Mobilizing students in the Brazilian National Health System (SUS) defense: interprofessional experiences of VER-SUS - Sobral, CE, Brasil

Abstract

This is an account of the experiences of VER-SUS project from 2012 to 2016 in the interprofessional education process of health academics and others in the city of Sobral, CE, Brazil. The analytical axes included: social and historical construction of VER-SUS, and interprofessional experience at VER-SUS. Six editions of the project were held during this period. Through conversation circles, interprofessional development workshops and feedback from immersions into the territories and health services, they enabled a dialogical and horizontal education in SUS’ reality. Therefore, VER-SUS/Sobral proved to be a powerful strategy, since it encourages interprofessionalism and development of health work expertise between undergraduate students and the service. In order to do so, these experiences provided dialogic spaces for knowledge (re)construction.

Keywords:
Brazilian National Health System; Higher education; Interprofessional relationships

Resumo

Trata-se de um relato das experiências do projeto VER-SUS no período de 2012 a 2016 no processo de formação interprofissional dos acadêmicos da área da Saúde e afins, no município de Sobral (CE). Os eixos analíticos abrangeram: construção histórica e social do VER-SUS e a experiência interprofissional no VER-SUS. Ao longo desse percurso temporal, aconteceram seis edições do projeto, que, por meio de rodas de conversas, oficinas de desenvolvimento interprofissional e devolutivas das imersões nos territórios e serviços de saúde, possibilitaram uma formação dialógica e horizontal acerca da realidade do SUS. Assim, o VER-SUS/Sobral mostrou-se uma estratégia potente por estimular a interprofissionalidade e o desenvolvimento de expertises do trabalho em saúde entre graduandos e o serviço. Para tanto, essas experiências proporcionaram espaços dialógicos para a (re)construção do saber.

Palavras-chave:
Sistema Único de Saúde; Educação superior; Relações interprofissionais

Resumen

Se trata de un relato de las experiencias del proyecto VER-SUS en el período de 2012 a 2016 en el proceso de formación interprofesional de los académicos del área de la Salud y similares en el municipio de Sobral / Estado de Ceará. Los ejes analíticos incluyeron: Construcción Histórico y Social del VER-SUS y la Experiencia Interprofesional en el VER-SUS. Durante este trayecto temporal se realizaron seis ediciones del proyecto que, por medio de ruedas de conversaciones, talleres de desarrollo interprofesional y devolutivas de las inmersiones en los territorios y servicios de salud, posibilitaron una formación dialógica y horizontal sobre la realidad del SUS. Así, el VER-SUS / Sobral se mostró una estrategia robusta, por incentivar la interprofesionalidad y el desarrollo de experiencias del trabajo de salud entre los alumnos de graduación y el servicio. Para ello, esas experiencias proporcionaron espacios dialógicos para la (re)construcción del saber.

Palabras clave:
Sistema Brasileño de Salud; Educación superior; Relaciones interprofesionales

Introduction

Professional health education has gone through important changes throughout the years resulting from cultural transformations and incorporation of technologies in different areas of knowledge, which influenced teaching and learning¹. Despite this revolution, the traditional view of education still sows vertical perspectives of knowledge transmission in the health education scenario, within the enclosures of an uncritical model. This has hindered the advance of interprofessional health education and collaborative practice perspectives.

These changes in paradigm led to higher education reformulation in Brazil. This motivated the definition of the National Curricular Guidelines of undergraduate courses, which provided higher education institutions with directions towards innovative political-pedagogical projects. This process began with the publication of Notice no. 04/1997 by Brazilian Ministry of Education’s Higher Education Department (SESU/MEC). It called higher education institutions to submit proposals to be systematized by Teaching Experts Committees (CEE) of each area of knowledge and forwarded to National Education Council (CNE)².

The National Curricular Guidelines of health courses shifted the responsibility for preparing future professionals for interprofessional teamwork to education institutions, since they advocate for interdisciplinary curricula aligned to public policies adopted by SUS³.

At this juncture, SESU/MEC aimed at strengthening actions to improve the undergraduate teaching quality. In order to do so, it took into consideration suggestions and criticisms from higher education institutions, as well as the perception of other references in discussions related to the National Curricular Guidelines. These other references included: the 1988 Federal Constitution; Organic Law of the Brazilian National Health System (no. 8080 of September 19, 1990); National Education Guidelines and Framework Law (no. 9394 of December 20, 1996); law approving the National Education Plan (no. 10172 of January 9, 2001); CES/CNE Opinion (no. 776/97 of December 3, 1997); Opinion no. 04/1997; ForGRAD’s National Graduation Plan of May 1999; Pan American Health Organization (PAHO), World Health Organization (WHO) and Rede Unida documents².

Based on these legal determinations, the Brazilian Ministry of Health made a commitment to professional health education, instituting guiding public policies. After the creation of Management Department for Work and Education in Health (SGTES), in 2003, the Policy for Education and Development of SUS: Permanent Health Education Approaches was created. The policy strengthened permanent health education centers, which in turn encouraged the review of health education, care, management, policymaking and social control strategies^4,5.

Based on permanent education institutions as one of its guidelines, the department undertook the role to qualify health professionals and workers in Brazil, strengthening Art. 200, Item III, of the Brazilian Federal Constitution, which states it is SUS’ responsibility to “organize the education of human resources in the health sector”⁶. Along this line, proposals to qualify health education were submitted, according to which undergraduate courses aim at guiding interprofessional practices, such as the project Experiences and Internships in the Reality of SUS (VER-SUS)⁷.

The VER-SUS project was developed by students for students throughout the country and acknowledges the health system as a learning space. The project has local organizing committees comprised of managers, students, higher education institutions, health service professionals and social movements that provide decentralized support for experiences, keeping touch with different agents and the federal committee. The federal committee, in turn, is comprised of the Ministry of Health in partnership with Rede Unida, Rede Governo Colaborativo em Saúde, National Union of Students (UNE), National Council of State Health Secretaries (CONASS) and National Council of Municipal Health Secretaries (CONASEMS)⁵.

This project has influenced interprofessional education as a means to strengthen health education and interprofessional collaboration. It prioritizes teamwork, integration between sciences and the domain of study of disciplines in order to integrate their theoretical and practical levels to achieve a broader acknowledgement, taking into consideration the specificities of each profession⁸.

Interprofessional collaboration is experienced when professionals from different health areas are able to practice interprofessional knowledge, strengthening interactions in the work space and generating better health results. Interprofessional education emerges in this education scenario as a strategy capable of achieving collaborative practice, since it enables interaction with knowledge share among students from different categories, promoting collaborative learning^9,10.

In order to do, it is important to acknowledge successful experiences related to interprofessional collaborative approaches in undergraduate health courses and other related areas in order to strengthen education and the development of ethical professionals aware of the society’s inherent issues and of proposals to value SUS. Based on what was discussed so far, this article aims at reporting interprofessional experiences of VER-SUS project in Sobral, Ceará, Brazil.

Methodology

This compilation of experiences is based on an experience report created through the VER-SUS/Sobral project’s history from 2012 to 2016. During this period, the authors of this report had an active participation in the following editions: 2012, 2013.1, 2013.2, 2014, 2015 and 2016, covering the contributions promoted to students from all levels of education, categories and education institutions.

The experience report documents human experiences, which enable the researcher to report his/her experiences and contextualize them with the relevant literature, making a connection with the technical-scientific knowledge¹¹.

From 2012 to 2016, the project had the participation of students from the following courses: Social Sciences, Physical Education, Nursing, Electrical Engineering, Pharmacology, Physiotherapy, Psychology, Letters, Medicine, Nutrition, Occupational Therapy, among others, such as Business Management. Students wanted to experience the health system’s reality in Sobral. Approximately 100 students participated in the project, with an average of 20 students per edition.

VER-SUS experiences are conducted through a theoretical, practical and experiential immersion. Students immerge into the project full time, 24 hours per day, inside the health services available in the city¹². Participants are divided into workgroups with students from various categories in order to provide dialogs from different knowledge and practices.

Experiences go beyond health services with a physical structure. They also contemplate spaces where complementary and integrative practices are developed in the health promotion process.

Therefore, choosing to report these experiences shows, on the one hand, the acknowledgement of education transformation movements that enable institutions to improve health education. On the other hand, it shows the authors’ experience in following the VER-SUS project’s experiences in the local health system.

The VER-SUS project’s focus was based on identifying the power of integrating education, service and the community, and the strategies instituted in PNEPS in order to effectively meet the Brazilian population’s needs in the education of health professionals and workers. It is one of the tools that can help meet knowledge production and healthcare practices, committed to strengthening SUS¹³.

The results presented and discussed here focus on the perspective of interprofessional education, and health teaching and learning views. This methodological practice is produced with meaning based on the experienced reality¹⁴.

The analytical axes include: social and historical construction of VER-SUS/Sobral, and interprofessional experience at VER-SUS/Sobral. These axes were built retrospectively, based on field journals written by this article’s authors.

Social and historical construction of VER-SUS/Sobral

The VER-SUS project’s pilot edition was held in 2002 in the state of Rio Grande do Sul and was based on the result of dialogs that started in the 1990s among higher education institutions, the Ministry of Health and social entities in order to promote experiences that integrate changes in the curricular matrix and that strengthen the health system. This edition had the participation of 16 professionals and 200 health students^5,15.

Based on the successful local experience, the first national VER-SUS edition was held in 2003, in articulation with 60 departments, until 2004. In the same year, Sobral integrated the group of ten cities that comprised the VER-SUS/Brazil pilot project. After the pilot project, the first national VER-SUS edition was held in sixty Brazilian cities¹⁵.

Still in 2003, after the creation of SGTES, other projects to stimulate education focused on SUS were developed and prioritized by the Ministry of Health. It is also worth highlighting the approximation between health and education based on the partnership between the Ministry of Health and the Ministry of Education for technical collaboration in the education and development of human resources in the health sector, instituted by Directive no. 2118 of November 3, 2005¹⁶.

This partnership promoted the creation of National Reorientation Program in Professional Health Education (Pró-Saúde), instituted by Interministerial Directive no. 2101, of November 3, 2005, and subsequently of Program of Education through Work for the Area of Health (PET-Saúde), created by Interministerial Directive no. 1802/MS/MEC, of August 26, 2008^17,18.

However, students who participated in the VER-SUS/Brazil project and its supporters conducted discussions on resuming the project in several political and academic spaces. These discussions resulted in the development of local initiatives with financial restrictions, but with the ideal of building a militancy in favor of SUS. Several students who participated in VER-SUS in 2004 started acting in strategic scenarios, such as universities, public health schools, municipal health departments and the Brazilian Ministry of Health itself. This amplified the discourse to resume the project and its importance in the education for SUS¹⁵.

The VER-SUS/Sobral project was resumed in 2011, with a local edition held by Visconde de Sabóia Family Health Training School (EFSFVS). This edition was aimed at students from different undergraduate health courses and related areas, teachers from higher education institutions and the local health system.

In late 2011, the VER-SUS/Brazil project was resumed. In 2012, based on the incentive to internalize the experience, Sobral held the project’s winter edition by strengthening the local committee made up of students who participated in the summer edition in 2011 and of supporting health professionals who participated in VER-SUS in 2004, representing the strength and energy of the students’ collective process.

The 2012 experiences were focused on Sobral’s healthcare network, particularly on ESF, health surveillances, social work services and social movements, in order to provide experiences with participation of the population and in social control scenarios. Additionally, the project editions included experiences in two neighboring cities: Valparaíso settlement, which is a result of Landless Workers Movement (MST), in Tianguá/CE, and the Tremembé indigenous tribe in Itarema/CE.

EFSFVS’ approach strengthened popular education and interprofessional collaboration practices through the Popular Art and Education Workgroup, the Permanent Education Workgroup and Multiprofessional Family Health Residency (RMSF).

In the 2013 VER-SUS/Sobral (winter and summer) editions, besides the city’s healthcare network experiences, there was an opportunity of immersion into the Prison Pastoral. The Prison Pastoral is a social movement comprised of religious groups that provide community services to the city’s public prisons. The 2013 edition also provided an experience in Francisco de Assis Spiritist Group (GEFA), in the city of Groaíras/CE, which provides sports, health, education, art and cultural services to the population. The performance of practices in diverse spaces enabled academics to have a broad critical view on the population’s different needs and thus reflect on the role to be played to positively contribute to the situation¹⁹.

In the 2014 edition, immersion remained in Sobral’s health network and social facilities, particularly with insertion into the city’s Counseling House, which helps children, teenagers and the elderly. The 2014 edition also enabled the academics’ approach to the fights and actions developed by the facility in order to intensify the support provided to these groups. It also included a visit to Association of Sex Workers of the City of Sobral (ASTRAS), which is a powerful space that tries to break taboos and promote healthcare to the women involved, fostering safe work and developing creative alternatives through qualification courses to improve work quality.

In 2015, VER-SUS/Sobral underwent innovative changes in the experiences’ pedagogical methodology, which brought the articulation between education, and research and extension programs closer. Therefore, VER-SUS/Sobral Extension Program was launched as a strategy to contribute to effective social responses in the city. The 2015 edition was held in two different moments. Firstly, as an immersion into the health network, social work network and social movement spaces for 11 days. Secondly, as a post-immersion extension program perspective in a specific service chosen by the workgroups during the immersion period.

The extension program was developed based on intervention projects triggered when questioning experiences. However, those who go through these experiences and the universities are not the only transformative agents. They can also be transformed in the experience process provided by the extension program. According to the I National Meeting of Extension Programs and Vice-Provosts for Extension Programs (1980), “extension programs are a two-way street,” because they enable the combination of knowledge construction in society and knowledge production in universities²⁰.

During this experience at VER-SUS Extension Program, for example, a group comprised of four students from the Nursing, Physical Education and Psychology courses articulated and developed an intervention project at “Arc’s Welcoming House: caring for mothers and babies”. Arc’s Welcoming House is a strategy by the city of Sobral to reduce mortality of mothers and children by supporting women addicted to crack. The actions developed in this service were focused on potentializing the space. During the meetings, conducted based on the theoretical framework of Paulo Freire’s Culture Circle, women would express their feelings and aspirations, and talk about positive expectations²¹.

Therefore, by adopting extension programs as a social mobilization tool, VER-SUS provided a significant permanent learning sense to professional education, consequently contributing to the integration among education, service and community.

In 2016, VER-SUS/Sobral was resumed with the experience and internship methodology articulated with PET-Saúde/GRADUASUS. PET-Saúde proposes a curricular change in accordance with the National Curricular Guidelines of undergraduate health courses and the qualification of the processes of integration among education, service and community articulated between SUS and teaching institutions²². Therefore, PET-Saúde was the supporter of this edition. Additionally, the experience’s differential was the visit to a group of permaculture designers in the city of Meruoca/CE who work with organic production and to the Tremembé indigenous community Queimadas, in the city of Acaraú/CE. These experiences provided a contact with communities that adopt alternative ways to promote health, based on natural sources and integrative practices.

Besides the experiences, there are also popular education activities performed by VER-SUS participants in their accommodation space. An example of these activities is the creation of the “book of folktales,” where each participant was able to creatively explain a folktale/popular belief of significant value to their lives. Another example is the “nucleus and knowledge” moment, where participants are divided into courses and have the opportunity to explain their knowledge on other SUS’ categories, e.g. nursing on physiotherapy and vice-versa, psychology on physical education and vice-versa, resulting in a collective construction of knowledge of what was discussed. Yet another example is the practice of biodanza that, besides relaxing, enables you to meet your inner self and the other.

Highlighting the continuous partnership with social movements, in all the editions mentioned above, discussion circles on diversity, gender and ethnicity were conducted with the participation of representatives from all these causes. All participants have an opportunity to briefly explain their views and experiences in the context. Additionally, the 2016 edition held “Transversus,” during which, after discussions, women dressed as men and vice-versa for a dance presentation. Everybody was free to express their inner woman or man their own way, with no prejudice.

Therefore, in all different experiences, students had the opportunity to participate in several activities, by immersion, divided into workgroups with the participants. Visits to different healthcare devices and social facilities, and discussion circles with VER-SUS members, health professionals and workers, and managers through activities developed based on active methodologies instigated the participants’ protagonism as social agents and encouraged them to be multipliers of knowledge as powerful mobilizers of hearts and minds in defense of SUS.

Interprofessional experience at VER-SUS/Sobral

VER-SUS proved to be a strategy that instigated interprofessional collaboration starting in undergraduate courses, since it provided unique contact and collaboration experiences among students from different professional categories.

In the VER-SUS/Sobral editions, undergraduate students from public state and federal, and private universities of the courses of Nursing, Physical Education, Psychology, Medicine, Physiotherapy, Occupational Therapy, Pharmacology, Nutrition, Social Sciences, Letters, Electrical Engineering, Business Management, among others, interested in experiencing the reality of Sobral’s health system had the opportunity to build, discuss and expand their view by combining different perspectives of each professional category based on critical reflections and on their protagonism.

Changes that potentialize professional education are more effective when subjects feel important and active in the teaching and learning process²³. In this perspective, VER-SUS/Sobral was organized by students, with the support of teachers and health service professionals, for other students. VER-SUS’ transformative potential is focused on the integration of several social agents who believe in SUS and fight for its qualification.

Intentionally divided into multiprofessional workgroups, immersion into different services and social facilities provides to those involved the possibility of integrating and sharing category-specific knowledge with the shared decision-making process. This immersion also enables to identify the possibilities provided by common functions, consequently interpreting and understanding the construction of health and inherent areas based on multiple views.

However, during the experiences, the interest of students from different areas not directly connected with SUS showed its importance to the construction of an interdisciplinary health space and to the expansion of reflections on different teaching and learning scenarios.

The VER-SUS/Sobral project is a game changer for students who have the opportunity to participate. The project expands their views and provides a dialogic relationship with different professional categories, managers and SUS users. For the education of health professionals, it represents a space that instigates permanent education based on reflections of its practices with the students’ “estrangement” view. For universities and the community, it is a possibility to increasingly strengthen this relationship. VER-SUS is thus an effective strategy that aims at integrating education, service and community in the city.

Therefore, in the current professional health education scenario and related areas, VER-SUS/Sobral is one of the strategies starred by students that strengthens the professional practice in SUS. Interprofessional education helps build collaborative relationships among different professional categories. This potentializes health services and public policies, strengthening the qualification of professionals who are more capable of working interprofessionally. It also helps promote respect and ethics, and eliminate stereotypes among professionals^9,24.

One of the most obvious contributions of VER-SUS, which is clear throughout its path, was the opportunity to build a shared education space that enabled the performance of collaborative practices, considering that, in the future, academics from different professional categories will work in teams²⁴. Additionally, the project favors the creation of bonds and knowledge, and provides university education for those professionals who are most committed to the public health system.

Undergraduate students need to develop a critical and reflective education that is socially committed to health needs, promoting people’s emancipation by becoming citizens in their humanization process²⁵.

Based on the circle’s methodological reference²⁶, where each individual is a protagonist, being responsible for learning, the students’ autonomy and co-responsibility for health education and practices provided to population are fostered. The collective discussion activities were conducted in circles where everybody could see each other and recognize themselves as essential to the teaching and learning process. In Brazil²⁷, conversation circles are a pedagogical strategy with the idea of conduction, continuity and reciprocity, where the relationship among subjects is horizontal, based on a democratic participation that allows for integration of different knowledge.

Based on VER-SUS/Sobral 2012 edition experiences, the need for learning about the different professional categories involved in the project was highlighted. At this time, a workshop idea, “Meeting with the other (exchange of ideas): discussion of nuclei and practice knowledge,” came to life. The workshop was focused on the fields and nuclei²⁸ of students who were part of the experience, so that they could learn more about the functions of each profession and the common ones.

The meeting space among categories aimed at minimizing the dichotomy experienced in the education of health professionals, since it provided a broader and shared education that met the health practice demands as an offer to the necessary changes to interprofessional and collaborative health work^28,29.

However, the experience goes beyond the one provided by the workgroups, since after each visit to services and health promotion spaces, VER-SUS participants are invited to share their perceptions and feelings. This moment is defined as feedback. This feedback is related to the experience of analyzing local health policies, which are given back in creative ways, involving popular health education and enabling all to see services through the look of other people. Feedbacks break the traditional presentation model, develop autonomy and value creativity³⁰.

Feedbacks of visits to the mental health network were called “insanity workshop,” which has been developed since the 2015 edition. A crown is given to each participant, with an adjective written on it related to some stigma suffered by people with any kind of mental disorder, such as “crazy,” “brainless,” “loony,” etc. As the visits’ discussions unroll, a “magna cape” is passed around the room. Every person with the cape goes to the center of the circle and says what their insanity is. This activity builds on empathy, since it shows how people feel when they are “labelled,” and provides intimacy and stronger bonds among participants.

Based on what was discussed so far, experiences were systematized by creating a portfolio where participants write their experiences on paper. Portfolios were published on Observatory of Information Technology and Communication in Health Services and Systems (OTICS) web page, being available to all. Reflections and experiences of the VER-SUS project were publicized aimed at strengthening a network of students committed to the system.

VER-SUS can then be allocated to one of the innovative processes Silva⁸ claims being necessary to induce and unleash discussions related to health practice in order to constantly problematize it, questioning its social responsibility based on models and values to be built in practice, (re)building educational processes and professional competencies, and integrating education to the reality of services and community.

VER-SUS/Sobral experience is similar to other editions of the project held in other cities, such as the 2014 VER-SUS winter edition held in the western part of the state of Santa Catarina and VER-SUS/Santiago, RS, summer edition. Active methodologies were also used as a strategy to build and exchange knowledge during the experiences, such as discussion circles, dialogs and dynamics involving all participants, instigating collective education, enabling discussions of topics and moments not effectively provided by undergraduate courses, the importance of teamwork, the opportunity to visit and talk to professionals and users of different parts of the network and all points that deserve a different approach^23,31.

Therefore, this project enables to learn more about SUS by participating, based on a critical reflection on how it works, its professional practice, services provided to users and their understanding, and students’ as protagonists²³.

In the meantime, interaction among students from different undergraduate courses provided by VER-SUS project was important for a collaborative and interprofessional learning process. In other words, VER-SUS students shared the same learning process with synergy and effective dialog during an immersion period in order to develop the necessary competencies for collaborative interprofessional practice in SUS, by SUS and for SUS.

Final remarks

Interprofessional education strategies such as VER-SUS show that, in order to improve teamwork, it is necessary to privilege affectionate relationships towards articulations of actions by practicing communication both within a team and among different teams. In this sense, teamwork is guided by investing in creativity, searching for new mechanisms to improve quality healthcare and interprofessional education.

VER-SUS is a project that resignifies ideas and conceptions of united professionals able to fight for a quality public health system that accepts differences and contemplates the other with a different, more sensitive and welcoming look. It is a space that shows there is not only one course and that interaction and exchange of ideas with other areas is necessary to practice and promote health.

Projects like VER-SUS contribute to improving education of health professionals and workers, since the relationship among education, service and community has provided a different education to academics, who now experience SUS’ challenges and therefore stimulate a critical view towards the services network in the system. The need for integrating different professionals to invent and reinvent ways of collaboratively and interprofessionally acting is increasingly discussed, providing better results at work.

These days of experience awaken students, bringing them closer through bonds created and affections shared. Therefore, education opportunities along this line need to be multiplied in order to meet growing social demands, contributing to the construction of a care model based on SUS’ principles. This can strengthen the promotion of comprehensive care and enable professionals to work in teams, offering resolutive and quality services to the population.

Acknowledgements

We would like to thank students, teachers, professionals and SUS users who believed in the educational and life-changing power of the VER-SUS project.

• Translator: Caroline Luiza Alberoni

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Publication Dates

• Publication in this collection
  2018

History

• Received
  12 Nov 2017
• Accepted
  04 July 2018