Use of narrative in continuing Health education: educational directions, successes and limits

Abstracts

The aim of this article was to discuss the educational directions, successes and limits of narratives produced in a training course for tutors and facilitators within continuing health education.

Conceptual landmarks

temporality, experience, hermeneutics-dialectics and active methodologies. This study took a qualitative approach and was based on the narrative method. It used 20 reflective texts and sought the meanings attributed to events, relationships and practices.

Results

The course participant group was the central character. In terms of scenarios, the ideas were explored more as spaces for construction of subjective experiences. The plots not only followed the chronological order of the course meetings but also formed groupings of experiences according to core meanings.

Conclusion

The narratives, as innovative educational tools within health education, deepened autonomy and self-determination. They led the subjects to be “authors” of their own lives and were as intense and transformative as “experiences of the self”.

Narrative; Temporality; Experience; Active methodologies; Continuing education

O artigo tem como objetivo discutir sentidos, êxitos e limites educacionais de narrativas produzidas em curso de capacitação de tutores e facilitadores em Educação Permanente em Saúde.

Marcos conceituais

Temporalidade, Experiência, Hermenêutica-dialética e Metodologias Ativas. O estudo – de abordagem qualitativa – pautou-se no método da narrativa, com vinte textos reflexivos, buscando o significado atribuído a fatos, relações e práticas.

Resultados

O grupo dos cursistas afigurou-se como personagem central. Em termos de cenários, as ideias foram mais exploradas como espaços de construção de experiências subjetivas. Os enredos tanto seguiram a ordem cronológica dos encontros do curso, como se constituíram de agrupamento das experiências por núcleos de sentido.

Conclusão

As narrativas, enquanto ferramentas educacionais inovadoras em educação na saúde, aprofundaram a autonomia e autodeterminação, levando os sujeitos a serem “autores” de sua própria vida, tão intensa e transformadora que foi a “experiência do eu”.

Narrativa; Temporalidade; Experiência; Metodologias ativas; Educação permanente

El objetivo del artículo es discutir sentidos, éxitos y límites educativos de narrativas producidas en un curso de capacitación de tutores y facilitadores en Educación Permanente en Salud.

Marcos conceptuales

temporalidad, experiencia, hermenéutica-dialéctica y metodologías activas. El estudio, de abordaje cualitativo, tuvo como base el método de la narrativa, con veinte textos reflexivos, buscando el significado atribuido a hechos, relaciones y prácticas.

Resultado

el grupo de los cursillistas se presentó como personaje central. En términos de escenarios, las ideas fueron más exploradas como espacios de construcción de experiencias subjetivas. Las tramas siguieron tanto el orden cronológico de los encuentros del curso, como se constituyeron en agrupación de las experiencias por núcleos de sentido.

Conclusión

Las narrativas, como herramientas educativas innovadoras en educación en la salud, profundizaron la autonomía y la autodeterminación, llevando a los sujetos a ser “autores” de su propia vida, tan intensa y transformadora fue la “experiencia del yo”.

Narrativa; Temporalidad; Experiencia; Metodologías activas; Educación permanente

Introduction

The basis for present-day Western culture was essentially formulated in the sixteenth and seventeenth centuries. The notion of a “living and spiritual organic universe” was replaced by the notion of the world “as if it were a machine...”¹(p. 49). In this vision, “Cartesian subjects are unattached, instantaneous and empty subjects without any history; they are practically nothing and simply are not subjects”² (p. 3). A systemic view of the world, in which the whole was always greater than the sum of its parts, emerged around the 1930s. The complete view of this world would only emerge from the connections and relationships of its parts within their context³.

Within education, bearing in mind that this change not only was one of comprehension but also was one of conduct that would need to be translated into daily practice, there was “consensual recognition of the need for transformations within the education of healthcare professionals and for new ways of working with knowledge”⁴ (p. 285).

This idea was disseminated by UNESCO in 1970⁵, through research centers and through the Educative City project⁶. So-called continuing health education (CHE) “arose in the mid-1980s and was disseminated by the Pan-American Health Organization (PAHO)”⁷ (p. 914) as a guideline for improving the quality of health care and services^5,8.

CHE was implemented as a national policy in Brazil in two stages (2004 and 2007), as an educational process that was applied to work^9-11. It generally involves use of tools for active teaching and learning methodologies¹⁰ and requires development of new professional competencies for teaching, anchored in a significant theoretical principle: autonomy^12,13.

In this regard, education takes place “as a function of experiences [...] through cognitive challenges and problem situations”¹⁴ (p. 514) that enable constant critical reflection on day-to-day practices within healthcare services. Workers can be expected to be protagonists¹⁵ for transformation of their own work contexts¹¹.

Lima observed that a variety of active teaching and learning methodologies have been developed, “such as problem-based learning (PBL), problem-setting and project-based learning, in teams, though games or use of simulations”¹⁶ (p. 4).

Although it is relevant to consider the differences that exist between active methodologies, [...] teachers who use them need to adopt a new stance [...] of co-participation in the teaching-learning process¹⁷ (p. 611).

In Brazil, it has been sought to use active teaching and learning methodologies for training healthcare professionals to work within the Brazilian National Health System (SUS)^12,18. Thus, capacitation of educators to use active teaching and learning methodologies, which would be a necessity for developing educational solutions for SUS, was put into practice in 2012, by the Continuing Education Center (NEP) of the ambulance service (SAMU 192) of the Fortaleza administrative region (NEP SAMUFor). This action had the initial aim of training educators for NEP SAMUFor alone, but today its aim is to train educators for the entire municipal health department.

PBL, problem-setting, team-based learning, realistic simulations and films were used in the course. The strategy chosen for evaluating the training thus provided was to require compilation of a reflective portfolio. The results from the training were assessed through a study to raise awareness of the path that had been followed (TCP), which was constructed in the form of a reflective narrative.

Dutra took the view that narrative is the “most appropriate form of communication for humans, since it reflects their own experience”¹⁹ (p. 373) and includes the “emotional content and sensory details” of this experience. In this manner, narrative "merges details [...] into a complete story that is bigger than the sum of its parts...”²⁰ (p. 20). Thus, it carries and constitutes an “infinite reservoir of meanings and understandings”²¹ (p. 264) regarding the cultural and individuals aspects of human experience. According to Bondía, experience "is what we go through, what happens to us and what touches us. It is not just what is gone through, what happens or what is touched. Many things take place every day but, at the same time, almost nothing happens to us as experience"²² (p. 21).

Narratives organize the “experience of the self” and constitute “a psychological process relating to the individual, who constructs meanings for experiences through telling a story and receiving it”²³ (p. 67). In this process, the chronological order of events is not necessarily followed. According to Ricoeur²⁴, “temporality” is central to a narrative. Investigating temporality is to investigate the subject’s self, understand the person’s experience and understand the person’s subjectivity better: “it is not that the subject goes through time; before this, we are time; it is not time that passes: we are what we constitute temporally”² (p. 3).

In addition to temporality, there is the spatial nature of narrative, in which time is organized and meanings for experiences are created, in a “a psychological process relating to the individual, who constructs meanings for experiences through telling a story and receiving it”²³ (p. 67): “these do not relate primarily to definitions of space that are merely physical; rather, they refer to constructions of social niches in which specific personal and interpersonal relations are put to work”²³ (p. 70).

Thus, in order to delimit the present investigation, we posed the following questions: i) What was students’ understanding of the teaching-learning process that they experienced during the course? ii) How did the educational process contribute towards personal and professional changes within work practices? iii) How might the innovative idea of reflective narratives contribute to subjects’ autonomy in continuing education processes?

TCPs were defined as the study subject matter: not as tools for assessing the results from the course but with the general objective of exploring the educational directions, successes and limits of these reflective narratives as a pedagogical strategy.

Methodology

This study formed part of a larger investigation in which the general objective was to explore the use of narrative as a means for comprehending the health-disease-care process and the process of management of health-related knowledge and innovation. It was approved by the research ethics committee of Hospital Sírio-Libanês, under report no. 430.067, on October 21, 2013. One of the specific objectives of the larger investigation became the focus of the present study, which was based on a master’s dissertation that was defended in April 2017.

Both the larger investigation and the present study were grounded in a qualitative investigative approach, i.e. a set of interpretative practices through which it was sought to investigate the meanings that subjects attributed to the phenomena and set of relationships within which they were situated^25,26. The study method consisted of narrative, in the form of problem-setting regarding the “relationship between cultural or symbolic matters and experience”²⁷ (p. 254-5). Here, narratives are not used merely as a technique, but as a method, given that this study involved epistemological and theoretical issues specifically related to production and interpretation of narratives²⁸.

This study was conducted between October 2016 and March 2017. It made use of TCPs produced within the scope of training for tutors and facilitators within continuing education at NEP SAMUFor. Hence, these TCPs were not produced specifically for the present study. Rather, they were summaries of the learning and achievements reached and were presented in a logical or serial manner, grounded in the pertinent literature or in empirical evidence, thus displaying the gains or changes to professional practice that had been attained.

This training began in 2013 and the 14^th training group had already completed its studies. In total, 56 TCPs had been produced (the first group did not produce TCPs). Because of the size of this body of work, 20 TCPs were drawn manually from among them, without using any exclusion criteria, as shown in Table 1.

Table 1
Distribution of the TCPs drawn from among the course groups.

Year	Group	Number of TCPs produced	Number of TCPs drawn
2013	II	5	2
	III	5	2
	IV	4	2
2014	V	1	2
	VI	1
	VII	1
	VIII	0
	IX	5	2
	X	4	2
2015	XI	7	2
	XII	12	2
	XIII	2	2
2016	XIV	9	2
Total		56	20

The narratives thus drawn were numbered from N1 to N20 and were distributed randomly according to the following analysis matrix (Table 2).

Table 2
Groups from which the narratives that were drawn originated.

Narrative	Group	Narrative	Group	Narrative	Group	Narrative	Group
N1	IV	N6	IX	N11	X	N16	III
N2	XI	N7	XIII	N12	XIII	N17	XII
N3	V	N8	III	N13	II	N18	IX
N4	XII	N9	XIV	N14	X	N19	IV
N5	II	N10	VI	N15	XIV	N20	XI

For our analysis and interpretation, the perspective of hermeneutic-dialectic criticism²⁹ was the approach chosen, given that “through hermeneutics, a consensus in interpreting and reading the ‘context’ within the narrative ‘text’ is sought, whereas dialectics is the art and science of dialogue, questioning and controversy and forms an auxiliary method for interpreting how conflict between different ways of thinking generates new ideas and attitudes.”

The analysis and interpretation of the narratives was done starting from the principles proposed by Gomes and Mendonça²⁸: (a) comprehension of the context; (b) unraveling of structural issues; and (c) interpretative synthesis.

Comprehension of the context

From Ricoeur’s perspective of temporality, we sought here to correlate the present (both with memories and expectations and with their projection to the future) with before and after the experience narrated, in order to attempt to understand the meanings that were attributed to the course. Gomes and Mendonça²⁸ put forward four types of analysis, which were followed as stages for the purposes of this study:

First stage: identify and describe previous “spatial-temporal situations” in which narratives were produced, in order to understand the experience;

Second stage: understand the “field of interaction”, i.e. how the narrator appropriated and transformed his representation as an educator from his position in the social space and on the path of interactions of knowledge and affection that were experienced;

Third stage: analyze the “social institutions”, i.e. the relatively stable sets of rules, resources and social relationships that have become established; and

Fourth stage: analyze similarities, asymmetries and differences in the fields of interaction and realities of the social institutions.

Unraveling of structural issues

Here, Gomes and Mendonça²⁸ emphasized two principles for analyzing the structural aspects of narratives, also in the form of stages:

Fifth stage: analyze how the course contributed towards personal and professional changes and how the experience was re-elaborated through the act of writing; and

Sixth stage: perceive the “characters”, “plot” and “scenarios of experiences”.

Interpretative synthesis

This stage relates to the dialogue between the findings, results from other studies and the analytical-referential markers.

Results

Previous spatial-temporal situations

We perceived that the students waited for ready concepts coming from the teacher and that they felt an obligation to be the best in tests and marks, or in other people’s opinions: “we are so accustomed to educational experiences in which the focus is transmission of material that we now instinctively expect just to “hear about” or “read about” something to learn about it” (N20, p. 4). In this model, “errors are punished, classrooms are large and full of students, and the teacher, often through ego, takes on the stance of executioner” (N8, p. 11).

This experience of education gave rise to trauma: it was monotonous, tiresome and less profitable. In this, learning was usually converted into simple memorization of lifeless information: “Is this type of repetitive machine what my child will become?” (N6, p. 4).

There was some curiosity and anxiety regarding the course because it was already known that its content would be very important for changes and for personal and professional growth within the institution:

[...] I had inside myself some expectation of transformation, because I knew that active methodologies had a perspective that differed from that of the teaching-learning model and from what I experienced in my educational life when I was younger (N2, p. 4).

The narratives spoke of long paths towards use of these new technologies in teaching. One sentence summarizes how the narrators projected their experience towards the future: “Today, my challenge is how to adjust my ways of doing things in an ongoing process, with some well-established bad habits, and get going towards the endpoint?” (N1, p. 10).

Fields of interaction

The set of narratives demonstrated how this learning was significant for development of important subtle abilities among these new educators:

An ability to direct things without controlling them and to be primarily a “sensitizer” [...] to remain neutral [...] to understand without judging; give and receive feedback about pace, content and process; not to look too much at the person who is speaking; to perceive non-verbal language; to perceive the functioning of the collective as a system; to favor creation of links (N1, p,10).

The importance of the following qualities was perceived: empathy; openness to new ideas; capacity to favor communication networks; capacity to promote involvement and motivation among professionals; emphasis on development of leadership and mediation qualities in group meetings. To achieve these, it would be necessary to surmount natural insecurities, have emotional control and develop patience and wisdom.

Educators need to improve their sensitivity towards the group, control their opinions, discern the times and ways to intervene and control the lengths of time for activities without this cutting the process of constructing group thinking.

[...] from speaking so much, I feel that I have been ambushed by my words: this has exposed thoughts that I’m conceptually unsure about [...] Skillfully, the attentive tutor did not let this pass (I too would not have allowed this)... what skill.... [...] I sought knowledge so that I wouldn’t be swallowed up by doubts (N16, p. 8).

Students need to go beyond the logic of “tasks” and to believe in themselves, express themselves in their own words and free themselves from still being held back by other people’s opinions or judgments, because in this process there is no right or wrong but, rather, different times and learning for different reasons: "And now, I would like to highlight how intense the course became at this point in the process. My feeling was that it was like nothing would go unnoticed. The group was so involved that everything became a learning opportunity" (N8, p. 14).

Social institutions

Apart from the various working environments, the family was the social institution that was most cited, both in the context of the home and in the context of the children’s school. Other examples of institutional spaces that were mentioned in the narratives included networks of friends, social institutions that were frequented and even groups in which teaching-learning experiences can be shared:

In my personal life, I have always prioritized family and friends... (N18, p. 22); At home, my little ones are starting to ask me for a new toy... (N4, p. 14); How can we develop this motivation, specifically among our colleagues at the PSF (Family Health Program)? (N6, p. 27); I commented about my recent experience as a technical advisor to the healthcare coordination team at the second regional office (N10, p. 5) [our emphasis].

A wide range of social institutions were seen to be present in the narratives, thus showing that the method used had the capacity to bring individuals’ realities to light, as the basis for significant learning to take place. Thus, the method reflected the relationships that were built up in the training institution with institutions within the world of work and with other social institutions.

Similarities, asymmetries and differences

The set of narratives demonstrated how the use of active methodologies involves limits and challenges: “Teacher training is a real barrier that cannot be dodged in achieving the perspectives for development of this country. There is no alternative to surmounting it” (N14, p. 5).

The process of daring to construct new ways of doing things involves many frustrations. Thus, paths and dialogues to deal with negativity or limitations need to be thought out: “teachers’ and students’ technological skills, access to technology, students’ autonomy (which remains low) and the need to train teachers to apply Distance Education (EaD) in their teaching practice” (N20, p. 12).

Government actions have not produced ethically-motivated, creative and self-controlled individuals. Nor have they, in themselves, promoted great transformations in the lives of young adults. New institutional values are needed, so that it becomes possible to “train professionals with freedom and autonomy to make choices and make decisions” (N11, p. 6):

Teaching institutions in particular need to add new values to teaching instruments; place greater value on and further democratize research activities; and give instruction for and supply tools that facilitate the new profile of students and educators, for teaching through active methodologies (N5, p. 12-13 e p. 50).

The narratives carried many contradictions that were very personal. Thus, for training to function, active and autonomous engagement from each of the participants is required:

How can I balance this acceptance with my tendency to withdraw from the world (through indifference), if what is urgent today is precisely the opposite? Once again, I could approach my contradictions, of a very personal nature, with a vision greatly influenced by idealized passion... (N13, p. 8-9).

Nonetheless, there were some successes:

[...] in practical application of learning within the professional environment; in planning and shared reorganization of work processes; in collective construction of knowledge; in giving and receiving criticisms with affectivity and real listening; and in using new educational tools in undergraduate programs and in training courses (N15, p. 10).

Personal and professional changes

The course made it possible to rethink and transform formal concepts and opinions, and to start to reconstruct various personal and professional aspects of living practices. Each participant’s contribution was recognized and values that hitherto had not been well grounded were added: “I underwent a rich transformation. I feel that I changed in many ways towards being a better person and I recognize the enormous potential of teamwork” (N4, p. 6).

Within the professional field, the course triggered many reflections on the role of the tutor and the use of active methodologies, in relation both to teaching and to work processes:

“Regarding the training, there’s no doubt that this became one of the most noteworthy educational experiences that I’ve ever participated in. [...] the importance of lovingness for learning. My feeling is one of profound gratitude for this experience, from which I leave transformed as a person and as a health education professional” (N20, p. 19).

Acquisition of abilities to do the following were cited: perceive group dynamics, welcome different thinking, administrate one’s own non-verbal language, perceive ways to relate and see what motivates or demotivates people; and extrapolate these to work colleagues (N1, p.15), to the family (N19, p. 4) and to life (N18, p. 52). Those “old” speeches of the past cannot be made anymore:

“[...] this (methodology) can be applied to stimulate professionals, to make them unburden themselves and use problem-setting in relation to the demands of the healthcare unit. This is also a method in which the facilitator can hear criticisms of the system and suggestions for improvements from (his own) group” (N10, p. 8-9).

At a personal level, the narratives related growth that had never been imagined, and over a short space of time: “it was as if I had gone up several steps of a staircase that represented my personal growth...” (N17, p. 24). As each day went by, the participants became more convinced about the therapeutic dimension that being in a group took on within their own lives: “being a facilitator is not an easy task and requires self-knowledge” (N7, p. 15).

The students reflected on their own stance regarding dealing with problems, with a level of maturity that did not previously exist. They would normally have retreated from such problems or have postponed dealing with them, as a form of defense.

“The experience of this first meeting, in a very intimate forum, also made me perceive how intolerant and impatient I am with differences of opinion. I’m very judgmental and also concerned about other people’s judgments about me. I also perceived that I’m not as loving as I imagined I was...” (N13, p. 5).

At each meeting, the participants realized that they were questioning themselves and their “truths” that had for long been unquestionable:

“[...] everything suddenly happened very intensely and the fact that I was able to externalize and register all of these feelings [...] shows that I have changed. Now I write. Sincerely, I don’t think that I’ve changed my view of the world. I’ve changed my view of the process and of how to place myself in it” (N9, p. 4).

The experience of receiving criticisms was new and stimulating. The narratives showed how the students perceived that openings existed within themselves to receive other people’s views. This was something that they had never imagined:

“But learning painful things is necessary and it enables very interesting changes of position. I made two big changes this week: I – My “mask” fell off; II – I perceived my patterns of repetition. Really, this will help me to follow new paths. That’s what I hope” (N7, p. 19).

It was also interesting to observe how the act of writing triggered reflection and reworking of the practices and meanings of the process that was experienced in the course:

“Through rereading the summaries that I produced from each meeting, I was able to relive the course, ask new questions and seek new replies (N16, p. 26). I need to explain a change in my way of writing that arose last week, precisely as a response to my need to organize my ideas” (N9, p. 5).

Characters, plot and scenarios of experiences

The “group” was the omnipresent character in all the narratives, implicitly or explicitly. Sometimes it was represented as a space for psychotherapy (N2, p. 7) and at other times as an active character who influenced the learning that was attained: “the group often served as an escape mechanism for potential negative sentiments that might, I believe, have blocked the learning under other circumstances” (N9, p. 4).

The “educator” was another character that often appeared, variously as a tutor, facilitator or preceptor. At many points in the narrative, the names of the participants or educators involved appeared: this was almost always in situations of learning, notable speeches, critical incidents or social group situations that said a lot about the experience of the course.

The plot, as an underlying order for the story that was told, functioned as a structure for the project and aims of the narrative, its direction and its intended meaning: “a sequence for the events and for the links between these events”²⁸ (p. 127). This was where the experiences, with their reflections and learning, appeared.

The chronological order of person-to-person meetings was generally followed. However, this sometimes did not work very well: “I am writing and trying to follow a line of reasoning, and all the time new ideas are crisscrossing and leading me to do other things. So, I’m getting somewhat anxious” (N9, p. 5). In some narratives, the plot chosen was to group the experiences into nuclei of meanings, thus separating the experiences into stages or into tasks that were done at the meetings.

The narratives analyzed here were poor in scenarios such as work spaces or environments, but they were rich in scenarios involving spaces for constructing subjective experiences of the “self”. The main physical scenario was the space that had been organized for developing the course. This was implicit in the narratives, but this scenario was the platform for other subjective scenarios of “threshold experiences between being oneself and being another person”, which can be separated into different categories, involving the methodology of the course, being in the group together, facilitating the group and evaluating the course.

Interpretive synthesis

From the analysis on the structure of the narratives and the experience, the complexity of the meanings present was revealed to us. We perceived from the students’ previous experience that they were accustomed to but not adapted to “teaching” that was based on a competitive environment, in which they received subject matter that was transmitted by a person who held knowledge on this matter, through presentational classes and theoretical activities. The students’ “learning” mostly consisted of memorizing and repeating information, given that they had become numbed to their right to think and create.

This was an experience with challenges, advantages and disadvantages that took place in educational spaces (teaching institutions), in meeting spaces (professional healthcare environments within SUS), in groups of friends and with the students’ children, in the context of the home and school.

Very many events in which the experience from the course led to personal and professional changes were narrated. Moreover, some of the students were already applying their understanding of the method, in their personal and professional lives, with challenges and successes.

The students also stated that they had acquired specific skills for this new role as educators: empathy; listening skills; belief in themselves; strengthening of groupality, love and affectivity; freeing themselves from still being held back by other people’s opinions or judgments; teaching other people to think; emotional control; knowing how to deal with their own fragilities, insecurities and impatience; and knowing how to administrate time.

The use of active methodologies involves issues ranging from curricular permission and authorization of management to availability of resources and low autonomy among students. Given the challenges and even frustrations, the students stated that there was a need for new institutional values for training professionals with freedom and autonomy of choice and decision-making.

The narratives analyzed here showed that personal change was a major challenge and showed the traps that might lead to a return to the old patterns. The following questions posed: How can we live together in a group, dealing with very many differences, if the individual tendency is to withdraw? How can we be responsible for continuing education processes without any training in education? How can we transform meetings that are obligations into pleasurable events?

Individual and institutional engagement seems to be crucially important. Institutional engagement depends completely on individual engagement for difficulties of understanding among managers and professionals regarding the method to be resolved. The aim is to ensure that the possibility of having dialogue on matters relating to individuals’ realities is, in itself, an intrinsic motive for a meeting.

Through listening practices, an opening has arisen for other people to look at themselves, regarding their own contradictions. This listening includes listening to oneself, in a process of self-learning that has so far been experienced through narrative-writing. It enables growth in self-esteem, curiosity and creativity, through questioning what had previously unquestionable. It has changed people.

Thus, being in the group together had an unexpected therapeutic dimension relating to self-reflection and metacognition, and to how one’s thoughts and feelings influence one’s attitudes. This gave rise to changes in thinking, feelings and attitudes.

From this, it was noticeable how the students started to observe and give greater importance to the way in which other people saw and heard them, and to the feelings that all people have, their life histories and their dreams.

The students’ surprise regarding the methodology, far from making them flee, aroused their curiosity and added to their enchantment with this innovative proposal for listening, integration, learning and transformation. In addition to enchantment, the students used terms like “magic”, “keeping the flame alive”, “singularity”, “challenge” and “immersion” to portray their experience from the methodology of the course.

Use of films was the tool that left the greatest impression as a experience, and this was the source of much learning and increased perception. It seemed to bring together poetic wonder, magical enchantment, the challenge of immersion and the flame of life. The construction of reflective and practical spaces was also a strong point in the course. The highest point was the experience of taking the role of the facilitator.

Being in the group together, in a space for trust and exchange, created links and affection and made the meetings intensely emotional, pleasurable and therapeutic. The thing that was learned most was the capacity to listen and perceive other points of view, especially in the continuous process of assessment and self-assessment within which the group was immersed.

Final remarks

The students’ experience from the course led them to perceive a new role for educators and education. This was learned with the great richness of meaning that was within reach and, for this, time and space that could be trusted was needed, so that the new viewpoint and perception could be savored. The process of reflection that was produced contributed towards providing new meanings and increased autonomy for the subjects.

This was a time and space for changing the meanings of memories, directions and thoughts, through an “experience of the self”: the only way to change habits, conditioning and attitudes. It was seen that this “experience of the self” in the narratives was intense and transformative, such that the narrators were transformed into the “authors” of their own lives; and that their appropriation of power over themselves was shared between their personal and professional lives. Thus, autonomous subjected were created, with the capacity to govern themselves, without external control or extrinsic motivation.

The narratives constituted tools for self-reflection that contributed towards reworking practices and meanings, although their compilation sometimes because confused through the intensity of the ideas and meanings that arose from experiences. Writing and reflecting on the process itself, as a means of raising awareness of the experience of the course, turned use of reflective narrative into an innovative tool for health education, and this made a major contribution to the processes of continuing education.

In the context of producing these narratives, it may be that some meanings or reflections were omitted. After all, this work was presented to obtain certification at the end of the course, and the students may have applied some filtration to issues that they considered to have been negative in relation to the course, so that these would not antagonize the evaluators of the narratives. In addition, it is possible that, consciously or unconsciously, some students may have omitted some personal emotional issues that were triggered during the course but were difficult for the psyche to deal with.

Given that, in narratives, time is an element of the subject, and not a reality external to this individual, it cannot be expected that narratives will be historical in nature. Rather, they will just be reports on the feelings that the narrator attributes to the experience. This is a limit to narratives as an educational tool. Moreover, implications uncovered later on were also naturally absent, since the deadline for handing in the narrative for assessment was 30 days.

Acknowledgements

Continuing Education Center of SAMU 192, Fortaleza regional administration Sírio-Libanês Teaching and Research Institute, Hospital Sírio-Libanês

Referências

• ¹
  Capra F. O ponto de mutação: a ciência, a sociedade e a cultura emergente. 20a ed. São Paulo: Editora Cultrix; 1997.
• ²
  Viana CA. Tempo e sujeito em Paul Ricoeur: uma introdução a partir da leitura ricoeuriana do livro XI das Confissões de Santo Agostinho. Contemplação. 2012; (4):1-19.
• ³
  Gomes LB, Bolze SDA, Bueno RK, Crepaldi MA. As origens do pensamento sistêmico: das partes para o todo. Pensando Fam. 2014; 18(2):3-16.
• ⁴
  Souza CS, Iglesias AG, Pazin-Filho A. Estratégias inovadoras para métodos de ensino tradicionais – aspectos gerais. Medicina (Ribeirão Preto). 2014; 47(3):284-92.
• ⁵
  Ministério da Saúde (BR). Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação em Saúde. Política Nacional de Educação Permanente em Saúde. Brasília: Ministério da Saúde; 2009.
• ⁶
  Gadotti M. A educação contra a educação. 5a ed. Rio de Janeiro: Editora Paz e Terra; 1992.
• ⁷
  Lemos CLS. Educação permanente em saúde no Brasil: educação ou gerenciamento permanente? Cienc Saude Colet. 2016; 21(3):913-22.
• ⁸
  Haddad QJ, Roschke MAC, Davini MC. Educación permanente de personal de salud. Washington, DC: Organização Panamericana de Saúde – OPAS; 1994. (Serie Desarrollo de Recursos Humanos).
• ⁹
  Ministério da Saúde (BR). Secretaria de Gestão do Trabalho e da Educação na Saúde. Departamento de Gestão da Educação em Saúde. Política Nacional de Educação Permanente em Saúde. Brasília: Ministério da Saúde; 2009. (Série B. Textos Básicos de Saúde. Série Pactos pela Saúde 2006; v. 9).
• ¹⁰
  Lopes SRS, Piovesan ÉTA, Melo LO, Pereira MF. Potencialidades da educação permanente para a transformação das práticas de saúde. Com Cienc Saude. 2007; 18(2):147-55.
• ¹¹
  Coriolano MWDL, Lima MDM, Queiroga BAM, Ruiz-Moreno L, Lima LS. Educação permanente com agentes comunitários de saúde: uma proposta de cuidado com crianças asmáticas. Trab Educ Saude. 2012; 10(1):37-59.
• ¹²
  Mitre SM, Siqueira-Batista R, Girardi-de-Mendonça JM, Morais-Pinto NM, Meirelles CDAB, Pinto-Porto C, et al. Metodologias ativas de ensino-aprendizagem na formação profissional em saúde: debates atuais. Cienc Saude Colet. 2008; 13(2):2133-44.
• ¹³
  Berbel NAN. As metodologias ativas e a promoção da autonomia de estudantes. Semina Cienc Soc Hum. 2011; 32(1):25-40.
• ¹⁴
  Conterno SFR, Lopes RE. Inovações do século passado: origens dos referenciais pedagógicos na formação profissional em saúde. Trab Educ Saude. 2013; 11(3):503-23.
• ¹⁵
  Lima JVC, Turini B, Carvalho BG, Nunes EDFPA, Lepre RDL, Mainardes P, et al. A educação permanente em saúde como estratégia pedagógica de transformação das práticas: possibilidades e limites. Trab Educ Saude. 2010; 8(2):207-27.
• ¹⁶
  Lima VV. Espiral construtivista: uma metodologia ativa de ensino-aprendizagem. Interface (Botucatu). 2017; 21(61):421-34.
• ¹⁷
  Ballarin MLGS, Palm RCM, Carvalho FB, Toldrá RC. Metodologia da problematização no contexto das disciplinas práticas terapêuticas supervisionadas. Cad Bras Ter Ocup. 2013; 21(3):609-16.
• ¹⁸
  Melo BC, Sant’Ana G. A prática da metodologia ativa: compreensão dos discentes enquanto autores do processo ensino-aprendizagem. Comun Cienc Saude. 2012; 23(4):327-39.
• ¹⁹
  Dutra E. A narrativa como uma técnica de pesquisa fenomenológica. Estud Psicol. 2002; 7(2):371-8.
• ²⁰
  Brusamolin V. Narrativas para a gestão de mudanças: um estudo de caso na indústria vidreira. Transinformação. 2011; 23(1):15-28.
• ²¹
  Bury M. Illness narratives: fact or fiction? Sociol Health Illn. 2001; 23(3):263-85.
• ²²
  Bondía JL. Notas sobre a experiência e o saber de experiência. Rev Bras Educ. 2002; (19):20-8.
• ²³
  Ribeiro AK, Lyra MCDP. O processo de significação no tempo narrativo: uma proposta metodológica. Estud Psicol. 2008; 13(1):65-73.
• ²⁴
  Ricoeur P. Tempo e narrativa (Tomo I). Campinas: Papirus; 1994.
• ²⁵
  Denzin NK, Lincoln YS. Introduction: the discipline and practice of qualitative research. In: Denzin NK, Lincoln YS, editors. Handbook of qualitative research. London: Sage; 2000. p. 1-29.
• ²⁶
  Deslandes SF, Gomes R. A pesquisa qualitativa em serviços de saúde: notas teóricas. In: Bosi M, Mercado F, editors. Pesquisa qualitativa de serviços de saúde. Petrópolis: Editora Vozes; 2004. p. 99-120.
• ²⁷
  Good BJ. Medicina, racionalidad y experiencia. Una perspectiva antropologica. Barcelona: Edicions Belaterra; 2003.
• ²⁸
  Gomes R, Mendonça EA. A representação e a experiência da doença: princípio para a pesquisa qualitativa em saúde. In: Minayo MCS, Deslandes SF, editors. Caminhos do pensamento: epistemiologia e método. Rio de Janeiro: Fiocruz; 2002. p. 109-32.
• ²⁹
  Alencar TOS, Nascimento MAA, Alencar BR. Hermenêutica dialética: uma experiência enquanto método de análise na pesquisa sobre o acesso do usuário à assistência farmacêutica. Rev Bras Promoc Saude. 2012; 25(2):243-50.

Publication Dates

• Publication in this collection
  30 May 2019
• Date of issue
  2019

History

• Received
  30 Jan 2018
• Accepted
  25 May 2018