Teaching-service-community integration in Dentistry: a cultural study^*

Abstracts

The aim of this study was to analyze teaching-service-community integration in a Dentistry course, based on curricular internships seen in the perspective of health workers, students, users, managers and teachers. Twenty-seven semi-structured interviews were conducted, transcribed and thematically analyzed. The cultural representations about the studied integration are procedurally re-signified from the interactions and clashes between their different agents, enabling the sliding of expressed and shared meanings. The representations also operate in a contingent way, sometimes facilitating, sometimes hindering an effectively dialogic dentistry education process. Teaching-service-community integration, studied from one of its devices, supervised internships, is a place to get out of the self to experience theory-in-practice and practice-in-theory, with social and pedagogical actions that produce modernizations, co-accountability and knowledge oriented collectively and intentionally to the Brazilian National Health System.

Cultural studies; Dentistry; Public Health; Teaching

O objetivo do estudo foi analisar a integração ensino-serviço-comunidade em um curso de Odontologia, a partir dos estágios curriculares vistos na perspectiva dos trabalhadores de saúde, estudantes, usuários, gestores e professores. Foram realizadas 27 entrevistas semiestruturadas, posteriormente transcritas e analisadas tematicamente. As representações culturais sobre a integração estudada são ressignificadas processualmente a partir das interações e colisões entre os seus diferentes agentes, possibilitando o deslizamento de sentidos expressos e compartilhados. As representações também operam de forma contingente, ora facilitando, ora dificultando um processo de formação odontológica efetivamente dialógico. A integração ensino-serviço-comunidade, estudada a partir de um dos seus dispositivos, os estágios supervisionados, é um lugar de “sair de si” para vivenciar a teoria na prática e a prática na teoria, com ações sociais e pedagógicas que produzem atualizações, corresponsabilizações e conhecimentos orientados coletiva e intencionalmente para o Sistema Único de Saúde (SUS).

Estudos culturais; Odontologia; Saúde Pública; Ensino

El objetivo del estudio fue analizar la integración enseñanza-servicio-comunidad en un curso de Odontología, a partir de las pasantías curriculares vistas bajo la perspectiva de los trabajadores de la salud, estudiantes, usuarios, gestores y profesores. Se realizaron 27 entrevistas semiestructuradas, que posteriormente se transcribieron y analizaron temáticamente. Las representaciones culturales sobre la integración estudiada se resignifican procesalmente a partir de las interacciones y choques entre sus diferentes agentes, posibilitando el deslizamiento de sentidos expresados y compartidos. Las representaciones también operan de forma contingente, tanto facilitando, como dificultando un proceso de formación odontológica efectivamente dialógico. La integración enseñanza-trabajo-comunidad, estudiada a partir de uno de sus instrumentos, las pasantías supervisadas, es un lugar para “salir de sí” para vivir la teoría-en-la-práctica y la práctica-en-la-teoría, con acciones sociales y pedagógicas que producen actualización, corresponsabilidades y conocimiento orientados de forma colectiva e intencional hacia el Sistema Brasileño de Salud.

Estudios culturales; Odontología; Salud Pública; Enseñanza

Introduction

The undergraduate curriculum and the selection of knowledge contained in it are cultural artifacts and, as such, gravitate in fields of power dispute, influence and conquest of meanings, in the scope of the pursuit of cultural hegemony¹ in distinct fields in the academic time and space.

Curricular choices are impregnated with cultural representations that reveal hierarchies between knowledges and actions. Cultural representations establish habits and values according to collective interests, associated with the construction of identities, productions, consumptions and regulations, arranged in a continuous circuit²,³. The set of knowledges considered important or secondary in the curricular guidelines involves different practices, which ensure institutionalization and the celebration of learning and specific competencies, as well as the graduates’ profile¹,⁴.

In dentistry education, which is (or used to be) predominantly established in the autonomous and private job market, without the possibility of analyzing its inclusion in the Brazilian National Health System (SUS), the tradition of more than a century is revealed in a culture that is solidly centered on technology and monopolized by the development of skills and attitudes for a competent biomechanical and specialized intervention in oral disease sequelae⁵-⁸.

The Brazilian Constitution of 1988, in its article 200, item III, highlights health as a right of all and a duty of the State, and the SUS’ organizing role in the education of human resources in the health sector⁹. The publication of the National Curricular Guidelines (DCN), in 2002¹⁰, and of different interministerial reorientation policies in the fields of education and health in the subsequent years, induced reformulation processes of pedagogical projects and curricula of the health courses¹¹,¹². All the legal frameworks had, as an image-objective in Dentistry, an education that problematizes the oral health conditions of the Brazilian population, the national, regional and local organizational arrangement of the public oral health systems, and the education of humanistic and critical-reflective dental surgeons¹⁰.

The formulation and implementation of teaching-service-community integration (TSCI), through articulation efforts between the health system and the higher education system, are materialized in the inclusion of students and teachers in the healthcare networks under development in Brazil, with interesting experiences discussed both in the national¹¹-¹³ and international¹⁴-¹⁷ spheres. This two-way regulation (education-health) also implies the development of curricular components, research and extension projects, and the amplified and diversified education of students, with all the complexities involved, inclusively in the field of the established narrative and cultural disputes¹²,¹³.

The presence of students and teachers in supervised internships in the SUS, democratically articulated with municipal governments and multiprofessional health teams, potentializes reciprocal learning and contributes to the outline of an educational culture that addresses the daily challenges of the public health policy, whether they are related to healthcare, surveillance, management, permanent education or regulation, among others.

Supervised internships bring singular issues to the educational dynamics, such as: the pedagogical roles of the preceptor (worker); the polyphony of the triptych teaching-learning setting: primary care unit-territory-catchment population; and, last but not least, the interaction with the plurality of working processes and conditions, like a realistic academic rehearsal of professionalism.

Paradoxically, the supervised internships have been undergoing a semantic and identity crisis since the publication of the DCN: they should not be understood, in a utilitarian way, solely as educational practices of colonizing hygienist bonomy nor as clinical exercises performed outside the university environment¹⁸, but as polysemic experiences in health territories.

The study aimed to analyze teaching-service-community integration in a Dentistry course based on curricular internships, seen in the perspective of health workers, students, users, managers and teachers.

Method

A case study¹⁹ was carried out to investigate the meanings and intentions of the teaching-service-community integration (TSCI) process, based on the curricular internships of a Dentistry course, performed at a Family Health Unit of a capital city in the Brazilian Northeastern region.

It is a cultural representation study²,³ that aimed to amplify and diversify the investigations about TSCI - an important theme for the contemporary reforms of undergraduate Dentistry courses in Brazil. The importance of the study of cultural representations lies in the fact that they establish connections between the meanings of the knowledge contained in the undergraduate curriculum and the practices developed in curricular internships.

The Dentistry course investigated in the present research belongs to a federal higher education institution founded 65 years ago. In 2002, the institution proposed a curricular guideline that includes supervised internships, in which the first four modules are taken in the course’s initial two years and are under the responsibility of collective health teachers. The modules total 120 hours - 30 in each semester²⁰,²¹.

The pedagogical outline adopted by the supervised internships is grounded on active methodologies, which stimulate students to have a participative behavior, with relationships mediated by the reflective construction of knowledge. The point of departure is the complexity and diversity of the world of health work experienced in the Family Health Strategy territory, which has multiple social institutions like schools, day-care centers and community centers²⁰,²¹.

The syllabus contains important themes for the fields of collective health and of the Brazilian collective oral health: the SUS and its different sectoral policies, primary care, family health strategy and the program of community health agents, territorialization, humanization in the field of health, health education, general epidemiology and epidemiology of oral diseases.

This study was developed in a Primary Care Unit intentionally selected because it has been, since 2005, the setting of the National Program of Reorientation of Professional Health Education (PRÓ-SAÚDE) and of the Program of Education through Work for the Area of Health (PET-SAÚDE) of the supervised internships of the Dentistry, Nursing and Nutrition courses. It is a service where a Family Health Strategy team and an Oral Health Team provide assistance.

A total of 27 participants were interviewed: nine undergraduate students, six community health agents, one health professional with a higher education degree, one oral health assistant, five child education professionals, and five users of the Brazilian National Health System. The interviewees were selected according to their participation in the activities of the supervised internships, in the social institutions and/or in the Family Health Unit. The students were regularly enrolled in the course, and workers who were on vacation or on leave of absence were excluded from the study.

The interviews were performed by three researchers (two undergraduate students and one teacher) from September 2016 to June 2017. Before the interviews, the researchers discussed the study’s presupposition, the interview as a data collection technique, and the ethos of qualitative research, in order to align the conduction of the work with the theoretical and conceptual framework of cultural studies²,³. Interview simulation exercises and discussions about them were also carried out.

To participate in the research, all the subjects signed a consent document. The interviews were audio recorded and subsequently transcribed for analysis. The reading of the transcriptions revealed that the 27 interviewees had answered the research question and that, if we were to conduct new interviews, this could result in redundancy, as the saturation plateau for qualitative studies had been reached, leading to the non-emergence of new meanings about what was being studied²².

The interviews were fully transcribed and thematic content analysis was applied²³, in three stages: pre-analysis, exploration of the material and treatment of the results. Pre-analysis meant the organization of the collected material and aimed to operationalize and systematize the initial ideas. The free-floating reading of the transcriptions consisted of establishing contact in order to know, analyze and explore them better. The third stage was the treatment of the obtained results. Codification was the process through which the data were systematically transformed and aggregated into units that enabled a description of the pertinent characteristics of the content. The fragments of the interviews used in this article were presented with the name of the participant’s category followed by a random number.

The project was approved by the Ethics Committee of Research with Human Beings of the higher education institution involved in the study, protocol number 1.653.507.

Results and discussion

The concept of culture is broad and diverse. In this article, it is seen as a way of understanding the sets of practices associated with power and hegemony²,³, which enables to discuss the cultural representations of TSCI, unveiling their presence in dentistry education.

To Williams²⁴, culture produces reality as the subjects involved in this movement of education, training and health interact, converse, do, plan, articulate and produce significant practices in a visited territory, which is never merely a health territory¹²,¹³,²¹,²⁵.

Cultural analysis is also a political analysis, and every health education is based on choices of knowledges, pedagogies and paradigms, which manifest themselves in the importance given to certain teaching-learning modes and in the invisibility given to others¹. Curricular guidelines illuminate things remembered and forgotten, reveal and hide knowledges and practices in specific contexts¹.

Cultural representation is a form of creation and understanding that connects meanings and practices; “it is a central part of the process through which meanings are produced, shared (consumed) and re-signified among members of a cultural community”²,²⁵. Understanding the meaning and the cultural representations related to supervised internships enriches and amplifies the discussion about their role in the health education that is oriented by TSCI.

Supervised internships are social constructions that can translate an epistemic and political bond with the Brazilian healthcare reform - the endless fight for the democratization of healthcare and for the survival of the SUS in times that are, almost always, so adverse. The presence of the undergraduate Dentistry course in the SUS as part of the educational spectrum is a becoming, an invitation to a relationship, to an encounter, to change, to impermanence in the learning process.

What is the meaning, in cultural terms, of the integration of a traditional undergraduate course, like Dentistry, into the services of the Brazilian National Health System in a specific community?

TSCI is the product of a collective work articulated and agreed by teachers, students, preceptors, managers, by the community of SUS users, and by the agents of different social institutions. The thematic analysis of the interviewees’ discourse reveals that the people involved in TSCI are artisans of cultural representations²⁶. The interviewees emphasize the need to include students in realities and contexts that are different from the academically familiar ones, showing them that it is necessary to ‘get out of the self’, of what they are used to seeing and doing, in order to be able to effectively see the other’s needs. The agents involved in TSCI expressed their representations, reflecting different positions assumed from their places of origin, educational backgrounds and life experiences, which compose their “symbolic representation system”²⁶.

One cultural representation of TSCI is that it is a practice or an ‘event’ with many positive aspects for the undergraduates’ education. According to the interviewees:

I think it’s important because the student will experience it in practice. Because, at university, they study it, but it is theory, and what matters is that you, in addition to theory, experience, in practice, what you’ve learned. Not only what we tell, but also what we experience. It’s good because the students themselves also have the opportunity of living the experience in different situations [...] then, they see different realities of conditions, of everything: health, financial condition, reality itself; type of family, everything that is directly or indirectly related to health. (Health professional)

Respect together with love, knowing people’s reality and daily life […] so, I think it’s very important that they work together with the children and together with the community, because they also like it, they feel important. (Teacher of Day-Care Center 3)

Knowledge production in the integrative experience is neither a neutral cultural field nor a consensually pacific field. It requires an intention that is mainly political and ethical, an activism¹²,²⁷,²⁸ committed to the defense of life, of health, of the SUS and of citizenship. TSCI enables that an entire theoretical-practical corpus is tested, from the reading of official documents (DCN, Organic Health Laws and National Health Policies⁹,¹²,¹³) to the immersion in the working process of the Family Health Strategy, passing by the community ‘experiment’ of territorial wanderings, home visits and plural forms (experienced, (re)invented and (re)signified) of healthcare³,²⁵. Each agent, in his or her own way, represented TSCI as a form of producing social changes:

to me, what changed most was the view I had of the SUS. I think this was what changed most, because when you don’t use the service and you aren’t part of it, you don’t understand well how it works, neither in theory nor in practice, so I think we have the opportunity of seeing how it works, that the dentist’s work is not only what happens in the clinic. (Student 1)

[...] we work trying to educate the professional in a general way [so that] they see the user in their context and not only their mouth... join courses, create a multiprofessional team... the work becomes rich, multidisciplinary, cross-disciplinary. Everyone gets out of their box with one single objective: the user. (Health professional)

TSCI, by offering support to transformations in the field of education, care production and strengthening of the SUS¹¹-¹³,²⁸-³¹, breaks with crystallized cultural representations that consolidate stereotypes, impoverishing the understanding of the set of experiential possibilities contained in the cultural arrangements²,²⁵-²⁷ of internships in health services and territories. According to the interviewees, involucres are broken when knowledges, skills and attitudes are modified and when social images are (re)signified. According to them:

It is extremely important that this integration occurs [...] for learning and knowledge exchange... we learn a lot from those who have been updating their knowledge with what they bring. (Health professional)

Sure, I guess, because they must see the environment where they are working, where they are doing the internship, as many of them don’t know the work provided by an entity, a day-care center, they don’t know the community people, they have a different image, a very different image. (Teacher of Day-Care Center 3)

[...] like the exchange of information and learning, to us, to the users and students, who are entering that home, that family, learning new things [...] and the visit in the territory is another world. (Community health agent 5)

because then they’ll be able to learn how to interact with different realities, they’ll learn how to deal with the situations that arise, because they are different situations. Each family has a situation, and each reality also presents different situations; so, the experience itself, this opportunity students have of participating in here directly, in the visits to users’ homes, I think they learn a lot, because we learn by living. (Community health agent 3)

'To Hall (2016)²⁵, culture is a constitutive condition of social life, with its communal symbolic values, and language is the means through which cultural representations are produced. The content analysis of the interviews enabled us to see that the researched subjects construct representations in a contingent way; therefore, such representations are not essentialized and have positionality.

In this direction, there is the construction of meanings of co-accountability with the population’s health, with the establishment of common agendas between the higher education institution and the team, and with the strengthening of bonds, which, through the continuity of the work, enable the reflective and critical maturation of all the individuals involved in the educational process²⁹,³¹,³².

If we don’t help, how will these students learn? Because, for them to have a base, they must start in the community, (...) to be able to form a professional profile. (Community health agent 1)

I feel important; in fact, we give, we try to be always learning and providing knowledge, helping families in the best way, facilitating things with our work, in the homes or even at the unit. As a health professional, I feel important. (Community health agent 2)

I liked it very much, we have questions about things and they answer that question we have in our head. We don’t know ourselves, and we come to the lecture, I attend all of them, except when I haven’t been informed about it... but I like the lectures very much, I like to listen to them, trying to disentangle the information to understand it, sometimes thinking of me, sometimes of my daughter, so that I can help when she needs advice, my advice, right? (User 2)

The undergraduate course, with its students and teachers, dives into the SUS, articulating bordering representational worlds, formed by teaching, work and other practices²¹. In dentistry education, there are socially defined professional roles that show, in advance, the place of recognized, valid and valued knowledge. Furthermore, they indicate the functional-instrumental character of learning, developed in a single way, and the modus operandi of the professional success that students must pursue. Students graduate aiming to provide clinical and individualized dental care, in the face of which ‘everything that exceeds’ is ‘alternative’, viewed as secondary and made invisible. These cultural representations proved to be insufficient, socially unsustainable and opposed to the DCN and SUS proposals.

The clash between representations potentializes the sliding of meanings in dentistry education. The value that has been historically placed on the biomedical know-how, exclusively intramural and intraoral, is amplified with the incorporation and recognition of a set of practices developed in collective health spaces and their challenging extramural know-how¹⁸, having as presuppositions: the amplified concept of health, the social determination of the health-disease-care process, and the presence of social and human sciences in the health context.

This sliding towards education via supervised internships, integrating teaching into the health work, does not happen easily and is not deprived of animosity; it is frequently accompanied by the feeling of annoyance and by explicit or veiled mistrust on the part of many agents involved in the education of dental surgeons. However, among the interviewees, supervised internships were culturally represented as a learning place:

Things not taught in books: to put yourself in the other’s shoes [...] and if we know that person’s reality, [...] if we understand a little that person’s priorities, we are able to work in a way that meets the needs that person has. (Student 1)

the internships show this, and when you are in the field, when you put your face outside your environment, of that world to which you are subject, you start to see many things that you didn’t see before. So, life out there is much more difficult than we can imagine. When we are working in a community in which there are countless problems, not only that problem we are seeing, there is an entire context behind it, you end up experiencing that and taking it with you. (Student 7)

In supervised internships, the pedagogical borders and limits are blurred and, given the existent porosities, the learning experience becomes ubiquitous. Students estrange the geographic and human territory, the rationalities and practices performed in the territory; but then they approach it, and familiarize themselves with it. There is an encounter of these students with ‘them’: indefinite, strange and ambivalent subjects of the work world (managers, workers and users). An encounter in motion, a crossing street that asks for translation, understanding and construction of meanings.

In the diaspora from the university to the health services (SUS), the cultural perspectives and the mental structures of the agents involved do not open pacifically and calmly from some individuals to others; when they do, labels and stereotypes can be present in view of the cultural difference between agents. Belonging to a culture means sharing the same conceptual and linguistic universe. It means belonging and being protected by symbolic understanding. Each interviewed subject, with his or her performativity, contributes a view of health education, as their cultural representations are an exercise of sociability in a culture of TSCI in the Dentistry course²,³. To different agents, TSCI is represented as the experience of collective construction in the territory:

Everything we do here at the unit is planned with the whole team. We articulate everything, we settle on things. Nothing is done right away, everything is articulated and we do it right. (Community health agent 4)

We will discuss with the students so that things become comfortable, both to them and to us. Also, we hear the community to learn what they want them to approach, what they consider important. The community also gives their opinion about what they want to hear. (Oral health assistant)

It was done together. Everybody contributed ideas about what we were going to take. The issue of food was the responsibility of the day-care center; we planned dynamics and how we were going to work with the children. The entire team seats! - and plans. Each one makes a suggestion and the one that is most accepted is implemented. (Student 4)

In addition, TSCI is understood, simultaneously, as a strategy for the implementation of permanent education actions¹¹-¹³, a learning process intended to last for life. To the students, the construction of TSCI via supervised internships represents “feeling progressively part of the Family Health Unit”, a formative experience that is qualitatively significant, with proactivity in the management of collective activities and communal bonds, with everything they have in terms of knowledge, skills, attitudes and possibilities of new ways of learning in the workplace, translated as care.

Studies have shown the dialog (and the lack of it) between preceptors and students, in an invitation to re-signify knowledge crystallized in practices¹²,²⁸-³¹. In this study, supervised internships were spaces of dialog culturally represented as territories of producing and consuming exchanges of knowledges and actions regulated by legal parameters⁹,¹⁰, by healthcare and formative policies. According to two interviewees:

I like it mainly because of the learning involved. We learn, we answer questions, and thus we can help our users. (Community health agent 3)

Yes, I think they learn, there is an exchange, because we have a little knowledge and they have knowledge, too, so there is knowledge exchange. (Community health agent 4)

The reorientation of health education requires new practices in the education and health systems⁵,¹¹-¹³. If, on the one hand, it is necessary to propose innovations in the pedagogical project grounded in the restructuring of the teaching-learning process, on the other hand, the healthcare model needs to reflect the public health policies in the perspective of comprehensive care and strengthening of the SUS. Thus, relations of autonomous interdependence between the health and education systems must be constructed in the dialogic spaces where critical and collective reflection on intentions takes place.

This study aimed to contribute to amplify the experience lived in the TSCI process in the path of the education of new dental surgeons. However, the study has limitations, as it considered one single territory where supervised internships occur. The selected Family Health Unit has already participated in previous editions of education reorientation programs and is the setting of many curricular internships of different professions.

Final remarks

This research studied the contemporary culture of dentistry education, based on the analysis of the cultural representation of regulating agents, producers and consumers of supervised internships in the teaching-service-community integration. Symbolic systems shelter cultural representations about TSCI that are internalized and re-signified, enabling the sliding of meanings based on the interaction between different agents present in the educational process.

Developing teaching in the undergraduate Dentistry course oriented by TSCI is still a challenge, and this happens in all the other professions in the field of health. It is necessary to raise agents’ awareness and pursue agendas that converge on the health problems of the collectivity. In addition, it is necessary to amplify opportunities and effective spaces of interlocution between the university, the health services and civil society, enabling the encounter of different agents.

Based on this study, teaching-service-community integration, fulfilled through supervised internships, is a place of education that enables students to “get out of the self” to experience theory-in-practice and practice-in-theory, with social changes that produce modernizations, co-accountability and collectively oriented knowledge productions.

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• *
  The study is part of the post-doctoral research of the author Franklin Delano Soares Forte at the School of Medical Sciences of Universidade Estadual de Campinas, supervised by the author Nelson Filice de Barros. Thanks to the Institutional Program of Scientific Initiation Grants (Pibic) of the National Council for Scientific and Technological Development (CNPq), Federal University of Paraíba, for the aid received.
• Translator: Carolina Siqueira Muniz Ventura

Publication Dates

• Publication in this collection
  28 Sept 2020
• Date of issue
  2020

History

• Received
  02 Apr 2020
• Accepted
  09 July 2020