Nursing training from the perspective of graduates

Objective: To correlate the satisfaction of graduates with their training according to their professional characteristics and general competences. Method: Descriptive cross-sectional study with a sample of 192 Nursing graduates from a private higher education institution in the city of São Paulo. Data were collected between 2016 and 2017. Results: Graduates placed in the job market within one year (p=0.01) had nursing as their main source of income (p=0.011) and occupation (p=0.014); those who considered themselves professionally successful and those who would choose the profession again (p=<0.001), if they could choose, were more satisfied with their training. Satisfaction with training was linked to the competences acquired during graduates’ training, such as decision making (p=0.002), leadership (p=0.004) and continuing education (p=0.005). Conclusion: The study shows that most graduates consider their training satisfactory when analyzed with the study variables. Descriptors : Education, Nursing; Students, Nursing; Job Market; Teaching; Professional Competence.


INTRODUCTION
The Political Pedagogical Projects (PPP) of undergraduate Nursing courses defines the graduate's profile description based on the National Curriculum Guidelines (NCDs) established by the National Education Council.The instructions on the graduate's profile indicate the skills and competencies based on healthcare, decision making, communication, leadership, administration, management, and continuing education (1) .
This graduate profile is also analyzed by the National Higher Education Evaluation System, a proposal developed as an advance for higher education. One of its objectives is to control the quality of what is done in universities under three aspects: institution, courses and students (2) .
The organizational structure of the National Higher Education Evaluation System has ten dimensions for internal and external evaluation of Higher Education Institutions (HEIs), and Dimension 1 stands out among them. It evaluates the Didactic-Pedagogical Organization of HEIs, and one of its indicators is the evaluation the graduates' profile, valuing the competences and planned and implemented curricular contents that provide the development of the upcoming professional (2) . Some studies (3)(4)(5)(6) corroborate this dimension with emphasis on: systematic monitoring of graduates by describing their opinions, attitudes and beliefs about the university and society; identification and assessment of the value added by the HEI, the strengths and weaknesses of the formation of new nurses regarding the demands of the health system; assessment of the opinion of employers and sectors of organized civil society about the adequacy and relevance of the professional and citizen formation of the graduates.
These informations allow the comprehension and reflection on issues related to Nursing higher education and permit the implementation of curricular changes and teaching strategies that bring the training of these professionals closer to the needs of the society and of the job market, such as the most considered areas of expertise, the greatest employment sector and if the actual occupation of these professionals is in their area of training (5)(6)(7) .
In a study (8) involving graduates, teachers and employers, an action plan was prepared collectively containing proposals for changes considered essential, such as curriculum flexibility, content resizing, continuing education, insertion of active methodologies and appreciation of students' practice and autonomy by providing concrete elements for curriculum improvement of the nursing course studied.
A study (9) of nursing graduates of a private HEI allowed the review of the PPPs, with emphasis on the need for teaching focused on the development of competences, that include the practice of nurses in management, care, education and research, that are the dimensions of the care process In nursing courses, the evaluation indicator for the graduate's profile is still little explored by the educational management of HEIs. The analysis of graduates' perception about the contribution of their course is fundamental, as it promotes a dialogue between training and praxis. This approximation between educational strategies and the reality where one intends to act can support the reflection on changes to acquire the competences, skills and attitudes expected of the future nurse (10) .
Other evaluative aspect to be explored is the graduates' satisfaction, that is considered a quality indicator of the teachinglearning process and service provision (11) , enables their reflection and the insertion in practice of what they best acquired during their construction of knowledge (4) .

OBJECTIVE
To correlate the satisfaction of graduates with their training, according to their professional characteristics and general competences.

Ethical aspects
The research was guided by the determinations of Resolution No. 466/2012 of the National Health Council (12) . The Informed Consent Form was signed by the participants and the study was approved by the reference Research Ethics Committee.

Design, study location and period
This is a descriptive, cross-sectional, quantitative study in which the STROBE tool was adopted. The scenario included a Higher Education Institution in the city of São Paulo with focus on health courses. Data collection occurred electronically between November 2016 and January 2017.

Population, sample and inclusion and exclusion criteria
The study population consisted of 200 Nursing graduates of the HEI who concluded the course between years 2012 and 2016. They represented around 10% of the total graduates in the period, during the term of the PPP related to the four-year period matrixes.
Some steps were taken in the search of the study population: requesting a list of graduates from the last five years in the undergraduate dean's office; search for e-mails and telephone numbers of graduates in files of the coordination of the Nursing course of the HEI studied and checking social media websites and nursing communities.
Of the 200 graduates in the indicated period, 197 (98.5%) responded to the data collection instrument. Of these, 192 (96%) answered all questions and were part of the study sample.

Study protocol
Data collection was performed through an adapted questionnaire authorized by the main researcher of the study that was applied to graduates (4) . The referred instrument (without a validation process) is structured in five parts, namely: the first with seven items of characterization of graduates; the second with 12 items referring to the job market, such as time of insertion, employment contract, workload; the third with an item on the competences acquired during training, described in Resolution CNE/CES 3/2001 of the National Education Council (1) ; the fourth part with five items on the training process and satisfaction with the course completed; and the fifth and last part with three items 8 of Nursing training from the perspective of graduates Guareschi APDF, Freitas MAO, Nunes MI.
on professional improvement. The questions regarding graduates' satisfaction with the salary and training are included in the second and fifth part of the instrument in the form of Likert scales (13) . In this study, the sub-items referring to the regional description of the nursing course and the minimum wage value that appear, respectively, in the first and second part of the instrument, were adapted. The item on competences acquired during graduates' training was also added.
The instrument was inserted in the LimeSurvey 1.9 (14) software and encoded for the confidentiality of participant's identity. Messages by e-mail and social network were sent to graduates with the invitation to participate in the study and a link to the LimeSurvey 1.9 software for access to the IC and the instrument.

Analysis of results and statistics
The data were analyzed using the statistical software R 3.4.2 (15) . For hypothesis tests, a significance level of 5% was considered. The tables built to answer the questions were described using absolute and relative frequencies. The measure of satisfaction was considered continuously (1-Very unsatisfactory to 5-Very satisfactory) and values of mean and standard deviation for each category were presented. Comparisons of mean values between groups were tested using Kruskal-Wallis and Mann-Whitney non-parametric tests (16) .
After analysis of data generated from each item in the questionnaire, variables were crossed as follows: satisfaction with nursing training with the professional characteristics of graduates; and satisfaction with nursing training with the acquisition of general National Curriculum Guidelines competences in order to broaden the understanding of the scope of this study.

RESULTS
Most graduates participating in this research were between 20 and 30 years old (76.6%), single (63.5%), had no children (79.2%), attended high school in a public institution (62%), had a postgraduate degree/specialization (72.1%) or residency (8.4%). Most were employed (76.6%), had no difficulty entering the job market in the first 12 months after completing the course (77.6%), with a significant amount entering the market in the first six months (54.7%).
Graduates indicated the income of up to five minimum wages (46.3%), up to 40 working hours per week (51.5%), and there was a significant number of graduates with total work hours over 40 hours per week.
Most graduates worked in private services (81.1%), were dissatisfied with their salary (42.2%), and indicated that nursing work was their main income and occupation (91.8% and 98.1% respectively).
The percentage of nurses performing care duties was quite high (89.2%) and 60.4% considered themselves successful in the profession. Although 83.4% of graduates considered the profession stressful, 63% indicated they would choose Nursing, were they given the opportunity to choose the profession again.
From data collected, it was possible to analyze the predominance of factors combined to the satisfaction of the graduate with their professional training, profession, income and employment related to the job market in nursing.
In Table 1, differences in the distribution scales of the variable of interest satisfaction with training were identified, with p-values below 5% (0.05). Graduates placed in the job market in up to one year, in general, were more satisfied with their training (p=0.01). The result is also reflected in the issue of difficulty in entering the job market. Graduates who indicated this difficulty had a mean satisfaction of 3.79 points, against 4.43 of those who did not (p=< 0.001). Satisfaction with training was also evaluated in relation to the formal work situation (p=0.001), that is, even unemployed graduates who worked in other areas, considered their training satisfactory.
Significance (p=0.047) was found between the correlation of graduates' salary and satisfaction with training. Graduates who earned up to nine minimum wages or more were more satisfied with their training, had nursing as their main source of income (p=0.011) and occupation (p=0.014) and were also more satisfied with their training. Graduates who considered themselves professionally successful and those that would choose the profession again, if they had the chance, were the most satisfied with their training (p=<0.001). Table 2 shows satisfaction with training linked to the general competences described in the National Curriculum Guidelines and acquired during graduates' training, such as: decision making (p=0.002), leadership (p=0.004) and continuing education (p=0.005). Graduates who had these competences were more satisfied with their training, but even those who declared not having acquired them, considered themselves satisfied or very satisfied with their training.

DISCUSSION
Most of the surveyed graduates indicated early insertion in the job market, acting as nurses. This information is in line with   the study conducted at a private HEI (17) , in which 93.3% of graduates were employed until the third month after graduation, and a study (18) in which 48% of graduates started their activities in up to six months after graduation, and most (67%) got their first job within a year after graduation. Thus, the conclusion that despite the recent economic crisis in Brazil, with a high unemployment rate and the limitations encountered by graduates in seeking entry into the job market (8) , the surveyed graduates managed to maintain employability. Despite the economic and financial difficulties, nurses have been gaining respect and credibility and revealing nursing as a promising profession with guarantee of prestige and social success (19) . With regard to salary, a study conducted in Ceará (20) , indicated that most graduates working in the public service earn three to four minimum wages and 44.4% work more than 40 hours a week. In this study, the majority indicated having a workload between 30 and 40 hours a week.
The satisfaction with the professional training of the graduates of this research is linked to their social status and income, that can be obtained through employment, career and salary During the phase of knowledge acquisition, in nursing education, when the student can have identification with the profession, there is a structuring of the learning process, joined by an adequate degree of satisfaction by the graduate (4) . It was evidenced the probability that the graduates satisfied with their education, also showed satisfaction with their income and, therefore, considered themselves to be successful professionals.
Regarding satisfaction with nursing training, considering the general competences described in the National Curriculum Guidelines and in the identification of graduates' profile described in the Pedagogical Political Project of the studied institution, this study showed competences, skills and attitudes related to the following: coordination of nursing care planning; motivation and technical-scientific updating of your team; conducting clinical reasoning and assessing the performance of nursing in different settings, with a scientific basis for their interventions, enabling autonomy in decision-making in care; attention to social health needs based on the National Health Service (Brazilian SUS), on the population's epidemiological profile and professional legislation, ensuring comprehensive and humanized care; management through the planning, organization, direction and evaluation of nursing care and services.
In a study conducted at a public HEI of Minas Gerais (18) , the competences recommended for a comprehensive training of professional nurses were listed, with emphasis on those described in the National Curriculum Guidelines and principles of the Brazilian SUS, especially the performance in comprehensive care programs; about ethical, technical and scientific issues for nursing practice; planning and production of scientific knowledge; health education; teamwork and conflict management; social role in political and health planning activities; coordination of nursing team activities and health management.
The aforementioned competences are evidenced in the results of this study and consistent with it (18) , since the graduates expressed their preparation to act as social agents in political, health planning and Nursing activities. In a survey conducted in the FAMEMA Nursing course (9) , the graduates signaled that changes made in the institution contributed significantly to the practice of humanized and scientifically based care, giving them the professional competence required in the job world, of greater autonomy.
A study conducted with nursing graduates from a public HEI (21) demonstrated that the exercise of autonomy must be fostered in nurses' training in order to mobilize their ability to adapt and create, to decide the best care to be provided, as well as the social approval of their performance, since the competence to make assertive and cost-effective decisions, based on scientific evidence, which allows for the evaluation, systematization and decision on the conduct related to human and technological resources and qualified assistance are other aspects that underlie the performance of health professionals (1) .
These data on autonomy and decision making corroborate what was evidenced in this study about graduates' satisfaction with their training linked to the acquisition of decision making and leadership skills.
In a study (22) conducted with recent graduates of the nursing course, leadership was identified as a challenge for nurses.The authors aimed at discussing the expected profile of the leader, but due to the changes observed in the world of work, these characteristics now show instability and dynamism.
In a study (23) investigating the view of teachers on the training of nurse leaders, the following personal characteristics of the leader were indicated: responsibility, commitment, motivation and good mood. It is important that leadership strategies are identified in the current context of nursing, and it is the professors' role to facilitate the development of this professional competence with appreciation for the transversal teaching of leadership (24) .
Regarding competences of continuing education and decision making, the professional qualification of graduates who decided to invest in their training was identified as a differential for professional nurses. In this study, most participants sought improvement in specializations (72.1%), residency (8.4%) and master's (1.6%). Corroborating these results, a study conducted with graduates from the School of Nursing at the University of São Paulo identified that 63.7% had attended specialization and/or residency (25) .
In this study, the analysis of graduates' satisfaction with nursing training linked to the competence of continuing education was characterized by participation in scientific events or improvement courses. Most graduates underwent continuing education that although in undesired amount (51.9%), did not negatively impact on the satisfaction with their training.
In this study, satisfaction with nursing training linked to continuing education was identified through graduates' participation in scientific events or improvement courses. Most graduates who attended continuing education, although not to the extent they would like (51.9%), were satisfied with their training, though without statistical significance.
The reasons that made participation in scientific activities difficult were the high cost of scientific events (p=0.014), books and journals (p=0.046), although they had no negative impact on the satisfaction with training. These data indicate that even though graduates have difficulty in attending continuing education, this did not interfere with their concept of satisfaction and great satisfaction with their training. Continuing education must be considered in the training of future nurses. It provides opportunities within teaching-service interaction and enables the adaptation of teaching to the real conditions in the job world. The investment and commitment of the two sectors, teaching and service, provide the effectiveness of continuing education by establishing intersubjective interactions in which the actors involved consider human beings in their entirety (23,26) .
Professionals, aware of their responsibility as nurses, must recognize the importance of building and improving their knowledge and from that, consider permanent education in the daily context of professional performance and assume an attitude of criticality and reflection in the face of their learning (27)(28) . A study (15) also carried out with graduates, showed that the majority recognizes that they were instrumentalized in the planning, implementation and participation of continuing education actions in the service.
A study (9) on the insertion of nurses in the job market showed that the competences described in the graduate's profile and acquired during the undergraduate course, prepared them for professional practice in part, and did not guarantee enough experiences within health sectors and understanding on the different functions taken over by nurses in the health field. This lack of full development of the competences of future nurses is in line with the analysis performed in the study (29) regarding the influence of teachers' training on the profile and competences of nursing graduates. The teaching-learning process of future nurses needs to be constantly reframed by teachers and HEIs in order to achieve the profile of competences established by the National Curriculum Guidelines.
In order to collaborate with studies that may be conducted with graduates, an instrument has been developed and is already validated for the evaluation of graduates from nursing courses (30) . As it was based on curricular guidelines, it can be used throughout the country and contribute to the process of regulating the quality of undergraduate nursing courses.
The professional nurse has several skills that are expected and those that are effectively performed in the day-to-day work, which lead to questioning what are the exact skills of this professional,their adaptation and performance in work settings, and the responsibility of education in the integration of theoretical and practical teachings at an earlier stage in the search for training professionals who can act and transform their practice (31)(32)(33) .

Study limitation
The conduction of this study was limited to a private educational institution and there was no qualitative analysis to identify the senses and meanings of the development of skills, as well as the profissional's entry into the job market.

Contributions to the nursing field
Studies with graduates are of great value for training institutions, especially as they reveal a "picture" of students' training.
This study directly contributed to the understanding of nurses' training process, the acquisition of competences proposed for these professionals, and the discussion about their insertion in the job market. It also enabled, from the National Curriculum Guidelines, a reflection on the PPPs guiding undergraduate nursing courses.

CONCLUSION
Most graduates rated their training as satisfactory when analyzed with the study variables. We highlight the satisfaction with nursing training with the variables: interval between completion of the course and insertion in the job market, formal work situation, difficulty in finding a job in nursing, salary, nursing as the main source of income and occupation, considering oneself professionally successful and would choose that profession again.
With regard to competences described in the National Curriculum Guidelines, nursing graduates were more satisfied with their training in the acquisition of decision making, leadership and continuing education skills.
The satisfaction with graduates' training related to continuing education was significant in the reasons that hinder participation in scientific activities, such as the high cost of scientific events, books and journals. However, this did not exert impact on graduates' satisfaction with the training received.

Nursing training from the perspective of graduates
Guareschi APDF, Freitas MAO, Nunes MI.