical Therapy courses and constructivist teaching methodologies (focused on the student, based on the combined construction of knowledge in significant environments and of real contexts for them) has obtained stimulating results. The experience of Universidade Federal do Paraná (UFPR) in the creation and implementation of a Physical Therapy course with a pedagogical project based on active teaching methodologies resulted (according to the authors) in the graduation of professionals with differentiated characteristics, despite the several difficulties found by the project, especially concerning the students who were graduated by the traditional model²⁵.

Likewise, the curriculum of the Physical Therapy course form the Medical Sciences and Health School of Juiz de Fora (FCMS/JF) was structured based on the pedagogical model of problematizing. Characterized by the construction of knowledge based on significant experiences, and supported by discovery learning processes, the act of problematizing was identified by the Physical Therapy course of FCMS/JF as a good pedagogical strategy, since it enabled the reorientation of education and care in Physical Therapy. Once again, some fragilities and difficulties were found in the implementation of the proposal: the need for school skills, a consistent pact between the education institution and the city to use the scenario of basic care as environments for practice, and to promote the articulation between pedagogical projects and health services²⁴.

CONCLUSION

Despite the changes in curricular proposals and the governmental efforts to implement programs, projects and actions aiming at approximating university education and the daily work of SUS, such as the program for education through work for health (PET-Saúde), the national program of professional reorientation in health (Pró-Saúde) and the project VER-SUS/Brasil, among others, Physical Therapy education still does not privilege SUS and its guidelines, such as integrality.

The detachment between undergraduate health courses and SUS is demonstrated by the statement of the students who participated in the study, and pointed out to the deficient educational process with regard to integral care to work in the current health system. It is possible to observe the valorization of traditional and transmissionist teaching, which is strongly marked by the biomedical and curative model.

It is important to mention that the students' statements also indicate the inclusion, even if incipient, of the integrality theme to health in the educational process of the physical therapist, both with regard to taught lessons and extension activities. However, it is possible to notice the difficulty to incorporate integrality as a cross-sectional subject, so that it is no longer restricted to a group of disciplines, becoming more present in different disciplines from various fields of knowledge; it can also be employed in practical activities, internships, research and extension projects, among others.

Therefore, it is necessary to invest in critical and reflexive spaces that can articulate the university (professors and students), health services, administrations and municipal policies, as well as social movements, in order to produce new teaching-learning possibilities that can contribute with the transformation for education for SUS.

This initiative does not refer to an easy task, exempt from conflicts and political and economic interests or power disputes. It is a dense and complex arena, and, despite being challenging, it can result in new ways to build the university, in order to favor more integration between education, service and management, trying to put the principles of SUS in practice.

It is important to mention that this study was focused on the analysis of three groups of students from three higher education institutions in the Federal District. New studies about the theme can be conducted by using other methodologies, such as the analysis of pedagogical projects of the courses, FGs with educators who compose the school board of undergraduate Physical Therapy courses. Therefore, it is expected to amplify the discussion about the theme and to produce subsidies for future interventions in the process of educating new health professionals.

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• Financing source: none
• Study conducted at Universidade de Brasília (UnB) - Federal District (DF), Brazil

Publication Dates

• Publication in this collection
  Jul-Sep 2014

History

• Received
  May 2014
• Accepted
  July 2014