Challenges for faculty training in nursing courses in Northern Brazil from the perspective of interprofessional education*

Study analyzing the challenges of training developed by teachers working in nursing courses in the Northern Region of Brazil, from the interprofessional education perspective. A descriptive, exploratory, qualitative research conducted in public universities in which twelve professors participated in a semi-structured interview. Content analysis was used, and five categories were selected: 1) Commitment to teaching and working with comprehensive care; 2) Improvement of teaching, research, and community extension from the perspective of interprofessional education; 3) Integrated action among health professionals; 4) Need for teaching development aligned to interprofessional education principles; 5) Continuing education in health as a strategy to induce interprofessional teaching and practice. Interprofessional education is a robust and complex field. Therefore, a teaching practice capable of undertaking innovative formative processes is key, inducing changes that positively impact training and work in health.


Introduction
The confrontation with demands of education and work in health is a driver to mobilize dialogic interactions and relationships, through an encounter with reality.There is no way to avoid this encounter, because, as Freire 1 states, "there is plurality in man's relationships with the world as they respond to a wide variety of challenges" 1 (p.55).Thus, in order to understand aspects of real life and intervene on them, it is necessary to have a dynamic, interactive posture between the subjects and their historical-social context.
Considering that education and practice in the settings of the Brazilian National Health System (SUS) need to go hand-in-hand with the changes in the epidemiological population profile, as well as adopt new strategies that enhance the integrality of care and collaborative practice between the various areas of health, this study discusses interprofessional education (IPE) and its importance in professional training in nursing, seeking to analyze how undergraduate courses have implemented the assumptions of IPE, as seen through the perception of teachers.IPE and its vast theoretical and methodological field are currently experiencing important global visibility.With over 50 years of history, its experiences, learnings, and merits have accumulated a robust repertoire of knowledge.The interest and exponential growth of this topic in the last decade have mobilized organizations, universities, governments, and health care facilities to adopt this emerging and powerful proposal for the development of innovative strategies, aimed at better qualification of training and work [2][3][4] .
Faced with the intense current challenges, IPE is essential to foster collaborative practice, providing articulation of actions, collective work, and quality of care 5 .Its principles, aligned under the guideline "learning with the other, about others and among themselves", permeate the production of knowledge articulated to continuing and permanent education, assuming an important role in the teaching, research and extension (outreach) settings 2,4 .
International IPE centers, such as Canadian Interprofessional Collaborative Health (CICH), Center for the Advancement of Interprofessional Education (CAIPE), and the North American Interprofessional Education Collaborative (IPEC) reinforce the principles and understandings about the theoretical-conceptual, methodological, and scientific framework of IPE.The consolidation and strengthening of these networks expand the sharing of information, provide opportunities for partnerships, and assist in overcoming social and health challenges faced by individuals in various contexts 6 .
The training contexts are anchored in the assumptions of interprofessional education and work, with emphasis on collaborative practice and teamwork, and they have the characteristic of promoting professional identity and expanding it to an interprofessional identity.The training founded on the assumptions of the IPE enhances the deepening of reflections on professional roles, problem-solving skills, and shared negotiation in decision making.Therefore, it is essential that the health and education systems work together, supporting the implementation of policies and proposals anchored in the IPE, stimulating the integrated work among different professions in an equitable way, as well as permanent support for faculty development, intentionally articulated, cooperative and collaborative, redefining references in an interdisciplinary and interprofessional perspective [7][8][9] .
The inclusion of proposals based on IPE in the undergraduate level has pointed to the urgency in seeking innovations that modify and guide professional education in health.Some assumptions of the Framework for Action in Interprofessional Education and Collaborative Practice2 are integrated in the National Curriculum Guidelines (NCG) for undergraduate medical education, enacted in 2014, and by Resolution No. 569, which defines the General Principles for the National Curriculum Guidelines for Undergraduate Health Courses.This allows educational institutions to redesign curricular proposals, as well as plan conditions to improve the quality of faculty under the perspective of IPE.
The debate around IPE has been gaining resonance in different contexts, with actions developed in teaching, research, extension, and continuing education.A recent study, which analyzed IPE in the context of Brazilian higher education, revealed that it can be characterized as a means of knowledge exchange, a space for reflection, and an element for comprehensive care 10 .
Particularly, other investigations discuss the relationship between nursing and IPE.In this sense, the researchers analyzed clinical practice in the interprofessional context of the Family Health Strategy.The study showed that professional practice based on an interprofessional and collaborative approach contributes to the production of comprehensive care, from the movement of redefinition of the nurse's clinical practice 11 .
Still, recent studies point out to the need for expansion and institutionalization of IPE initiatives in the curricular plans of undergraduate nursing, assuming the commitment to appropriate theoretical and methodological frameworks that support interprofessional education and clinical practice in the workplace 12,13 .In this context, reflection imposes dilemmas and opens perspectives, revealing trails and paths to overcome gaps in the academic field.For these reasons, researchers recommend, among other initiatives for the promotion of IPE in undergraduate nursing courses, to include topics of interprofessional approach, to implement pedagogical practices that encourage interaction, the exchange of experiences among students of Health courses, among others 13 .
In this sense, it is understood that the faculty development under the perspective of the IPE requires the creation of new configurations based on collaborative learning and teamwork, as powerful inducers of change in training environments and health work.To this end, it is essential to have a collective commitment and flexibility to cross borders and redesign collaborative and sustainable curricular paths 14 .
The faculty readiness in IPE implies efforts linked to changing behaviors and recognition of good practices, promoting collaboration, communication, mutual respect, and sharing of knowledge, facilitating the construction of new training proposals that seek to redirect the teaching action for the formation of interprofessional health teams 15 .
In this context, faculty development is configured as a fundamental axis to enable changes in training and work in health, anchored in the principles of

Method
This is a descriptive, exploratory, qualitative study carried out in four public universities in the Northern Region of Brazil that offer undergraduate nursing courses.
The Nursing courses located in the capital of each state were included, which provided the informed authorization and agreement to participate in the research, by signing the Institutional Authorization Term.
Twelve professors from universities located in the states of Acre, Amazonas and Tocantins participated in the research, voluntarily agreeing to sign the Free and Informed Consent Form.The sample was selected based on the following inclusion criteria: having been a full professor at the institution for at least two years.
The study had ethical clearance from the universities involved and from the Research Ethics Committee of the Federal University of São Paulo, with CAAE: 83263818.4.0000.5505and Opinion No. 2.557.056,dated March 22, 2018.
The semi-structured script was organized with an initial part of characteristics of the teacher profile, including: name, age, gender, area of training, time of training, time of experience as a teacher in higher education, and the highest academic degree.The questions focused on the understanding of comprehensive care for nursing education, the curricular paths to interdisciplinarity and interprofessionalism, the challenges for the development of competencies for comprehensive care, and teamwork to strengthen the Brazilian National Health System (SUS).
The interviews were pre-scheduled and happened remotely, in a reserved virtual environment, free of interruptions, during January and February 2021.The conversations lasted an average of 50 minutes, were recorded and later transcribed in full.To preserve anonymity, all participating teachers were identified by the letter and sequential numbers (Dnº).For data analysis, we used the content analysis framework proposed by Bardin16, carefully following the stages of floating reading of the transcribed speeches.After that, a spreadsheet was prepared to insert the context units (CU) and record units (RU), followed by the categorization of the semantic elements, which were grouped in analytical categories16.

Results and Discussion
Twelve female professors participated, all linked to Nursing courses in the Northern Region of Brazil, aged between 27 and 55 years.Regarding academic qualification we found: one specialist, five with a master's degree, and six with a doctorate.The time spent teaching in higher education varied from two to 29 years.
The analysis of the data produced by the semi-structured interviews, allowed the following analytical categories to emerge: 1) Commitment of teaching and work with comprehensive care; 2) Improvement of teaching, research and extension from the perspective of interprofessional education; 3) Integrated action among health professionals; 4) Need for faculty development aligned to the principles of interprofessional education; and 5) Continuing education in health as a strategy to induce interprofessional teaching and practice.Next, we will discuss the thematic categories and present the selected narratives.
There are many challenges associated with the health care process.To approach such challenges involves the expansion of conceptions about health, education, and work processes, since they are complementary.For Carnut17, "care emerges as a central category in the practice of any health professional, thus requiring that all those who dedicate themselves to the area understand the constitutive elements of care" 17 (p. 1179).In order to make this care concrete and compatible with the demands looking for services, it is not enough just to have a physical structure and technical framework; on the contrary, it is essential to provide spaces and share interdisciplinary knowledge, as a way to contribute to the strengthening of the health care network and SUS management.

Category 1: Commitment of teaching and work with the comprehensiveness of care
This category highlights characteristics that sustain the training processes and health care practice.
In primary care, I see that it is a little more integrated, but even so, it has its difficulties.For example, I'm from the "PET interprofessionality" (Project for Education and Work), and we have been trying to work on this issue of comprehensiveness, but we have difficulties, because many times we don't know what the other does.(D4) This integration with other areas is fundamental, even to see the work flow and you can give an answer to the treatment or in a health campaign, in whatever you are developing.It is fundamental that we manage to work as a team and add our knowledge as a nurse with the knowledge of the doctor or the psychologist so that we can give an answer as a whole, especially collectively.(D14) In fact, comprehensiveness is a highly complex and challenging concept, especially in the context of the serious health, economic, and political crisis we are going through.The approach of the integrality principle in training and in the act of caring finds resonance in the critical and reflective essay by Carnut, who assumes that, "in a synergistic manner between training and care, comprehensiveness will reach higher levels in the concrete reality of health services" 17

(p. 1181). 6/17
The intertwining between teaching and work configures convergent paths, key for the transposition and re-signification of practices rooted in the uni-professional perspective and not guided by the real health needs of the user.
Category 2: Improvement of teaching, research, and extension from an IPE perspective The abovementioned category shows the concern to provide an innovative and meaningful teaching-learning process.The teachers' speeches indicated that, despite the difficulties inherent in the training process, it is necessary to develop a curriculum capable of anchoring the principles of IPE and that the activities gain a concrete body in the teaching-research-extension tripod.
So, we offer optional subjects to all students who want to join.And we try to bring their reality into the classroom.So, I know that I have students that will be doctors in my classroom, so, I try, within my class dynamics, to make them feel represented, even though I am a nurse.That they identify with my speech.In medicine it happens this way, in nursing it happens this way, and to exemplify even with scientific texts so that they feel represented, feel accepted, and realize this linearity.(D11) [...] the research projects, the teaching projects, they can involve other professionals.Even the teacher as a mediator, he can invite, he can take professionals from other areas to the classroom, to promote moments of exchange with the students.Bringing professionals from other areas.I think this would be very appropriate.We need to involve other professionals in our teaching, extension, and research projects (D12) Ferla and Ceccim 18 , critically reflecting on health education, emphasize that the propositional posture of the NCG to guide training represents an important increase in how current education policies induce training processes, enhancing innovation, creativity, and meaningful learning abilities.In the authors' point of view, "the current norms break away from the proposal of molding professional identities defined by disciplines and areas of knowledge and radically bet on the reciprocal interference between Education (teaching/research) and Health (care/management)" 18 (p.15).
In turn, analyzing the profile of competencies prepared for the graduates/ professionals, Leonello and Oliveira 19 warn that, in order to achieve a change in practices, it is not enough just to outline competencies; it is essential to evaluate the experiences, seeking to identify potentialities, weaknesses, and possibilities.
As part of this movement, we are faced with challenges that occupy the academic and service spaces, which require new learning and effective changes in the institutional reality (formative) and in the world of work (practical).
In this context, reflection opens perspectives, inspiring the development of collaborative competencies and teamwork.Thus, we have another important category, called integrated action among health professionals, reinforcing the need to produce changes in training.The largest challenge does not reside in bringing together different health professions (students and/or professionals); the intentionality lies in providing a teaching-learning process based on the development of collaborative skills, through the articulation and interlocution of objectives aligned to the proposal of IPE, as well as having diverse scenarios that favor learning experiences together, integrating theoretical and practical knowledge.
Several studies argue that the movement of teaching and learning needs to happen in parallel to the daily life of services, in an attempt to produce innovative and creative knowledge that effectively collaborates to overcome individual/ collective health needs 20 .

Category 4: The need for faculty development aligned to the principles of Interprofessional Education
Category 4 encompasses reports that illustrate a concrete demand related to teacher improvement, in order to mitigate actions from the perspective of IPE as a way to improve training, work and health outcomes.However, traditionally uni-professional curricular proposals blocks and hampers opportunities to explore formative approaches with emphasis on communication skills, interprofessional collaboration, and stimulation of recognition and interaction of the various health professions 3,21 .
[...] even in teaching... if we look at teaching, we realize that it teaches the student in a fragmented way, the disciplines don't interact with each other.(D6) Bringing this interprofessionality, the importance of this, this interprofessional education for the teacher himself ... e ... he starts to bring this to his experience, to the academy [...] I think this is a great challenge!Because I think that this [this formation] has to start here [university].So, when we find, for example, a professional at the top who doesn't know how to work with other professionals, it's because he wasn't trained for that.We are failing here in training!(D4) Research on interprofessional teaching and practice indicates that, as the IPE advances, there are greater possibilities of achieving better results related to the development of collaborative competencies, which in turn can positively impact teaching and the outcomes of health work 3 .
The effectiveness of teamwork, a characteristic considered essential to overcome fragmented and specialized practices, proves to be a fruitful way to share knowledge, skills, and decisions, in a perspective of comprehensive and collaborative health care, advancing the quality and resoluteness of the health care network 22,23 .
Resolution 569 of the National Health Council defines the guiding principles of the NCG for courses in this area, which "should stimulate the development of therapeutic projects based on an interprofessional and collaborative logic, recognizing service users as active protagonists and co-producers of health care, overcoming the perspective centered on procedures or professionals" 24 (p.4).Thus, there is evidence of the need for training of faculty and health workers who exercise preceptorship activities, to foster the training of future professionals anchored in the interprofessional perspective.
A reflective essay on nursing education in Brazil recognizes the progress produced by the NCG, but points out that the educational process in this area is still involved by dilemmas and challenges, which must be considered as a starting point for the structuring of innovative perspectives25.In this context, the process of teaching in health requires careful articulation and expansion of possibilities for the "construction of knowledge, relationships, interactions, skills that can be enhanced through dialogue, individual and collective experiences in the academic setting" 26 (p. 6).
In this same direction, there is a movement for the construction of new NCGs for undergraduate nursing, led by the Brazilian Association of Nursing (ABEn).This initiative had the participation of associate members, education specialists, teachers, students, managers, representatives of health services, and other interested parties.Twenty-five state forums were held, with the participation of approximately 1,250 people.The draft emerging from the ABEn analyses contemplates changes, proposing interdisciplinary training to achieve interprofessional work, and reinforces the integration of theory and practice, the use of student-centered methodologies, as well as the expansion of practice fields based on the epidemiological profile, the health needs of the population, and the principles of the SUS.Resolution No. 573, from January 2018, descriptively develops the recommendations of the National Health Council to the proposed National Curricular Guidelines for the undergraduate course in Nursing 27 .
There is an evident need for initiatives capable of producing transformations in education and work in health.To adopt interprofessionalism as an educational guiding principle is to glimpse possibilities of new arrangements, configured by means of alternating teamwork, networking, collaboration, and cooperation 28 .Now we are participating in the course of active methodologies [...] for us to renew... because the course is already 10 years old and it has always been the traditional way.I think it would be the same way if we were to work with interprofessional education... we would have to update ourselves [...] because we, as students, had no contact with this... so it is very difficult for us to visualize how this would happen in practice.So, the main point would be really, a training involving the teachers in the process.(D7) So... if in the training we don't have a work of integrating, of learning to talk to the other, in professional practice this will become much more difficult.(D2) These reports underline the challenges related to the teaching characteristics in most nursing courses in Brazil, which maintain a traditional, technical, highly specialized model, with emphasis on hospital-centric practice.To move forward in the face of these particularities, it is necessary to review models and reconstruct globalized, interdisciplinary and interprofessional processes.It is important to emphasize that the planning and insertion of interprofessional actions in the initial training are fundamental for the expansion of the scope of professional practice, with emphasis on integral care and care centered on the user, family, and communities 29 .
Another important issue, not to be excluded from the discussion, is the interaction between education and work processes.In this context, interprofessionalism emerges as a fundamental element for the reconduction and realignment of conceptions and practices capable of triggering dynamic changes in health education and service.It is a complex issue that requires deepening and concrete experience in different contexts, as a way to qualify and improve the realities of training and work in health 30 .
Understanding the articulation between the dimensions of education and work involves the construction of new meanings and shared knowledge linked to the principles of interprofessionalism. Incorporating these principles brings breakthroughs and discoveries of innovative paths, mediated by connections of interdependence, reciprocity, collaboration, and partnership.

Category 5: Continuing education in health as a strategy to induce interprofessional teaching and practice
In turn, category 5 appears as an alternative for remodeling fragmented formative processes with emphasis on the biomedical model.
[...] then ... if we don't start working here [university], we will continue to be 'kind of disjointed'.If we don't articulate here, we continue disarticulated in the service, we continue disarticulated here in the academy, we graduate nurses, just like the doctor and the social worker graduate, ... but, ... no one knows each other, no one integrates... we can't work in interprofessionalism to offer integral care!(D4) In teaching, it is a great challenge!it will depend a lot on the teacher to try to work with the student this view of interprofessionality to try to achieve integral care... but I think it is something that depends on each one of us, it is not something that has been worked on here in relation to teaching... it is not!so it is a challenge too! (D10) In this same sense, the dimensions of education and work in health allow us to think, among other aspects, about the careful systematization of horizontal experiences and the adoption of creative strategies that avoid the disarticulation of teaching-service, diversifying modes of interactions and work processes 31 .
The topic of IPE and its approximation with the assumptions of the National Policy of Continuing Education in Health (PNEPS in the Portuguese acronym) represents a powerful device for the reorientation of training processes and health work.The strengthening of Permanent Health Education (PHE) from the perspective of IPE can contribute to the improvement of service responses and action planning, providing quality and safety to health systems 32 .To this end, it is essential that the health and education systems work together, supporting the implementation of policies and proposals for IPE, stimulating the work among different professions in an equitable way and investing in professional qualification, in the interrelation between teaching, work, and health, through continuing education programs 2,33 .
The PNEPS, instituted in 2004, aims to promote the transformation of health practices in Brazil.This policy, known as education in health work, has two modalities linked to its proposal: continued education and permanent education.
The continuing education modality covers formative, accumulative activities, aimed at the systematic acquisition of technical-scientific information by the professional, by means of formal schooling.Meanwhile, continuing education is defined as "learning on the job, where learning and teaching are incorporated into the daily life of the organizations and into the work" 34 .
Therefore, the change in biomedical and fragmented thinking translates and signals new actions and perspectives intertwined and connected to the IPE movement as essential for overcoming decontextualized practices that are incompatible with the principles of the SUS.I think it would be extraordinary to have interprofessional education!we get out of our square!Even because we can't handle... no professional can deal with a health problem of the user, the family, and the community alone.(D4) [...] a weakness that I perceive is the issue of training, we need to have this vision, we need to work on this here [university] among us, so that we can work interprofessionally [...].(D9) SUS proposes specifically the principles of universality, comprehensiveness and equity, as a way to systematize a degree of interaction between the various fields of care production and knowledge nuclei necessary to face the demands and meet the current health needs 28,30 .Thus, it is understood that "breaking models is only possible through investments in education, qualification, and professional updating, important strategies for the transformation of reality" 33 (p.7).
In addition, the scenarios and their interfaces in teaching and in the service need to establish flexible and open interconnections to face concrete changes in the processes of re-reading and reorganization of the curriculum and health care.Otherwise, the management of the SUS health care network will continue to be "hijacked by conservatism in logics and traditionalism in initiatives, with the preservation of obsolete conditions of work organization" 35 (p. 13).
Based on the understanding of the meanings of the reflections and reports obtained in this study, an innovative proposal to meet the need for permanent teacher training from the perspective of IPE is the Virtual Community of Practice (VCoP).The VCoP is configured to promote the sharing of knowledge and practices, mobilizing and involving professionals from different professions and institutions36.In order to enhance interprofessional practice, VCoP is key to boost the creation of networks of people, intentionally engaged in the development of collaborative competencies.Thus, the mediation and contribution of digital technologies during the professional qualification/improvement process are essential for effective distance communication, especially in distant regions with scarce training opportunities 36 .
The cooperation and partnership for the implementation of a VCoP -IPE in the Northern Region of Brazil, under the realm of the Federal University of Amazonas (UFAM in the Portuguese acronym), is a possibility to expand its participation in the development of society, collaborating as a permanent training space for teachers and professionals linked to the health care network.
In order to structure the proposal of the VCoP-IPE, the possibilities of the educational pathway of these actors were organized from the gaps identified in the analysis of the interviews.The central topic proposed was entitled, 'Service-learning integration: theoretical-practical development from a IPE perspective'.The action plan was structured by modules, with three guiding axes: 1) Learning about others, with others and among themselves; 2) Teamwork and collaboration; and 3) Person-centered health care.

Final considerations
The analysis of the educational process of teachers working in nursing courses in the Northern Region of Brazil, looking at the preparation to train future professionals from the perspective of IPE, was the driving force to think of strategies to allow minimizing existing gaps and bringing together teachers and health workers in the region, characterized by the scarcity of educational opportunities and the wide and disperse geographical dimension.
The movement around IPE drives the creation and dissemination of effective practices oriented in shared learning, teamwork, communication, and interaction.Improving the capacity of human resources in health proposes new itineraries and realignments that favor processes that converge toward the articulation between By proposing the VCoP-IPE, it is expected to stimulate and expand the participation of educational institutions and services as a way to strengthen the theme of the IPE in the Northern Region of the country, as well as open permanent spaces for dialogue and reflection among teachers and professionals, regarding the challenges and possibilities of health care anchored in the theoretical, conceptual and methodological assumptions of the IPE, with expectations of changes that positively impact the training and work in health.
It highlights the importance of assuming the process of faculty development and continuing education in health as an institutional, systemized, continuous and sustainable action.
Regarding the limitations of the study, the investigation included only the faculty's perception of an undergraduate health course, not allowing a current comparative analysis with other areas of Health.For the development of future research, there is a remaining challenge: to identify innovative initiatives in undergraduate courses in Health, as well as to seek evidence on the impact of IPE in academic spaces, services and health care networks.Resumo O objetivo do estudo foi analisar os desafios da formação desenvolvida pelos docentes atuantes em cursos de Enfermagem da região norte do Brasil, na perspectiva da Educação Interprofissional.Trata-se de uma pesquisa descritiva, exploratória e qualitativa realizada em universidades públicas.Doze docentes participaram de entrevista semiestruturada.Utilizou-se a análise de conteúdo e cinco categorias foram selecionadas: 1) Compromisso do ensino e do trabalho com a integralidade do cuidado; 2) Aprimoramento do ensino, pesquisa e extensão na perspectiva da educação interprofissional; 3) Atuação integrada entre os profissionais da Saúde; 4) Necessidade de desenvolvimento docente alinhado aos princípios da educação interprofissional; e 5) Educação Permanente em Saúde como estratégia indutora do ensino e prática interprofissional.A Educação Interprofissional é um campo robusto e complexo.Logo, é fundamental uma prática docente capaz de empreender processos formativos inovadores, induzindo mudanças que impactem positivamente a formação e o trabalho em saúde.
interprofessionalism, enabling shared, collective, and significant learning.Therefore, what are the needs perceived by teachers of nursing courses in the Northern Region of Brazil?How to implement teacher training based on the theoretical and methodological framework of interprofessional education?This article aims to analyze the challenges of training developed by teachers working in nursing courses in the Northern Region of Brazil, from the perspective of interprofessional education.

Category 3 :
Integrated actions among healthcare professionalsThis category proposes new meanings, based on the principle that the reorientation of training and work in health seems to constitute powerful spaces for the comprehensiveness of professional health practices as seen below in the interviewees' statements: I think it would be great for the student!Because since university, they would have contact with other professionals [...].They would have contact with other educations, this would make it easier for them to open horizons for what they find even in practice.To have this contact, to know how others work.(D7) I like to mention CAPS (Psychosocial Centers), because in CAPS you have a work team made up of several professional categories, but when the user arrives and if it is the turn of professional X to attend, he will receive him, until he makes specific referrals, where each professional works on his specific competence [...].(D14)