Students's point of view of their professional preparation to practice in the Brazilian Universal Health Care System

Abstracts

OBJETIVO: Apresentar e discutir resultados de consulta feita aos estudantes da área da saúde da Universidade Federal de Santa Catarina, sobre aspectos de sua formação relacionados ao Sistema Único de Saúde (SUS) e participação popular e seu entendimento sobre a Carta dos Direitos dos Usuários da Saúde, discutido com os participantes da pesquisa supra-citada. MÉTODOS: Como método foi aplicado questionário estruturado, complementar à coleta de dados qualitativos, a 145 estudantes de graduação de cursos da saúde. RESULTADOS: O resultados apontam mudanças no perfil dos estudantes nos cursos adequados às diretrizes curriculares. Destacam interesse em trabalhar no SUS, mas a remuneração é fator impeditivo; percebem os usuários como pessoas de poucos recursos financeiros; desconhecem os princípios da Carta, concordam com a humanização. CONCLUSÕES: sugerem que a participação popular e controle social são pouco valorizados pelos estudantes e considerados como fragilidade na formação.

Sistema Único de Saúde; Pesquisa em Enfermagem; Educação profissionalizante; Direitos do paciente; Educação superior

ORIGINAL ARTICLE

Students's point of view of their professional preparation to practice in the Brazilian Universal Health Care System^*

La mirada de los estudiantes en su formación profesional para el Sistema Único de Salud

Alacoque Lorenzini Erdmann^I; Anna Carolina Ribeiro Lopes Rodrigues^II; Magda Santos Koerich^III; Dirce Stein Backes^IV; Livia Crespo Drago^V; Patrícia Klock^VI

^IProfessor of the Department of Nursing and Post Graduation Program in Nursing of the Universidade Federal de Santa Catarina - UFSC – Florianópolis (SC), Brasil; Researcher of the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

^IIStudent of the Undergraduate Nursing Course of the UFSC - Florianópolis (SC), Brasil; Member of the GEPADES; Fellow of the Programa Interinstitucional de Bolsas de Iniciação Cientifica do CNPq (PIBIC) by the CNPq

^IIIPostgraduate student (Doctor); Assistant Professor of the Department of Pathology of the Universidade Federal de Santa Catarina - UFSC – Florianópolis (SC), Brasil

^IVPostgraduate student (Doctor) of the Post Graduation Program in Nursing of the Universidade Federal de Santa Catarina - UFSC – Florianópolis (SC), Brasil; Brazil. Fellow by CNPq

^VStudent of the Undergraduate Nursing Course of the Universidade Federal de Santa Catarina - Florianópolis (SC), Brasil. Member of GEPADES. Fellow voluntary

^VIPostgraduate student (Masters), Nurse in Neonatal Intensive Care Unit of the Hospital Universitário of the Universidade Federal de Santa Catarina - UFSC – Florianópolis (SC), Brasil. Fellow by CNPq

Corresponding Author

ABSTRACT

OBJECTIVE: To identify and describe the point of views of healthcare students from the "Federal University of Santa Catarina - Universidade Federal de Santa Catarina (UFSC) regarding their professional preparation to practice in the "Brazilian Universal Health Care System - Sistema Único de Saúde (SUS), the participation of the general population in health care issues and their understanding of the patients bill of rights.

METHODS: Data were collected using a structuralized questionnaire to complement other qualitative data from 145 undergraduate healthcare students.

RESULTS: Findings suggested changes in the profile of the students concerning the healthcare core curriculum. Students reported interest in working for the Universal Health Care System, but they expressed that salary paid by this public health care system may be a disincentive. They perceived that the people have limited financial resources and do not understand the patients' bill of rights. Students support humanization of health care services.

CONCLUSIONS: Students did not see great value of the participation of the general population in health care issues or social control. This may suggest inadequate professional preparation.

Keywords: Single Health System; Nursing research; Education, professional; Patient rights; Education, higher

RESUMEN

OBJETIVO: Presentar y discutir resultados de consulta realizada a estudiantes del área de la salud de la Universidad Federal de Santa Catarina, sobre aspectos de su formación relacionados al Sistema Único de Salud (SUS) y participación popular así como la comprensión de la Carta de los Derechos de los Usuarios de la Salud, discutido con los participantes de la investigación antes mencionada.

MÉTODOS: Como método fue aplicado un cuestionario estructurado, complementario a la recolección de datos cualitativos, a 145 estudiantes de pregrado de cursos de la salud.

RESULTADOS: Los resultados apuntan hacia cambios en el perfil de los estudiantes en los cursos, adecuados a las directivas curriculares. Destacan su interés por trabajar en el SUS, sin embargo la remuneración es el factor de impedimento; perciben a los usuarios como personas de pocos recursos financieros; desconocen los principios de la Carta, concuerdan con la humanización.

CONCLUSIONES: Sugieren que la participación popular y el control social son poco valorizados por los estudiantes y considerados como fragilidad en la formación.

Descriptores: Sistema Único de Salud, Investigación en Enfermería; Educación profesional; Derechos del paciente; Educación superior

INTRODUCTION

Nowadays, qualification of future professionals in the area of health is influenced by different socio-economic-political circumstances, as well as by job market trends for the several related professions. In this context, students' involvement in social issues is an aspect that has been heavily promoted by the Ministries of Health and Education, pointing to the possibility of meeting the actual requirements of the Brazilian population regarding the formation of human resources, production of knowledge, and provision of services comprising the Sistema Único de Saúde (SUS – Unified Health System).

One example of this trend is the Pró-Saúde (Pro-Health), a program launched in 2005 by the Ministries of Health and Education, geared to higher education institutions that offer courses in the area of health, and aiming towards undergraduate qualification in the country and primary care needs, symbolized by the Estratégia de Saúde da Família (Family Health Strategy) in Brazil, coming closer together⁽¹⁾.

At the Universidade Federal de Santa Catarina (UFSC), the Nursing, Medicine and Dentistry courses had their curriculum reform projects approved by the Pró-Saúde. These changes have led to an increase in the number of students receiving training in primary health, in addition to the traditional training programs conducted in public hospitals and school clinics.

The way work processes and health professional qualification are structured and managed "have caused them to remain apart from sector management organization and the critical debate about health care structuring systems, revealing that they are completely unaffected by the social control over the base sector of the official Brazilian health model"⁽²⁾. Such statement points to the need for studies that include the practice of professionals qualified and how these professional practices should be, according to the country's needs. "The way work processes are structured and managed is one of 'the major obstacles' faced by proposals that aim to change the technical-clinical health model in Brazil, which has been found to be committed to many types of interest, except for the citizens' health⁽³⁾.

"We live at a time when profound changes in the health professional qualification system are required, because the current, individualistic and anthropocentric system does not meet either the needs of people or those of the health work process any longer"⁽⁴⁾.

The expansion of the concept of health conducted by the Reforma Sanitária (Sanitary Reform), in addition to the growing process of health decentralization, which sped up in the 1990s, should function as a catalyst for change, both in the field of health practices and in that of professional qualification.

Thus, given the pluralism observed in modern society and the complexity of health problems, in addition to the growing sophistication imposed by technology, the educational system needs to rethink its role as qualification provider for professionals who will act in this same society. They will be involved with technical, scientific, social and ethical issues and it is expected that they will be prepared to use their knowledge when decision-making is required⁽⁴⁾.

Several initiatives and programs have contributed for the development of critical thinking and the movement for qualification process changes, such as the Programa de Interiorização do Trabalho em Saúde (Health Work Internalization Program), the Programa de Incentivo às Mudanças Curriculares nos Cursos de Medicina (Incentive Program for Curricular Changes in the Medical Course), the Programa de Capacitação e Formação em Saúde da Família (Family Health Qualification Program), the Programa de Profissionalização dos Trabalhadores da Área da Enfermagem (Professional Qualification Program for Nursing Professionals), the Programa de Aperfeiçoamento ou Especialização de Equipes Gestoras (Professional Development and Specialization Program for Management Teams), and the Programa de Formação de Conselheiros de Saúde (Health Advisor Qualification Program). All these programs "enabled people and institutions to mobilize, in the sense of such institutions providing qualification and SUS actions and services coming together"⁽²⁾.

Given the changing circumstances of educational and health institutions in the country, researchers conducting this study felt the urge to question the following, "To what extent are students enrolled in health courses, the main participants in this process, adhering to the current qualification trends?". In addition, "What do they know about and expect of the SUS, as well as the users and social representation institutions associated with it?"

These questions arose from the results of a research-action developed in the project entitled "Humanization and health user rights as basic principles of citizenship", where meetings with SUS users to discuss the Carta dos Direitos dos Usuários da Saúde (Health User Bill of Rights) were held. This study was conducted in a public hospital of a city located in Southern Brazil. During the meetings with users, their opinions about health professionals were found to be contradictory in several accounts, with a significant difference in care provided by the several health profession representatives. This fact encouraged researchers to search for the origin, beyond the technical competences of each profession, and the differences in service given to users by nurses, doctors and dentists especially. These reflections showed the health professional qualification as an essential tool for future professionals to effectively participate in the SUS consolidation as they join it.

Such aspects characterize the current trends of qualification proposed by the Lei de Diretrizes Curriculares do MEC (Ministry of Education and Culture Law on Curriculum Directives), based on distinct official opinions from the Câmara de Educação Superior do Conselho Nacional de Educação (National Education Council Higher Education Chamber), and including all sectors of health and biological sciences – Biomedicine, Biological Sciences, Home Economics, Physical Education, Nursing, Pharmacy, Physiotherapy, Phonoaudiology, Medicine, Nutrition, Dentistry, and Occupational Therapy⁽⁵⁾.

This study aims to present and discuss results of a consultation with Universidade Federal de Santa Catarina (UFSC) health students about aspects of their professional qualification for the SUS and public participation in health, as well as their understanding of the content of the Carta dos Direitos dos Usuários da Saúde, a document initially presented to and discussed with users who had participated in the above mentioned research.

METHODS

During the performance of a study that used research-action as its method, participants pointed out that lack of information and relationship problems between professionals and users were very common. In addition, they emphasized the interference in the qualification of future professionals as one of the measures that can resolve this problem.

Thus, after considering the curriculum reform process that occurred in many higher education institutions, including the UFSC, a structured questionnaire was designed, with open and closed questions, to compare the opinion of students enrolled in courses that have already had the new curriculum proposal implemented, aimed at the SUS and its directives, with that of students whose curriculum continues to follow the traditional model.

The use of a quantitative tool as a procedure that complements qualitative data collection was proposed by researchers, not only to search for information, but also as a tool to develop practical research abilities with the PIBIC-funded students and doctoral students involved with the project. The analysis was not restricted to statistical data exclusively, but sought a theoretical reflection akin to qualitative research, which does not intend to have generalizations.

In this tool, designed by undergraduate students, the following were dealt with: expectations about the SUS as job market; acquisition of academic knowledge about the SUS; profile of the professional for this system; participation in social representation institutions; and knowledge about the content of the Carta dos Direitos dos Usuários da Saúde⁽⁶⁾. Such characteristics were considered important for future professionals to work in the SUS.

The first idea was to apply the questionnaires to all students from a certain stage of their undergraduate studies, randomly selected from each course of the Centro de Ciências da Saúde da UFSC (UFSC Health Sciences Center). Sample was not calculated by conventional parameters of quantitative research, once it aimed to be an academic exercise to triangulate qualitative data collection tools.

Thus, in October 2007, of all the 225 students who represented one of the stages of each course, 145 answered the questionnaire and comprised the sample.

Participants were distributed as follows: 21 students of the seventh stage of Nursing; 24 of the seventh stage of Pharmacy; 25 of the sixth and eighth stages of Medicine; 34 of the fourth stage of Nutrition; and 41 of the third stage of Dentistry.

This project was approved by the Comitê de Ética em Pesquisa com Seres Humanos da UFSC (UFSC Human Research Ethics Committee), registered under nº 074/2007. The remaining ethical aspects are expressed with the fulfillment of the Conselho Nacional de Saúde (National Health Council) recommendations from Resolution nº 196/96. Participants were informed about the objectives and methodology proposed, shown the Informed Consent Form, and guaranteed access to data and anonymity. As a result, the written contributions used in this study are identified by the first letter of each course (NR, P, M, NT, D), representing the Nursing, Pharmacy, Medicine, Nutrition, and Dentistry courses respectively.

RESULTS

Before beginning the statistical analysis and categorization of questionnaire responses, researchers believed they would find significant differences in responses, according to courses, especially those that had already had the new curriculum implemented, aiming at professional qualification for SUS, emphasizing primary health care, and based on humanistic philosophies, whereas the previous curricula prioritize the biological-technical model.

The directives for new curricula meet the SUS educational policy, whose concept of qualification for the area of health involves education, management, care and social control. This qualification is part of the health system management, changing the image of the services as health management and care, and valuing social control⁽²⁾.

However, even though not all courses underwent the curriculum reform process, the majority of university students reported having received some information about the SUS during their undergraduate studies, as shown on Table 1.

The fact that many students had different levels of knowledge about the SUS also reveals similarities in terms of the characteristics professionals should have when dealing with public health. The following expressions, characterizing skills SUS professionals are required to have, were frequently mentioned by students from all courses: "to know how to deal with people/needy or poor patients" (M), "to know how to adapt to difficulties" (NT), "patience" (D), "responsibility" (NR), "social commitment" (NR), "willpower" (P), "to know the SUS" (M), "to deal with the community" (M), "to like what you do" (D), and "to deal with the poor" (NT). These expressions, due to significant repetition, represent categories that characterize SUS professionals, according to students.

In addition, more than half of the students intend to work in public health services, except for representatives of the Nutrition course and a great number of the Dentistry course. The highest number of people interested in following a career in public health predominates in the Nursing and Medicine courses, as shown on Table 2.

It should be emphasized that these two courses have already had curriculum reform implemented, meeting the directives proposed in 2001, aimed at a general qualification, with a sense of social responsibility and commitment to citizenship. This allows students, from the start, to learn about the different levels of health care, enabling contact with the SUS in many practical situations. Thus, with foresight, professional qualification for the SUS can be viewed as one possible path for the system to be consolidated and meet the population's actual health needs, once future professionals can be informed not only about the private system, but also about the SUS, as a professional possibility and goal.

For those who intend or do not intend to work with public health, regardless of health care level, the arguments that justify students' choices are somewhat similar, irrespective of their course. In this analysis, the relationship between health system and economic conditions as determinants and even restrictive factors, when choosing to work or not to work with public health, is remarkable.

Furthermore, it is curious to observe the paradoxes among questionnaire responses, once what represents strength and a source of motivation to work for SUS for some students, it is precisely a weakness of the system for others, as shown by the sample accounts given by those who intend to work in the SUS, in contrast with those who do not, according to all courses. Thus, Nursing students emphasize better pay and working hours – "stability and guarantee of salary, employment and retirement", "better pay"; whereas Pharmacy, Medicine and Nutrition students consider the low pay – "low pay", "delay in payment" or, yet, the excessive hours of workload emphasized by medical students – "many working hours", as opposed by Pharmacy students, who consider the hours of workload as providing an opportunity for other jobs – "a workload that enables you to have another job". Dentistry, Medicine and Nursing students also pointed out the possibility of financial stability, with similar responses – "good pay and financial stability", "there is stability, a career and retirement".

These discrepancies in opinions reflect students' aspirations, not only as regards their placement in the job market, but also as regards financial payback. The area of human resources in health currently combines old problems, still associated with pay, with more recent problems, resulting from the post-industrial society, with multiple, diversified interests⁽⁷⁾.

"However, in the perspective of the SUS consolidation, it is important to maintain the focus on the advances already made. In addition, it should be considered that the SUS has enabled the job market for health professionals to increase more and more since the 1980s"⁽⁷⁾. In this context, the Programa de Saúde da Família (Family Health Program) stands out, with important contributions for these results, once municipal health systems have hired several professionals such as doctors, nurses, nursing assistants, health community agents, dentists, consulting room assistants and dental hygiene technicians.

Moreover, it became evident that, from the categorization of responses, while many students viewed the SUS as a possibility for social change, according to their accounts: "to contribute to consolidate the system" (NT), "to know society's problems" (D), "to contribute to the SUS/give something to society in return" (M), "multiprofessional work" (P), "the SUS can improve with the effective participation of professionals" (NR), others viewed it as an old-fashioned system, with little possibility for growth: "lack of resources" (NT), "lack of structure" (D), "absence of a career plan" (M), "I have other personal and professional interests" (P), "practice is very different from the theory and lack of services for the demand" (NR).

These accounts do not reveal new facts and are in accordance with what is known to all – health professionals, students, users, the press, and politicians. In other words, everybody knows where the weaknesses are.

According to public participation and social control in health, students were questioned about their participation in social control institutions. Only five interviewees participate in one of these institutions, whereas the remaining ones do not know about their existence or know about it, but are not involved with its activities. The Dentistry and Nutrition courses were those that had the highest rate of students who had never heard of the Conselho Local de Saúde (Regional Health Council), even though they were aware of the Associações de Moradores (Residents' Association). This is a concerning situation, once the SUS directives emphasize the Conselhos Locais e Municipais de Saúde (Regional and Municipal Health Councils) as forums for public participation and promotion of social control. The initiative for promotion and greater participation could come from professionals, as users learn about these organs through them. It is worth remembering that these courses have not had the new curriculum implemented or have just begun this implementation.

Another point to be analyzed is the students' knowledge about the content and existence of the Carta dos Direitos dos Usuários da Saúde do SUS. This document, issued by the Ministry of Health on March 30^th, 2006, aims to enable citizens to become aware of their rights as health system users and to contribute to the improvement of health service quality for Brazilian citizens. However, Table 3 shows that less than half of the students reported they were aware of the content of the Carta dos Direitos dos Usuários da Saúde, and none of them could correctly inform what principle they considered the most important, mentioning and at times mistaking SUS principles. Once more, the Nutrition and Dentistry courses stood out, with numbers that indicate the little knowledge about/interest in public health, as shown on Table 3.

The Carta dos Direitos dos Usuários da Saúde is comprised by six principles and each of them includes topics that detail the rights. These rights are as follows: the right to ordered and organized access to health services; the right to adequate and effective treatment with guaranteed quality and continuity; the right to humanized, discrimination-free service; the right to respect personal values and citizenship; the right to management commitment; and the right to user responsibilities⁽⁶⁾. It is essential that all students learn about this document, once it directly influences them. If users have rights, health professionals should at least respect them.

DISCUSSION

By analyzing responses, other questions were found to be implicit: What still needs to be done to consolidate the SUS? Are curricular changes enough? What is the role of public participation in social control? How to sensitize politicians to the need for greater investments in health? What is the commitment of the press to its role of opinion maker? These are questions that deserve more in-depth studies and reflection to search for plausible answers.

The qualification process of human resources in health must: stimulate critical, productive thinking; be in accordance with the service; be based on the problems of the population served, so that professionals can play a part in changing reality. This perspective of qualification emphasizes the role of higher education institutions in overcoming the mere, restricted reproduction of knowledge, also enabling the combination of erudition and creativity, which is very necessary to resolve public problems⁽⁸⁾.

Another relevant aspect of these results is the perception of a gap between practice and theory, as promoted in the academic environment, especially in the SUS-oriented courses. This is because the "role of perceiving reality and making sense in health belongs to both the SUS and the institutions providing professional qualification. It is the SUS's and these institutions' responsibility to permanently collect, systematize, analyze, and interpret information from reality; question to identify problems associated with work and educational and health institutions; and construct socially-oriented practices and meanings, with the active participation of sector management teams, professionals from institutions that provide qualification, users and students"⁽²⁾.

The exercise of professional practice needs to be contextualized, aimed at the community's needs and demands. In addition, it should intend to promote autonomy, citizenship, social participation, user satisfaction, and problem resolution, through commitment and welcoming between professionals and service users. This inclusion presupposes a close partnership between the academic world and health services, once it is through reflection and theorization, and based on practical situations, that the teaching-learning process is established^(8-9).

Another aspect that stood out unanimously in this study was the association between the SUS and poverty, i.e. the SUS as the poor people's system. It became clear in the students' speech, whether discussing their career choices or characterizing workers, that the SUS serves the low-income, low-class and intellectually-limited population exclusively. In addition, they believe the SUS is aimed at impoverished people who have no resources or a private healthcare plan, showing they are not aware of the SUS as the country's current Health System, with possibilities of funding and service in primary care, hospital care and specific areas. It is estimated that 90% of more complex health procedures and 97% of hemodialysis procedures, considered extremely costly, are funded by the SUS. Another good example concerns AIDS treatment. For such cases, those who have a private healthcare plan also fall back on the SUS as well, even if it is just to obtain expensive medication or exams.

This poverty-related view of the SUS is associated with the concept of health changing into a commodity, something that can be purchased. Health is more than a "thing", it is a value, a perspective, a project of standard of living, and a right. "The 'user/consumer' is, at the same time, a virtual, democratic individual in the construction of a health policy, rather than an impoverished person to be served by an institution that has become a 'service provider', which, in practice, denies the citizens' rights. [...] health service is a right of the citizen, even though health, as a right, is more than the health service"⁽¹⁰⁾.

Thus, it can be noticed that even with curriculum adaptations, changes in students' way of thinking are far from being achieved. Such changes are associated not only with the SUS as a poor people's system, but also with public participation in politics, education and health services. Thus, service providers have to know what is present in the user's symbolic dimension and, in this dimension, what the health-disease representation is and what their health service demands are⁽¹⁰⁾. The achievement of such objective is also associated with a qualification process of educators that includes the review of educational concepts, enabling students to become active agents in this process, with a critical perspective of their own professional practice⁽¹¹⁾.

FINAL CONSIDERATIONS

Qualification of health professionals, necessary for the SUS to develop and succeed, must be accessible to such an extent that it can be controlled by society, causing its social relevance to be in accordance with the implementation values of the Brazilian sanitary reform. To achieve this, it is necessary to invest in educational practices that are founded on their critical-reflective participation.

For the time being, curricular changes seem to have had no effect on students' way of thinking. However, at least for the Nursing course, involved with the SUS problems for a longer time, data collected point to an increase in the perspective of public health as job market and an opportunity to change society.

Even though the proposals included in the Plano Político Pedagógico (Educational-Political Plan) of health courses have good intentions, when qualifying for the SUS, it is important to emphasize an old, opposing force that has caused the strong technical-biological contents to be the only ones valid and meaningful for qualification. Based on the curricular and educational changes, attempts to break away from such logic can be noticed. However, critical education still has a long way to go, full of obstacles, until it can have an actual impact.

In the last years, the SUS has increased access to the population and its area of coverage, thus increasing the number of positions available. This shows that further advances are still required to consolidate the system, including curricular changes of health courses. The profile of graduates has found to be inadequate to prepare them to perform, according to comprehensive health care and practices that consider promotion, protection, prevention, early care, healing and rehabilitation actions.

Further studies on curricular changes and adaptations of health courses should be pursued, primarily seeking care for the population's health needs and consolidation of the SUS as the country's health system. There are great expectations for the performance of professionals who graduated according to the new curriculum, as they are the only ones who can prove or disprove the material and human investments made by schools and institutions that provide qualification to these professionals.

REFERENCES

References

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*

Estudo desenvolvido na Universidade Federal de Santa Catarina – UFSC – Florianópolis (SC), Brasil.

Publication Dates

• Publication in this collection
  16 July 2009
• Date of issue
  June 2009

History

• Received
  29 May 2008
• Accepted
  08 Dec 2008