STRUCTURING OF A PROPOSAL FOR THE NURSING PROCESS THEORETICAL AND METHODOLOGICAL BASIS: PROFESSORS’ MOTIVATIONSABSTRACT
Objective: to describe the motivations that mobilize professors-nurses in the construction of a proposal for the theoretical and methodological basis for the Nursing Process teaching.
Method: a Convergent Assistential research, conducted with professors-nurses. Six convergence groups were developed, with triggering questions on the theme. The reports were audio-recorded, validated by the participants and analyzed in the light of the Convergent Assistance Research.
Results: there are three thematic approaches: professors' perception of the nurses' professional practices; dissatisfaction with the current health model; and dissatisfaction with the current teaching model. The thematic approaches reveal the motivation to overcome biomedical/cartesian practices in teaching and nursing care, which converges to the development of a proposal with a philosophical, theoretical and methodological framework for the Nursing Process teaching, aligned with the assumptions of the Unified Health System and consistent with health expanded clinic.
Conclusion: this study allowed for the expression of concerns and discomforts with the current model of education and health, triggering reflections on the paradigm that guides the field of health teaching and dominates our life in society. The results reveal what is desired in the health scenario, as educating individuals and society, enhancing the perspective of social changes in the health sector, acclaimed and desired politically and socially, basing the development of philosophical, theoretical and methodological proposals for nursing care, consistent with society's current demands.
DESCRIPTORS: Nursing; Nursing process; Framework; Health policy; Nursing education
RESUMEN
Objetivo: describir las motivaciones que impulsan a los enfermeros profesores a elaborar una propuesta para definir las bases teórica y metodológica para la enseñanza del Proceso de Enfermería.
Método: investigación Convergente Asistencial, realizada con profesores enfermeros. Se desarrollaron seis grupos de convergencia con preguntas desencadenantes sobre la temática. Los relatos se grabaron en audio, fueron validados por los participantes y analizados bajo la óptica de la Investigación Convergente Asistencial.
Resultados: surgen tres enfoques temáticos: prácticas profesionales de los enfermeros en la percepción de los profesores; la insatisfacción con el modelo de salud vigente; y la insatisfacción con el modelo de enseñanza vigente. Los enfoques temáticos revelan la motivación para superar prácticas biomédicas/cartesianas en la enseñanza y en la atención de enfermería, lo que converge para desarrollar una propuesta de referencial filosófico, teórico y metodológico para la enseñanza del Proceso de Enfermería, alineado con las presunciones del Sistema Único de Salud y en coincidencia con una clínica ampliada en salud.
Conclusión: este estudio permitió expresar inquietudes y malestares con el modelo vigente de enseñanza y de salud, iniciando reflexiones sobre el paradigma que orienta al campo de la enseñanza en salud y rige nuestra vida en sociedad. Los resultados revelan lo que se desea en el ámbito de la salud, como individuos formadores y sociedad, potenciando la perspectiva de cambios sociales en el sector de la salud, aclamados y deseados tanto política como socialmente, y sirviendo como base para desarrollar propuestas filosóficas, teóricas y metodológicas para el cuidado de enfermería, en coincidencia con las demandas actuales de la sociedad.
DESCRIPTORES: Enfermería; Proceso de enfermería; Referencial; Política de salud; Educación en enfermería
RESUMO
Objetivo: descrever as motivações que mobilizam enfermeiros professores na construção de uma proposta para o embasamento teórico e metodológico para o ensino do Processo de Enfermagem.
Método: pesquisa Convergente Assistencial, com professores enfermeiros. Desenvolveram-se seis grupos de convergência com questões deflagradoras sobre a temática. Os relatos foram audiogravados, validados pelos participantes e analisados à luz da Pesquisa Convergente Assistencial.
Resultados: surgem três enfoques temáticos: práticas profissionais dos enfermeiros na percepção dos professores; a insatisfação com o modelo de saúde vigente; e a insatisfação com o modelo de ensino vigente. Os enfoques temáticos revelam a motivação para superar práticas biomédicas/cartesianas no ensino e na assistência de enfermagem, o que converge para o desenvolvimento de uma proposta de referencial filosófico, teórico e metodológico para o ensino do Processo de Enfermagem, alinhado com os pressupostos do Sistema Único de Saúde e condizente com uma clínica ampliada em saúde.
Conclusão: este estudo permitiu a expressão de inquietações e desconfortos com o modelo vigente de ensino e de saúde, disparando reflexões sobre o paradigma que orienta o campo do ensino na saúde e domina a nossa vida em sociedade. Os resultados revelam o que se almeja no cenário da saúde, como indivíduos formadores e sociedade, potencializando a perspectiva de mudanças sociais no setor da saúde, aclamadas e desejadas política e socialmente, alicerçando o desenvolvimento de propostas filosóficas, teóricas e metodológicas para o cuidado em enfermagem, condizentes com as demandas atuais da sociedade.
DESCRITORES: Enfermagem; Processo de enfermagem; Referencial; Política de saúde; Educação em enfermagem
INTRODUCTION
The nursing practice is based on scientific references, through which philosophical, theoretical and methodological conceptions are revealed that guide and subsidize these practices. For the nursing training process, it is essential that these concepts are aligned, as well as revealed, in the professors' and students' attitudes, in correspondence with the current health model.1-2
Because of their properties, nursing theories articulate concepts and models for practice that contribute scientifically to professional actions, endorsing the relevance of basing daily care on theories that have applicability, serve the population, and provide care.1
Brazil advances in the organization of health practices, seeking to understand the meanings imbricated in the current care model, with their respective terminologies, considering what is proposed in the principles and guidelines of the Unified Health System (Sistema Único de Saúde, SUS).3 It is important to clarify that the philosophical and theoretical conceptions implicit in the SUS proposal converge with the Historical-Dialectic Materialist world view, which emits a new look at health care, transcending the positivist heritage and thus inaugurating a paradigmatic modernization in Brazilian health. In this sense, it is recently recalled that the elaboration of health policies in Brazil, as well as the strategic organization for its development, took place amid Marxist thought.4
In this transformation context in the health field, the university assumes a preponderant role as a privileged space for theoretical and philosophical deepening about the foundations of health praxis, serving as a framework for what the national guidelines for health courses register, contributing to leveraging the Brazilian health system. The National Curriculum Guidelines (Diretrizes Curriculares Nacionais, DCNs) of the health courses have been aligned with the contemporary changes of the health care model, subsidizing public policies peculiar to training, recognizing the health training issue as an essential theme for the Ministry of Health (Ministério da Saúde, MS).5 Given this reality, it is proposed to health professionals the challenge for reflection and development of theoretical models of health care, envisioning the political scenario and the MS and the Ministry of Education (ME) prerogatives.
In terms of the theoretical deepening in nursing training, the nursing care philosophical, theoretical and methodological basis refers us to the Nursing Process (Processo de Enfermagem, PE) structure, recognized as a priority tool for the nurse's care/work process. We argue that the PE, understood as a scientific method for the nursing care development, structures the scientific scope of the profession, unifies the language, promotes autonomy and qualifies the care provided to users and, in this sense, should be developed, consolidated and valued.6 However, the PE is in line with the positivist paradigm, in which the health biomedical is inscribed, which ultimately promoted the fragmentation of knowledge through specializations, providing, on the one hand, significant improvements in health sciences and, on the other hand, an inability to observe the human being in its entirety.7
This secular paradigmatic foundation, recognized for its merit in the structuring of science and disciplinary components, is still today translated into the alienating fragmented curriculum, the training in content health and the hierarchical/verticalized relationships that reduce the user to the study object and intervention, to be managed in its anatomical parts, from a scientific knowledge - sovereign to popular knowledge, as well as it resists the contemporary initiatives of health care humanization and curriculum integration. Faced with the reductionist and technical limitations inherent to the health professions, the commitment is clear of researchers mobilized for a reorientation of the nursing care/orthodox-pedagogical model towards a circular, complex, clinical expanded model and centered on the person, based on integrality and human dignity, generator of autonomy and horizontality in relationships, and may it be permanently questionable in nursing schools, in the light of progressive pedagogical references.2,8
Under this reflective perspective, a teaching-learning model is projected, supported philosophically, that integrates knowledge and doings, attending with justice to the population's real socio-political, psychological, biological, cultural and spiritual demands. It is a model that resists the institutional rules and regulations of the health area, focusing on the essence of a profession regulated by the subjectivity of being and human dignity, in which nursing can institute the exercise of citizenship for the health services professional and users.9-10
Given the presented scenario, this study starts from the current empirical reality of restructuring the Nursing Course Pedagogical Project (Projeto Pedagógico de Curso, PPC) in a Brazilian federal university. It is a proposal motivated by the disquieting discomfort of the professors regarding the static and technical curriculum format, as well as concerning the quality of work that is currently presented in health and nursing, perceived as out of step with the demands of society, good international practices, and the nursing humanist ideology. This process of collective concern and self-questioning in relation to the quality of training, now developed, triggered an ethical movement of the group, perceived as healthy, supported by the stages of this research, to develop a proposal for structuring a theoretical philosophical methodological framework that supports the practice of PE teaching.
In this sense, the philosophical theoretical framework put forward by the group to support PE teaching, the Historical and Dialectical Materialism (Materialismo Histórico e Dialético, MHD), aims to offer theoretical elements that support professors, students and nursing professionals in the process of reorienting their practices, from a biomedical model, centered on disease, to an expanded clinical model, centered on the person.11 As a consequence, and considering the academy's responsibility on the nursing social status, the challenge that this study imposes on contemporary nursing training is the following: What is it that mobilizes the professors-nurses of an undergraduate nursing course to structure a proposal for a philosophical, theoretical and methodological framework for the practice of Nursing Process teaching? The objective of this study was to know the motivations that mobilize professors-nurses in the structuring of a proposal for the philosophical, theoretical and methodological framework for the practice of Nursing Process teaching.
METHOD
A study with a qualitative approach, of the Convergent Assistance Research (Pesquisa Convergente Assistencial, PCA) type, which seeks to elucidate the complementary relationships between theory and practice, producing knowledge aimed at resolving conflicts or problems in everyday practice. The research scenario was the Undergraduate Nursing Course in a university located in the South Region of Brazil, where the researcher is immersed as a professor and where the object of study was presented, which is relevant in the PCA.12
The study participants were professor nurses mobilized, in a collegiate setting, to reflect and restructure the theoretical and methodological references for the PE teaching, in front of the demand for the reformulation of the Course Pedagogical Project (PPC). From the universe of 25 nurse professors, all invited to the research, 17 accepted. They were tenured and came from different regions of Brazil, with a predominance of the South Region, in the age group between 27 and 55 years old, postgraduates, 11 being doctors, three in their doctorate studies and three masters.
Duly informed about the research, the participants signed the Free and Informed Consent Form (FICF). Data collection occurred in six meetings at the university, in convergence groups, as it is an option used especially in the nursing area, with the purpose of implementing participatory care practice projects, aiming at the development of knowledge on emerging themes in the group.13 The reports generated by the group were audio-recorded, transcribed and validated by the participants.
For the operationalization of the meetings under the PCA's assumptions of dialog, expansibility, immersion, and simultaneity,12 firstly, the researcher instigated the nurse professors to think about the nursing praxis and share their desires with the group. Consequently, the following questions arose: In everyday work, are professionals mobilized to the desire to transform the praxis? What is the reason of being of the professional professor-nurse? Is there any concern about the nursing care results found in everyday life? These provocations caused the professors' concerns to erupt, triggering dialog on philosophical, theoretical and methodological references of the nursing care, leading to expansibility, when the professors then broadened the debate on the theme, triggering emerging themes of interest regarding the model established in the course for the practice of care and PE teaching, which happened in the second and third meetings.
In the meetings, there was immersion and simultaneity, when the researcher sought to assist the professors in achieving the necessary deepening to recognize their motivations for structuring a proposal of philosophical, theoretical and methodological basis for the PE. From an analytical point of view, the PCA can be divided into apprehension and interpretation processes, containing three stages: synthesis, theorization, and transfer.12 At the end of the analysis, the elaboration of meanings and discoveries is configured, which leads to the re-signification that the new conceptions provide to the professional and the work process qualification developed in the scope of the PCA action.14-15
To protect the integrity and anonymity of the participants, in the results presentation they are identified by letters from the alphabet, from A to Q.
RESULTS
The results are organized into three thematic focuses, namely: professors' perception of professional practices; dissatisfaction with the current health model; and dissatisfaction with the current teaching model.
Perception of the professors on professional practices
The reflection on the own world view is implicit in the participants' speeches and reveals their opposition and frustration with the practice of nursing professionals, perceived as a biomedical model dimension, as well as the impact of this model on the university graduates' doing when they enter the health services. Admitting the nursing orthodox model at the egress seems to cause suffering, referring the participants, as agents in the training of these nurses, to their share of responsibility for the reproduction of technicality and reductionism. The awareness that it is necessary to transform reality is a focus for reflection.
The nurse receives the user in the emergency room, performs the Manchester and, after that, the nursing technicians take care of the patients. I reflected, another day […] the sadness of seeing Nursing this way, [...] what we have been doing when we become professional, they pass, they pass (A).
They reproduce the current practice, they do not think of adding values, and reflecting on the work issue, we perceive that this professional sees the work aiming to receive their salary at the end of the month, but not as a service in the sense of adding value (A).
Using Marx's referential, they start playing the oppressor's game (B).
So these things affect us. Oh my God, where do we have to change? What must we do? Or I do not now, you know. It seems to me that something has to be done to change this thing that is on. Not that that is a rule, but we experience this reality a lot (A).
[...] I'll just take care, or, I'll just do something, from what I am. What kind of human being am I in all my actions? They will reflect on my work. And this happens here, therefore, we need to improve ourselves as human beings, to work on our self, and this will automatically reflect on our daily basis. Or it is bullshit, and there is going to be no change (C).
Listening to these questions, the first question that comes to mind is: Are we willing to problematize our work process? Because it gets incoherent for us to want to make others work in a dialectical perspective etc if we do not do our own process. I think the “boom” of using a historical and dialectical framework is that it puts you in a position where you also need to be a participant in that process. So, if we do not succeed, if we do not want to problematize our working process as professors, we will hardly succeed on the other side (F).
Dissatisfaction with the current health system
The reality of the health practices in the services and dissatisfaction with them is expressed by the professors as a motivation to rethink training, analyzing the quality of health services, both public and private.
And then you see, for example [...] a private hospital administration, where you have the methodology of production at the expense of continuing education. So, you don’t agree, you don’t want to do what is established in the service, you are fired! (L).
Faced with this scenario, problematized in-hospital care, there is hope that in primary care there will be a different reality, with regard to the work process, since the relationship between nursing and user happens in the habitat, where the bond is a work tool to assist the population in the daily development of more satisfactory health standards, where it is spoken about quality of life and autonomy. However, when observing the whole of the services' provision in primary care, we see the technical and alienating reproduction of the traditional model, causing again discomfort in the participants, as follows in the reports.
When you think about feeling well about health work, perhaps in Primary Care, people have more satisfaction than in-hospital care, precisely because the work does not have the same logic. There, it is a moment and the rest will be in the territory, and in this, the territory, you can follow up (I).
But then they rang between hemodialysis and the hospital. That is what I say, the health unit in their neighborhood, we can say, has totally lost contact [...] if they are referred [...] it is understood that it is no longer the health unit’s responsibility. Care, let's say, of high complexity, on the other hand also sees like this [...] when referred to other services, monitoring is discontinued [...] (P).
And then the basic unit has no bonds with them (A).
Dissatisfaction with the current model makes us reflect on the theoretical and methodological bases that subsidize health practices.
The expanded concept of health is derived from the insertion of Marxist conceptions in the health field in Brazil (B).
When we discuss this [the current health model and its philosophical theoretical construction, in this case], I get anguished, because we want to see all this [the dialectical historical framework, in this case] materializing there in practice, in care, the integrality, improving the life of that person (M).
Dissatisfaction with the current teaching model
The conventional and oppressive Cartesian posture of the professors was questioned and triggered critics, according to the reports.
I say, if we do not change, we will stop here!!! We want to have good conditions, but do we want to provide good conditions in training? If as health educators we maintain an oppressive stance, ah, certainly!! [...] And entering Paulo Freire's line, that is, as soon as they have the opportunity to oppress, they will. Look at this, think! When the professor speaks in the test [...] “Get ready!” What am I producing? A threat, an intimidation, that is serious! We do this so naturally. Well, if we do not improve our relationships between peers and between students and professors, leaders, etc., we cannot transform, because if we do not have this harmony between us, there is no point in wanting to go there and take action, differentiated care, because that reflects! So I keep saying! Do we want to change? If we want to, cool, but if we do not want to, we'll stop here and we'll touch our private lives, private projects, without any problems, because it is a choice, we can choose, but it's important that it be a collective decision. [...] Do we want to walk? For sure, my brother, my colleague will feel discomfort, but the question is, do you want to be uncomfortable to improve or not? The situation is discomforting, comforting, discomforting (F).
The students' stance was also an element of reflection.
There is a very complex situation, in which sometimes the student does not know how to use their time well either, this is not only the student, we have this difficulty in general. The student is not used to reading, reflecting, thinking, taking responsibility in their process of formation and knowledge. Each time this is worse. We cannot blame ourselves that much either [...] It is a national conjuncture process, the students are uncommitted, in my opinion (C).
In the teaching-learning process, the participants recognize the fragility of the teaching-service relationship, pointing to the vital university articulation with local and regional services, considering the demands of the services as guide for the training process.
We need the service to be together discussing the Pedagogical Project of the course [...] This would be the effective integration of service, academy, and community. The community would also have to be represented by the municipal council [...]. Unfortunately, you do not have that in practice [...] we need to continue, and use strategies that conquer the service to approach this discussion and realize how important is the participation of the service in this discussion on the PPC, the nursing consultation, in short, the importance of the service, not only as a scenario of practices and learning, but as a, in fact, orderer of health training, which is provided by law. The service is the orderer of health training, but this is still very timid in service, the gaze of service (M).
DISCUSSION
Given the complexity that permeates this theme, beyond the curricular scope, which has been reflecting an international collective movement of nursing professionals to paradigmatically reorient their praxis, following the example of what has been happening with other disciplines in the health area. And guided by the clamor for a more active and critical society, it is necessary to consider aspects such as the professors' world view, the educational institution philosophy and policy, in which they are enrolled, the political-administrative reality of health services and the demands related to educational and health policies.
The study's participating professors exemplified situations of practice, involving nurses and graduates, that reveal orthodox paradigmatic elements, which they considered objectionable. The human beings' concept of life, that is, how each one, in its social aggregations, assigns meaning to life, the "world view" of each person, is constructed in an individual and collective context, starting from its cultural, political, economic, spiritual/religious organization. When faced with biomedical practices produced by nursing professionals and get bothered/indignant with them, the professors revealed a humanized and self-reflexive attitude, according to their world view, which meets the philosophical and theoretical reference now worked or proposed, historical and dialectical, raising a broader perspective of caring for the human person, and not its parts. The reports also revealed the perception of these university professors regarding the probable life conceptions of nursing professionals, revealed in their daily work, through their technicality actions, pointing to the paradigm that mobilizes them, positivist, which influences the development of their practices.
Society's materialist appeal allows for the exteriorization of a humanity that is unnoticed in the recognition of its desires. Thus, developing solidarity and tolerance are expectations that equality of rights is a premise, from which people position themselves against undignified acts, guiding the trajectory of life on an ethical basis.16 Nevertheless, life conceived in a capitalized world, as is the case, refers one to labor relations, inscribed under the perspective of exploration that is sustained by the production and appropriation of social surplus, which is intimately linked to the accumulation of capital. To deliberate that exploration, therefore, is directly related to the concept of surplus, leads it to a central position in the capitalism dynamics.17
Naturally, these ideas need to be deepened with regard to exploration at the heart of labor activity in the face of the capitalist paradigm; however, despite this, there are indeed oppressive relationships, as observed in the presentation of results, stating that nurses oppress middle-level professionals and that professors oppress students, reproducing the relationships they intend to change. Thus, authority consists of a dimension of class relations among employees in a capitalist labor regime, justified by the need for employer control, in order to ensure that their effort is sufficient for the desired production. Thus, they can, at the same time, be situated as belonging to the capitalist class or the workers class, since, as capitalists, they dominate the workers, and, as workers, they are controlled by capitalists and explored within production.17 Is the user also oppressed, beyond the production line, under the same logic of tensions and clashes between strong and weak in the production of health (and/or disease)?
Considering that the Health machine reflects the teaching in related areas and its paradigmatic foundation, as well feeds it back, under the productivist perspective, it must be inferred that the nursing professor, the nursing professional, and the nursing student, as well as the user, are permanently forced to reproduce their roles, thoughtlessly and tirelessly, ensuring the necessary breath for this machinery's uninterrupted operation. In this context, the user, for whom the efforts and investments of the former are intended, a priori, whether in education or assistance, remains at the mercy of professional and institutional positions regarding how they will be met in their demands.
The possibility of thinking about this assistance reality before the convergence group, provided by the study, allowed the professors to reflect on the genuine desire for transformation, that is, their motivations, daring to break with the dominant paradigm which, although it is thus characterized, for some, is not consistent with the guiding philosophical conceptions of their lives.
Human care is a recurrent agenda in the health field debates. Nursing care is often associated with care, dating back to its emergence in society.5 We infer that Nursing has an intrinsic potential to adhere to changes that aim to break with health practices that reduce the human being to a mere object for obtaining profits. The progression of the nursing technical rationality results from changes in the dominant thinking of each era, therefore the reflective practice and the development of critical thinking are fundamental for the compression of the profession in a social and critical perspective,18 as the current nursing practice requires developing skills compatible with the experience in the current historicity and global changes11. Therefore, it must start from the initiative of each professional to mobilize energy to achieve the necessary transformations to the consecration of a new model of care.
Based on this, using the nursing PPC as a tool for change, the study participants discussed the MHD as a philosophical current that is intended to be able to oppose the productivist crushing reality of nursing professionals, by allowing deep reflections to emerge on world concepts and nursing care and the consequent PE application. Studies point to the MHD as a relevant philosophical and methodological reference in the health field, when it guides the individuals' perception of reality through their historical contexts, as well as their relationship with the world. 19
The triggering questions of the study referred the participants to the need for modifications in the teaching-learning process, as guidelines for the professional practices' qualification process, to the extent that they need to respond to the ethical demands and dignity of society, a pulsating desire in the convergence group of this research.
The dissatisfaction with the health model experienced in practice was declared by the professors, an aspect that can be added to those perceived as motivating for the development of an innovative praxis, which, ultimately, affects the nursing care methodology, characterized by the PE. Professors pointed out that, in the hospital network, there is a disheartening context, exhibiting inhumane and chaotic care, where the priority is often to achieve goals that are responsive to capitalist production. The organization of work in a hospital institution exteriorizes internal and external selections, influenced by, among others, elements of economic, political, sociocultural, technological order, that make explicit a latent view of the world and social purposes in a historical context.20
It is in this paradigmatic, rigid scenario that the hospital setting is conceived and, before it, specific public policies are structured that aim at the effective attention to the population's needs, constituting a priority agenda in the discussions about assistance in the Unified Health System (Sistema Único de Saúde, SUS), considering its relevance in the health network organization and its considerable demand for resources.21 The context in discussion raised the issue of the work object's fragmentation in the hospital care, (disease and patients) and its technical division; then, the challenge was focused, as reported by the participants, on the rescue of integral and human care. It is indeed necessary to review the model of relations between health team and users, taking as a guideline the defense of these users' rights and the appreciation of their singularities.21 Thus, the needs evidenced by this study’s participants meet the National Policy for Hospital Care (Política Nacional de Atenção Hospitalar, PNHOSP), which proposes to renew the SUS's current form of management and hospital care,22 with the expectation of a health care construct modification in-hospital care, which has long been corrupted and distorted of its real role.
On the other hand, regarding the care provided in Primary Care, the professors-nurses revealed dissatisfactions, at the same time that they designed in-habitat assistance, guided by the integral health practice with individuals, families, and communities. They postulated that this care logic is the result of the philosophical conceptions that guide the SUS health policies; on the other hand, they were disappointed when they perceived the break of ties when the user needs to be referred to a specialized service. We know that the network services provision configures organizational arrangements, whose purpose is to promote the systemic integration of actions and services, aiming at the continuity, completeness, accountability, and humanization of care, which will lead the health system to an effective and efficient structure, from the clinical and economic point of view,23 contrasting what the professors observed in the network routine.
This dynamic of dissatisfaction/satisfaction reinforces for the participants the elements that indicate the need for the study to support the development of the intended construct. This ambivalence that is written in the participant's satisfaction and dissatisfaction reports in relation to the nursing care performed in Primary Health Care can be interpreted from the coexistence of two care models in this same care area, one focused on medical care for the diagnosis and treatment of diseases - traditional primary care - and another conceived as innovative, which is close to the SUS principles and guidelines - the Family Health Strategy, which prioritizes the link between the health team and the users,24 treasuring the life quality, subjectivity and the population empowerment. Aspects of both care dimensions were reported, reflecting dualities that show advances and setbacks in the area and compromise the quality of care.
Amid this contextualization, the study participants felt able to argue that the MHD, a reference that conceives the current profile of the Collective Brazilian Health and the SUS, is compatible, indeed, with the emerging social transformations in health. The MHD allows for the problematization of issues related to the working condition as a nursing production mode intervening element, as well as gives relevance to the institutional and administrative policy of health services, in this same perspective, which allows guiding the nursing actions in its work processes, making arise the dialectic present in the historical context regarding these same processes.11
It is undeniable that dissatisfaction consists of a driving force for reflections and future changes in a universe discerned as improper. Thus, nursing, an area of the health field that encompasses a series of challenges to be overcome, can be a field for proposing a care logic in which the true desires of workers and users of health services are considered.
The professors, when discussing teaching and learning practices, described a scenario in which it is evident that the degree of dissatisfaction reached them in such a way that they felt powerless and apathetic. By allowing this whole range of sensations to emerge, we understand that they are facing something dense, profound and complex. The clash beckons reflection on the guiding paradigms of their lives, of the health and teaching macro-institutions and of their own health social structure. The experience refers to relevant questions since many conditioning elements induce people and societies to perpetuate a model and structure of life. Thus, they questioned the professor's interest in promoting changes, questioned the student's ability to aggregate the emancipatory proposals and their contributions, the social role of the professional Nurse and, finally, the adherence of services and communities in a strengthened and strengthening partnership of health practices transforming projects.
The promotion of ethics, citizenship, and interlocution among health, education and work, referenced in SUS assumptions, cannot be restricted to technical aspects of teaching content, didactic procedures and pedagogical techniques. It is a priority that these procedures are aligned with the adoption of a theoretical-pedagogical framework that demarcates meaningful learning, transforming and adjusted to the social and professional demands required by contemporaneity.25 The teaching/service/community articulation; the union between theory and practice throughout the activities; the use of active methodologies; the problematization of social situations and contexts; the opportunity to experience the reality of SUS users; the student protagonism and the stimulus to student movements and extension projects were marked by nursing students as fundamental for a training guided by the principles of the SUS.26
Currently, in the field of health, there is a series of emerging, questioning, instigating and challenging conceptions; however, we know that historically, even with ongoing changes in the political paths and in the social relations, the direction of these transformations depends, above all, on human awareness on the directions and existing moral values, or not, in the construction of these changes.27 It is highlighted that the professional should recognize their responsibility in the construction and improvement of their knowledge and, aware of this, adopt continuing education as a daily practice, assuming a critical and reflective posture that leads them to seek answers to their questions.28
From these considerations, it is highlighted that the participants were invited to elucidate, in the convergence group, their motivations before the structuring of a proposal for the PE teaching theoretical basis, being presented to the MHD as a proposal to achieve what is expected. From this point of view, the authors assert that the worker incorporates an agent of transformation by assuming joint responsibility for the work process. By integrating the movement and positioning themselves in the face of political processes of facing reality, the possibility of changes and improvements emerges, which could materialize.28
Therefore, the reflections converged on three thematic focuses that express an articulated phenomenon: the professionals' practices are regulated by the health system, consummated by public policies and, at the same time, the professional legitimizes this living system, ensuring the survival of a care model that values high complexity, cure, specialties, and subspecialties, reiterating the controlling and idealized role of the health professional and reinforcing the users' subjection. It is up to the nursing professional to internalize protocols and booklets, as well as to respond to this with productivity, which apparently, is true for the education system, by feeding and retro-feeding this production process, with the Cartesian scientific production and technical rigor as starting points. In their dissatisfaction with these phenomena, the participants recognized their motivation for change.
The humanized and inquiring attitude revealed by the participants in their reports, which opposes the objectification of users, is, by itself, dialectic. As well as it reveals itself historic, as these professors drank Cartesian waters throughout their own training, considering their classical professional trajectory, in traditional Brazilian nursing schools, but were open, reflective and critical about all the problems so far developed, expressing attitudinal plasticity, as historical beings. Far from asserting that this attitudinal position presented by the participants of the study reflects concretely on a progressive, integrative and humanized teaching practice. It may be inferred that these professors were positioned themselves as inquirers, questioners and possible agents of subversion to the Cartesian model of teaching and the biomedical model in health, who recognized themselves motivated to restructure the philosophical, theoretical and methodological framework that subsidizes the PE teaching, as a possibility of effective contribution in nursing practices enrolled in the health system.
The results, of a qualitative nature, can be generalized as they express a current reality in higher education institutions and can guide the discussions on the reorientation of PE teaching from the MHD's philosophical theoretical framework, beyond the traditional one. The study shed light on one of the complex phenomenon dimensions of PE teaching structuring, the professor's motivation, being limited by its clipping, type of study and sample. The aim is to offer clues for further research on the multiple dimensions inherent to the philosophical, theoretical and methodological structuring of PE teaching, in the direction of an expanded PE understanding and its responsible operation and sustained by consistent references and scientific evidence.
CONCLUSION
The present study allowed for the expression of worries, sometimes repressed and that, because they are awakened, lead to reflection on the paradigm that guides the field of health education, as well as dominates life in society. When looking at this reality, in a viable space for revelation, understanding, and articulation, like the convergence group was constituted in this study, conceptions demonstrating, simply and singularly, what is effectively desired by individuals and society in the health scenario emerged.
In this sense, the motivations that mobilized professors-nurses in the structuring of a proposal for the theoretical and methodological framework of the PE practice in an undergraduate course refer to the negative impression that nursing practices marked by oppression, trivialization, and indifference concerning the users' singularities caused in these professors. Based on this, and looking at the results presented, we bring to light that the professors considered the need for a theoretical-philosophical, historical and dialectical proposal that would support their practices, taking as a reference the nurses' practices in the services, the dissatisfaction with the health services and with the current teaching model.
Since government initiatives announce a new era for health education, the MHD constitutes the theoretical, philosophical and methodological framework of the SUS and, it is believed, can subsidize a praxis capable of exhorting paradigmatic precepts rooted, in daily materialization in welfare actions, obviously below all the indispensable political and social reform that involves the public and private sector. The results are intended to inspire higher education institutions to reflect the MHD as a foundation for curricular/care reorientation.
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NOTES
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ORIGIN OF THE ARTICLE
Article extracted from the thesis - Constructing a proposal for a theoretical-methodological framework for the teaching of nursing care/process in an undergraduate nursing course, presented to the Programa de Pós-Graduação em Enfermagem of the Universidade Federal de Santa Catarina, in 2017.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee on Research with Human Beings of the Universidade Federal da Fronteira Sul Opinion 1,347,983, CAAE 50701815.2.0000.5564.
Publication Dates
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Publication in this collection
13 Mar 2020 -
Date of issue
2020
History
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Received
11 June 2018 -
Accepted
03 Dec 2018
