Memorials and narratives in the training of health educators: writing about oneself, monitoring and biographical mediation¹

ABSTRACT

The narratives of health educators are configured as a device that favors the understanding of experiential learning in the formative space of graduate studies in Health Education. Its context of insertion is Health Residencies, training spaces that integrate the teaching and services of the Unified Health System (known as SUS) in Brazil. Based on principles of the (auto)biographical research and in the use of memorials, the objective is to discuss issues related to the monitoring process, its interfaces with the writing about oneself, and the investigation-training provisions mobilized by writing the memorials of three educators in the field of Health Education, as preceptors in the Residency Program of the State Foundation for Family Health (Fundação Estatal Saúde da Família - FESF-SUS) in Bahia. The experiences of care and education in multi-professional teams are reflected in memorials for the training of health educators, as a process of mediation of what was experienced, and of the relationships between trainer and trainees, through the narratives of experiences with an emphasis on personal and professional development in the context of Health training.

Keywords:
(Auto)Biographical research; Memorials; Health; Training; Educators

RESUMO

As narrativas de educadores da saúde configuram-se como dispositivo que favorece a compreensão de aprendizagens experienciais no espaço formativo da Pós-Graduação em Educação na Saúde. Seu contexto de inserção são as Residências em Saúde, espaços de formação que integram o ensino e os serviços do Sistema Único de Saúde (SUS) no Brasil. Ancorados em princípios da pesquisa (auto)biográfica e na utilização de memoriais, objetiva-se discutir questões relacionadas ao processo de acompanhamento, suas interfaces com as escritas de si e as disposições de investigação-formação mobilizadas pela escrita de memoriais de três educadores no campo da formação em saúde, na condição de preceptores no Programa de Residências da Fundação Estatal Saúde da Família (FESF-SUS) na Bahia. As experiências de cuidado e de educação em equipes multiprofissionais são colocadas em reflexão nos memoriais de formação de educadores da saúde como processo de mediação do vivido e das relações entre formador e formandos, por meio das narrativas de experiências, com ênfase no desenvolvimento pessoal e profissional no contexto da formação em saúde.

Palavras-chave:
Pesquisa (Auto)biográfica; Memoriais; Saúde; Formação; Educadores

Narrating life and thinking about the profession: indicating clues

The text is inserted in the area of ​​Education and Health and seeks to discuss issues about narratives and writings about oneself in memorials for education inscribed in the experiences of health educators, considering the context of their production, the process of authorship, of writing monitoring, its textual form and its content. We understand, as systematized by Souza (2014), that the narratives enable moments of education, implying movements of reflexivity, of individual and collective identity processes, of becoming aware of their own story, allowing the subjects in training to re-elaborate everyday events, transforming them into experiential learning.

The activity of narrating and reflecting on the experiences from their perspectives on the context, on the people they relate to and, especially, on how they perceive themselves in this relationship with the context and the people, caused the memorials for education to emerge from implicit writing and interpretation of reality, from the perspective of health educators inserted in the graduate studies in Health Education. We focused our attention and analysis on the memorials produced in 2017 by a dental surgeon, a nurse and a Physical Education teacher, as preceptors in the Residency Program of the State Foundation for Family Health (Programa de Residências da Fundação Estatal Saúde da Família - Fesf-SUS) in Bahia, Brazil, in the context of the specialization course in Health Education for Preceptorship in the Brazilian Unified Health System (known as SUS).

We understand writing as a research-training device in the field of auto(biographical) research, as the narratives contained in memorials are revealed as an educational opportunity for educators, enabling them to revisit their memories and life-profession trajectories in connection with training, their motivations for entering preceptorship and the possibilities of personal and professional training updated in the reflective movement related to the contexts, practices and challenges of professional practice as a health educator.

(Auto)biographical research seeks to understand and apprehend ways of “seeing/listening/narrating life and experiential learning” (SOUZA; MEIRELES, 2018, p. 285, our translation) when we assume the memorials for education (PASSEGGI, 2010b) of health educators as a research-training device. The training memorial is configured as a training practice centered on reflective and (auto)biographical writing in the field of initial or continuing education, which implies putting the subject in transaction with him/herself and with temporal dispositions, biographical reflexivity and writing from experiences as fertile for other understandings about the formation, notably, of health educators.

The memorials for education allow the systematization of the narratives, involve writing, graphically expressing its story, through reading and re-reading processes, handling of technologies and choices about what one wishes to narrate (PASSEGGI, 2010a). It differs from the spontaneous oral narrative about life itself, accesses thinking and language, self-criticism, the temporal interpretation of historical and cultural contexts, implying a movement of authorship and identity reconstruction.

The construction of narratives for education is characterized as a formative experience, as it allows educators to question their identities, anchored in “reference memories” (JOSSO, 2010) and organize, through the writing of the memorial, narrative temporalities and identities of their own story and life-training-profession experiences. The reference-memories focus on concrete and visible dimensions, social images and invisible dimensions, emotions and values ​​that are articulated with the process of (auto)biographical reflexivity writing about oneself. The narratives for education allow reflections and clashes between the past and the future, implying questions about the present time and about the ways in which the subjects reshape their narrative identity, through the writing of the memorial.

The narratives of health educators are located in a biographical time (DELORY-MOMBERGER, 2012), allowing collectives and subjects in training to obtain other perceptions about teaching and understanding the role of health educators, through elaborations in connection with their personal, professional and social lives with the specialization course, intertwining situations and contexts that would touch their lives, with regard to the previous personal trajectory as a student, health professional and educator.

The analysis of the memorials for the education of three preceptors, such as health educators, leads us to discuss movements concerning the contexts of insertion and training of health educators, processes of monitoring and mediation of narrative writing in memorials for education, the strangeness involved in the act of remembering and narrating life, narratives about training pathways and recognition of health educators, reflections of training processes in connection with life and, finally, conclusive dialogues concerning contexts, narratives and health education.

Context of insertion and training of health educators

The teaching identity in health has been built upon the entrance of the role of educator. The discussion on the lack of training spaces for health educators portrayed by recent doctoral dissertations (RAMOS, 2018; CARNEIRO, 2018; SILVA, 2017; LOTTERMANN, 2016; BORBA, 2017; PIO, 2017) registered training paths mainly focused on clinical practice in undergraduate Health courses and on research in clinical specializations in stricto sensu graduate studies - Masters and Doctorates. Health educators begin their search for pedagogical training through individual investments or in a few initiatives from the educational institutions in which they work.

Educators responsible for the training of the Brazilian Unified Health System workers are called and recognized as preceptors. They are inserted in the health services and associate to their daily clinical practice the role of educators of other undergraduate or graduate workers. The workers in training accompany the preceptor during the execution of care activities associated with study and research activities, in an intense integration between teaching and health services.

The Health Residency Programs are part of the lato sensu graduate program, they are highly valued and considered a high-quality standard in the training of health workers since the 1970s in Brazil. They have a minimum duration of two years and a workload of 60 hours per week, with a national scholarship financing system and competitive selection processes for admission.

The educator-preceptors that make up the Residency Programs are workers in the Brazilian Unified Health System services, with recognized experience and a minimum degree of specialists in the areas of the residency programs in which they work. Admission to preceptorship at the Brazilian Unified Health System often takes place through direct invitations from coordinators and educational institutions (MATTOS, 2016; ARNEMANN, 2017; SILVA, 2017), with experiences of selection processes for the position being rare. Experiences in specific remuneration for the exercise of preceptorship are also rare in Brazil, and the assignment of educator to the previous assignment in assistance is cumulative.

The training context in the Residency Programs is rich in opportunities for reflection on what was experienced and constantly invites one to look at oneself and the care practices in the dialogue with the people assisted in the health services. The unique life stories, the socioeconomic, historical, cultural, psychological contexts, cross and interconnect with the stories of health and illness that are shared daily by people who seek health services. Thus, health practices go beyond clinical procedures and tangible technology, they involve a complexity of analyzes, care offering and negotiations between health workers and the population, which, consequently, makes the training context conducive to putting oneself in analysis and permanent reinvention of the self.

National experiences in the use of reflective portfolios and memorials for education are growing as an opportunity to elaborate on what was lived in connection to the learning provided in the trajectory of health courses, such as the course developed by the Teaching and Research Institute of Sírio Libanês Hospital (OLIVEIRA et al., 2017) that has already enabled the training of more than 5,500 educators, between 2015 and 2020, who work in the preceptorship and coordination of medical and multi-professional residency programs in the Unified Health System in various specializations, in several Brazilian states and municipalities.

The narratives presented in this paper register training trajectories and experiences of three health educators - a dental surgeon, a nurse and a Physical Education teacher - inserted in the specialization course in Health Education for Preceptorship in the Unified Health System developed in 2017 and who acted as preceptors in the Fesf-SUS Residency Program in Bahia, Brazil.

As these are narratives previously produced strictly for educational purposes, the researchers made contact with the three educators, requesting authorization for the use of the memorials, explaining that this would follow the criteria of ethics in research in Human and Social Sciences according to Resolution no. 510/2016 of the National Health Council (Conselho Nacional de Saúde - CNS), that participation would be voluntary and there would be no risk or harm to educators, along with the objective of the research that was explained, as well as possible benefits for the production of knowledge in the area of ​​Education and Health, in addition to ensuring confidentiality about identity.

Role of the trainer: monitoring, biographical mediation and writing about oneself in memorials for education

The memorial for education is understood as a device for the apprehension and interpretation of experiences, records on the development of experiential learning during the training course for health educators (OLIVEIRA et al., 2017), being a transversal activity over a period of approximately one year and final product of completion of the specialization course in Health Education for Preceptorship in the Unified Health System.

The trainer’s guidelines on writing the memorial involved requesting weekly records, in which educators were encouraged to write in the first person and honestly register how they felt in the situations, how they constituted the role of educators and what was possible to review about their practices, potentially producing displacement commitments with themselves.

The following triggering questions were used: “What do I see?”; “What do I feel and think about what I see?”; and “What do I do with what I feel and think about what I see?” (EPS EM MOVIMENTO², 2014). These questions should include the reality experienced daily as an educator in association with the experiences and knowledge gained from the specialization course, making connections especially between these two contexts. Expand the narrative about the activities developed (what I see), including reflective criticism about the activities developed (what I think about what I see), the educators’ permanent self-assessment and the possibility of reviewing practical strategies in the relationship with the students-residents under their responsibility (what I do with what I feel and think about what I see).

During the production of the narratives, it was also encouraged that the preceptors identified gaps in knowledge that limited their practice as educators. When making the movement to reflect on their own reality, the challenges and strengths that surrounded their daily activities, they felt compelled to look for answers that could support them in the qualification of educational practices and health care. Thus, the pedagogical spaces of the course supported the search for theoretical references and other systematized experiences that could dialogue with their concerns.

The first narrative requested in the first meeting of the course was about their previous training path up to the moment of entering the course. It was hoped to outline a “baseline” on educators’ understandings of their own life paths in connection with their unique training processes until they took on the current role of educators in the context of the Residency Program.

The process of monitoring the writing of the narratives and mediation of the trainer with the educators involved individual meetings, monthly or bimonthly, scheduled according to the need for dialogue between educators about their writing process. The meeting had a short duration and was based on the trainer hearing about what each educator wanted to present: the advances in the writing of the memorials. The questions arose during the dialogue from the selections narrated by each educator and were intended to expand the reflective movement of authorship. Regarding the authoring processes, Passeggi and Cunha (2013, p. 46, our translation) affirm that they are “[...] autobiographical narratives, the author (consciously or unconsciously) chooses, selects, organizes the facts in a plot, manages and adapts this plot, transforming beliefs and values ​​through reflection, giving meaning to what had no meaning before [...]”.

Thus, we understand the monitoring process (PINEAU, 2002, 1998) and mediation in the relationship between trainers and educators as a constant and continuous movement of sensitive and welcoming listening as to the singular experiential learning, implying support for educators in their writing path, through dialogue and problematization without judgment or prescriptions. The meeting between trainer and educators is an opportunity to review, speak, reflect and re-elaborate their experiences and records, as well as the (self)formative possibility linked to the processes of writing about oneself and biographical reflexivity.

The notion of monitoring and its relationship with (auto)biographical research emerges from the francophone movement of life stories in formation, enabling us to understand that monitoring, in the context of the education of trainers, makes use of epistemological principles of life stories in training and means walking together, sharing experiences, participating in professional development or reintegration through non-directive mediations about the story and uniqueness of the adult in constant learning and training.

The approximations between monitoring (PINEAU, 1998, 2002) and biographical work (DELORY-MOMBERGER, 2004, 2008) are made from the work of mediation of training and (self)training practices experienced by subjects in their life paths-training. To Pineau (1998), the notion of monitoring is linked to an anthropological dimension, since, from the word - oral or written - the adult in training questions professional and existential conditions, seeking other meanings for their life-training.

At the end of the specialization course, each educator was asked to re-read and analyze the narratives, seeking to find recurrences, nuclei of meaning and more mobilizing points related to their life-training trajectory. Based on the analysis, they should reorganize and complement their narratives, if they found it necessary, based on new learning resulting from the socialization of experiences and reflective and analytical exercise on their own stories and formative trajectories. Thus, each educator produced a training memorial, with the production of a final text organized from freely titled sections that marked experiential learnings built throughout life and training-profession.

Ways of saying and becoming a health educator: to be unfamiliar, to train and to be trained

When analyzing the memorials written by three preceptors in 2017, in the context of the Fesf-SUS Residency Program, in Bahia, in the specialization course in Health Education for Preceptorship in the Brazilian Unified Health System, we will take as corpus of analysis three memorials built by a dental surgeon, a nurse and a Physical Education teacher, as preceptors. Three thematic axes mobilize our reflections on the process of writing the memorials and the formative implications for the three collaborators. The first axis focuses on the discussion of issues of “initial unfamiliarity to the act of narrating life”; the second urges us to think about the relationships between “narratives, training paths and recognizing oneself as an educator”; and the third is anchored in “reflections on the formative process in connection with life”. The thematic axes emerged from the exercise of writing, monitoring and biographical mediation, attentive listening and reading and re-reading processes of the memorials, enabling us with comprehensive-interpretive inferences (SOUZA, 2014) of the life-training paths of the preceptors, health educators.

The first narratives briefly registered aspects related to life, education and work trajectories. When narrating previous experiences, the educators expressed at first unfamiliarity to the format of the memorial and reflected on their difficulties in writing freely what they thought and felt about the lived, the world of life. On this issue, the E1 memorial shows that:

Before beginning my reflective narrative, I confess that it was not an easy task to narrate the facts experienced, to detach myself from traditional formats and that imprison us in a model that does not allow us to be creative and free to write as subjects, in the singular of the word, convey the rhythm, tone and emotions that are at stake in what is being reported. The reflection? I am changing my way of thinking and in this exercise, reinventing myself and updating my memories as a student and educator, rethinking my practices. What did I discover? The memories do not remain intact because we also change, after all, we are historical subjects, unfinished as Paulo Freire (2002) said, and more than that, subjects who are continuously writing and rewriting their life story (E1).

The excerpt from E1 memorial narrative highlights the discovery, by the educator, about the importance of writing and the difficulties initially linked to the writing of the memorial. It registers the perception that his current interpretations are part of a historical, social and political context, are crossed by a set of representations and beliefs constructed collectively and individually that are in constant transformation, being, therefore, a “portrait” (DELORY-MOMBERGER, 2012) about what he thinks at that moment and in that specific context.

The educator remembers previous moments of his education and reframes the model of education that he considers to have “imprisoned” him, by not allowing his creativity and freedom to narrate what he thinks and feels. The possibility of a critical education happens when the educator leaves a position of merely transferring knowledge, imposing memorization of contents and allows students to assume the role of their learning. “The democratic educator cannot deny the duty, in his/her teaching practice, to reinforce the critical capacity of the student, his/her curiosity, his/her resubmission” (FREIRE, 2000, p. 26, our translation). Thus, the memorials for education can support the educator to revisit his personal references, in the sense of remaking his story as a student and as an educator, in the interaction with his students, supporting them to speak, write and free themselves from possible bonds in order to express themselves.

With regard to the fertility of narratives, their relationship with formative paths and movements to recognize themselves as educators, we highlight that the origins and motivations for choosing a health profession and the path to becoming an educator are demarcated in the initial exercise of narratives. The implication is noticeable and determinant in the decision to occupy the current space, as can be seen in the excerpt of E2’s narrative, when she states that:

I decided to take a course in the health area because I believe in the potential of care: a creative path for a health service capable of transforming, repositioning human beings and their surroundings. A recreation of oneself. The care of each other. Traditional, ancestral values ​​and knowledge, articulated with new knowledge and technologies, in a shared, collective and public way.

However, through this dream, I realized that I was inadequate during my undergraduate course in Dentistry [...]. Despite having joined the Center for Integrated Research in Collective Health (NUPISC) during my undergraduate course and having professors who defend Public Health and the Unified Health System, in the game of forces, expressed in the micro behaviors of students and professors, there was much more a reproduction of training and health work fragmented and focused on a relationship of the private market. It was my need to extrapolate this health training circuit, to go beyond the banking education paradigms that imposed a pattern that reproduced a social logic that I do not share, and a logic of existence in society that was not enough to produce meaning for me. I went through Pedagogy, Philosophy and at a certain point I would distance myself from the Health Sciences thinking that this is a path of no return. It was then that I had the opportunity to join the Multiprofessional and Medical Residency Program in Family Health by the State Foundation for Family Health (FESF-SUS), linked to the Oswaldo Cruz Foundation (Fiocruz) and the Ministry of Health (E2).

The training of health workers has been undergoing transformations, driven by the new curricular guidelines of health courses (BRASIL, 2001), and investments in the renewal of projects to include training for health promotion, prevention, recovery, rehabilitation, humanization, general training and expansion of autonomy to learn.

Undergraduate and graduate health courses currently experience a moment of transition from conceptual and practical paradigms, both in the conceptions of the health field and education. The practice of educators is permeated by the reproduction of contradictory educational practices (DAMIANCE, 2016) between the valorization of individual biological care - reductionist conception of health - versus care as a collective and individual intervention on the results of the population’s ways of life and work - expanded health conception -; between prescriptive, vertical pedagogical practices, centered on the professor and with a disconnection between theory and practice versus emancipatory practices with the encouragement of reflexive criticism focused on action and the new practices resulting from it.

At the end of the undergraduate studies, I decided to take the Multiprofessional Residency in Family Health (RMSF), I tried in many programs and passed the selection of the Faculty of Medical Sciences [...]. I had the opportunity to compose a Family Health Support Center (NASF) with seven different professional groups: Psychology, Nutrition, Physiotherapy, Speech Therapist, Occupational Therapy, Social Work, and Physical Education. In addition to a minimum team complete with a Doctor, a Dental Surgeon and a Nurse, in the Family Health Units (USF) of [...]. During the residency it was a time to discover a new world. A variety of health programs, the possibility of offering that I had not even heard of during undergraduate studies.

A passionate moment in my professional career. Possibilities that fit with the thought of generating equity, and mutual learning between a user who knows what he/she wants and a professional willing and available to assist him/her in this search (E3).

The educators who narrated their experiences are graduated from other residency programs or from the program in which they now assume a new role, went from students to educators in a few years. The narratives refer to the influence of this path, to the implication and motivation to qualify, while it is also evident how challenging the position change in the same work context is, producing an intense process of self-assessment, being affected and significant learning.

Meeting in a residency with people open to criticize and reflect on their teaching-learning-service processes (actively) contributed to rethinking my training as permanent and focused on the integrality of health care in the Unified Health System in its ethical and political character. Living side by side with others [users and health professionals] with whom it is possible to jointly face the difficulties of health institutions and services makes alterity the most transforming and challenging aspect in the training of professionals to build and work in the Unified Health System, and I wish to remain part of that process.

Now, instead of tutoring, new challenges are presented to me. How in this other place can I be a transforming agent of this mechanized care logic and of an education of reproduction? How can I subvert and contribute to the construction of my first care dream in the teaching-service practice? It makes sense because this dream is not just mine, but of many! (E2).

This new challenge made me realize the fragility that is the role of preceptor and how I often saw myself without knowing if I am helping residents to develop or if I am pruning this growth. This fragility became more and more evident in the training spaces of the pedagogical staff of the FESF Residency (E3).

The discussion about the role of the preceptor in the context of health residences points to the constitution of a subject who must aggregate multiple actions, which inevitably imposes a tension so that he/she can meet so many needs that reality presents. If before the professional had only the responsibility for a territory and the care of people, which was already heavy and complex for most professionals, when he assumed the role of preceptor, also assumed the pedagogical responsibility for the training of other workers and other tasks of managing the educational process and the consequent expansion of the complexity of the health service itself by adding more workers, since:

The territory preceptor’s role is to be an educator and a caregiver: to be responsible for the permanent education of professionals, within the perspective of health promotion, to take care of the resident in his/her training and performance in the territory and of the issues related to residence; as well as taking care of the health team in which the resident is inserted. (PAGANI; ANDRADE, 2012, p. 105, our translation).

The spaces for listening and supporting the educators who are understanding each other in this new place become essential for the training of these subjects. The institutionalization of permanent education spaces can accommodate the concerns and doubts that arise about the actions to be developed and especially shelter the need for a reflective space for the consolidation of these workers in the role of educators, strengthening the relationships between people and resulting in qualification training and health care processes.

The narratives focused on reflections on training processes in connection with life show the recognition of the role of emotions. When considering and stimulating them in the process of writing the narratives, the training of educators takes other forms. When affected by mobilizing situations, they potentially carry transformations for all dimensions that make up their life. The narratives of the memorials make it possible to perceive that the changes happen not only in the experiences of insertion at work because the dimensions of people’s lives are inseparable.

During the course, I managed to achieve competencies of better listening to the different and not imposing my position on the other. I learned to evaluate and reassess in different ways and the importance of understanding that each type of evaluation has an objective in training and learning.

The course not only met my expectations of rethinking and modifying my work process, it also exceeded them in the first month. PSUS [Preceptors in the Unified Health System], after my residency, was where I found myself most as a person and professional. I had not yet taken a course that would change me so much in several aspects of my life as a NASF [Family Health Support Center] student, professor or professional along with users, students and colleagues, whether they are in university level management or not. The different forms of approach to any theme of life, taking into account previous experiences are increasingly internalized in my syntheses and new synthesis of knowledge (E3).

The adoption of the narrative device, anchored in the writings about oneself in the training memorials, demarcates fertilities for the reshaping of the narrative identity of the preceptor-educator in health, as well as interactions between educators and students, producing movements of progressive “waves” of repositioning and resignifications of these subjects who, in this reported context, positioned themselves favorably to the implementation of another health and education model, making themselves available and open to individual and collective changes in the field of training and professional practice, as health educators.

(In)conclusive dialogues: context, narratives and health education

The current context in Brazil fatally influences and slows down the changes that until 2016 were progressively advancing in health education. The context of the parliamentary legal coup that has been producing intense political and institutional instability in Brazil, followed by an election surrounded by a lot of violence, manipulation and virtual fraud, associated with an intense economic crisis and, more recently, the serious health crisis with the Covid-19 pandemic, affects health and education with financial restrictions to maintain the health services of the Brazilian Unified Health System and public universities, with cuts in the resources implemented more intensively since 2019. These factors have been producing a scenario of insecurity and instability also in all projects recently implemented in the last decade. As one of the most striking examples, we highlight the “Mais Médicos” [More doctors] Program (BRASIL, 2013), which imposes a setback not only in the provision of medical professionals in all regions of the country, resulting in a perverse lack of assistance to the most vulnerable populations, but also destabilizes the complex health training policy that was linked to the formation axis of this national policy, including the expansion and offer of scholarships for residency programs in family and community medicine and multi-professional in family health, areas that are crucial to reverse the health care and education model, and which resume practical learning in the community and at home in real contexts of people’s lives.

It is also essential to understand the praxis of health educators who continue to work in

the Unified Health System services, that is, to understand the process of problematizing reality, seeking solutions, transforming reality with their own action and at the same time transforming themselves, exercise a critical conscience based on the subjectivity-objectivity dialectic, a liberating praxis (FREIRE, 1987, p. 27). How are these educators constituted? How do they build their identities? What are the possibilities of education in their life trajectories? How have singular education movements been formed in dialogue with the institutional offerings of public policies for teacher training in the last period, connected to the social context of contemporary times?

When discussing the influence of the State in the fabrication of educators’ identities, Lawn (2001) states that laws and norms determine the reorientation of educational policies in different historical periods and impact on identities and ways of regulating them. The author finds some aspects involved in the construction and maintenance of identities, among them: the growth in the number of educators, the social instability resulting from low wages, the strengthening of an image of moral and servile example, the growing regulation, control and charging for efficiency in the work process. The existence of a discursive standard on what it means to be an ideal educator in each period is connected to the national project to be implemented. At the same time that educational policies try to standardize and police discourse, educators undeniably have their place of local power, within the school, in the classroom, in health services, in society. The idea of ​​ educators who do not conform to “official identities” causes distrust, such as, for example, the involvement of educators in social movements. From “colonized professional”, more submissive and “neutral”, to “modern professional”, to the educator who corresponds to the idea of ​​performance, individualization and leadership that has circulated in more recent times, identities remain in dispute and strongly influenced by the State and the competitiveness imposed by the capitalist system.

The dimension of the construction of identities from the perspective of health educators in the context of public policies for the training of preceptors for the Unified Health System, linked to the understanding of the teaching work conditions associated with the professional socialization movements of the Unified Health System preceptors, can be problematized from three theses presented by Dubar (2012), namely:

1. The workers, regardless of race, gender, religion, learn duties during their lives, they are recognized based on skills that can be certified and that allow them to get a job, and this learning is not necessarily acquired through formal instruction in schools, but at and through work, through the experiences and skills acquired. This learning involves subjective engagement. Do health workers, when experiencing educational practice in health services, develop skills for preceptorship and start to be socially recognized as educators in their contexts?

2. Vocational training is not restricted to just one stage of life or the stage of schooling. Learning takes place throughout life and is driven by the need to change jobs, professions or work, in addition to the requirements imposed by new technologies and public policies or by large companies. On-the-job training has become as important as the initial training of workers. Monitoring this second thesis, we highlight the concept of permanent health education that has sustained a paradigm shift in health education, whether in the practice of preceptors with other workers or in the pedagogical training of preceptors, a conception that recognizes and values ​​“[...] relational skills, for learning reflexivity at work [...]” (DUBAR, 2012, p. 365, our translation).

3. Training stages associated with work, whether in the form of internships or other names assigned to this entry into professions or careers through an initial period of low wage or even temporary absence of wages, have been increasingly common in several areas and several countries. It is important to consider that there is a diversity of organization of jobs, professional training and careers, associated with different social traditions and political regimes. In health, in Brazil, in the specific context of health residencies, a great deal of experience accumulates in the differentiation of this first professional stage, associating work with in-service training, but with several specificities that will be explored in the course of this research, but which they allow the absence of remuneration, with a national system of grants financed primarily by the Federal Government, through the Ministries of Health and Education, in addition to state and municipal health departments. In this case, what is still worth exploring is the controversy over the specific remuneration for the exercise of preceptorship, when the health worker joins in as an educator, accumulating new activities within the health services. There are different experiences in the country, from the absence of specific remuneration to the valorization of preceptorship with the payment of scholarships, rewards and bonuses.

Teaching work conditions can be broadly understood considering the work process in a given historical-social and economic context, in addition to the objective, structural or physical resources necessary for the development of work, but also the employment conditions as contractual relationships, remuneration, stability, in addition to the resulting living conditions. It is also interesting to understand in the teaching work conditions in health the meaning that they attribute to the educational work associated with health care work, the satisfaction of relationships based on investments and development possibilities in that context. Also understand the relations between employer and employees, intensification of work, precariousness, possible risks, constraints and pressures, commonly present in the working conditions of a capitalist society (OLIVEIRA; ASSUNÇÃO, 2010).

Also, recognize the processes of strengthening and attrition that constitute the sphere of social reproduction. The understanding of the object of collective health, with the analysis of the profiles of social reproduction and those of health-illness, also allow us to broaden the reading about the working conditions, while the ways of working and consuming, the way they produce and distribute their work socially, the forms of organization, the relationships established between people to produce social life, the social class belonging and the articulated ways of life are elements that need to be taken into account in the biopsychic expressions of each educator’s individual story (VIANA; SOARES; CAMPOS, 2013).

When analyzing health education historically (PADILLA, 2020), we can see that the disputed movements established especially during the last century and intensified in the last decade in Brazil were moving towards the restoration of the principles of humanistic training, of learning that values experience, which transcends illness, which defends life and human relationships, health as a universal right.

Health education has accompanied the revolutions and counter-revolutions in the history of education. The creation of school systems at the service of state, religion and industry bureaucracy also determined the training of health workers in order to train and control bodies for work. Capitalism was the most powerful factor of intervention on the school and has been a determining factor in the dispute of conceptions about health and educational practices in health.

In the current scenario of so many uncertainties about the possible consequences of the current pandemic of Covid-19, there is a latent doubt about the transformations in health education. The recent setbacks in financing and education and health policies in the country will inevitably lead to a reflux of progressive movements, resistance and political engagement of managers and educators who took on the challenge of establishing new educational spaces in the past is what remains at a time of such a global and national crisis.

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• 1
  Translation by Janete Bridon. E-mail: [e-mail]. Proofreading: Louise Potter. E-mail: [e-mail]
• 2
  Note of translation: Movement that seeks the Permanent Education in Health.

Publication Dates

• Publication in this collection
  26 Apr 2021
• Date of issue
  2021

History

• Received
  23 July 2020
• Accepted
  01 Sept 2020