Nursing dialogues during the pandemic: reflections, challenges and perspectives for teaching-service integration

Abstract

Objective

critically and reflexively address challenges and perspectives of professional nursing practice, training, and teaching-service integration in the context of the Covid-19 pandemic.

Method

the practical activities of a discipline that addresses the management of the Unified Health System were suspended during the pandemic. In view of this fact, a group was formed to discuss the professional practice, ensuring the teaching-service integration. From the dialogues and texts produced, this reflection was elaborated, using Institutional Analysis as a theoretical framework.

Results

some analyzers revealed challenges such as the influence and difficult access to digital technologies in teaching and in the work process, as well as the fear and insecurity experienced by the authors. The group analyzed their implications, sharing feelings and anguish, without losing sight of the necessary changes in the work processes.

Conclusion and implications for the practice

the Institutional Analysis contributed to carry out this study “in the heat of the moment”, in this pandemic context, bringing to light questions and contradictions experienced in health services and in the university, strengthening the teaching-service integration. But, due to the cut-off of time, practices and scenarios, this study has limitations regarding the impacts on teaching and the care provided, making it possible to carry out other research.

Keywords:
Nursing; Nursing course; Health services; Coronavirus; Teaching Care Integration Services

Resumo

Objetivo

abordar, de forma crítica e reflexiva, desafios e perspectivas da prática profissional da enfermagem, da formação e da integração ensino-serviço no cenário da pandemia da Covid-19.

Método

as atividades práticas de uma disciplina, que aborda a gestão do Sistema Único de Saúde, foram suspensas durante a pandemia. Diante desse fato, constituiu-se um grupo para discutir a prática profissional, assegurando a integração ensino-serviço. A partir dos diálogos e dos textos produzidos elaborou-se essa reflexão, tendo como referencial teórico a Análise Institucional.

Resultados

alguns analisadores revelaram desafios como a influência e o difícil acesso às tecnologias digitais no ensino e no processo de trabalho, além do medo e da insegurança vivenciados pelas autoras. O grupo analisou suas implicações, compartilhando sentimentos e angústias, sem perder de vista as mudanças necessárias nos processos de trabalho.

Conclusão e implicações para a prática

a Análise Institucional contribuiu para realizar este estudo “à quente”, nesse contexto de pandemia, trazendo à tona questionamentos e contradições vivenciadas nos serviços de saúde e na universidade, fortalecendo a integração ensino-serviço. Mas, mediante o recorte de tempo, práticas e cenários este estudo traz limitações quanto aos impactos para o ensino e para a assistência prestada, possibilitando a realização de outras pesquisas.

Palavras-chave:
Enfermagem; Curso de Enfermagem; Serviços de Saúde; Coronavírus; Serviços de Integração Docente-Assistencial

Resumen

Objetivo

abordar de manera crítica y reflexiva, los desafíos y perspectivas de la práctica profesional de enfermería, de la formación y la integración enseñanza-servicio en el escenario de la pandemia Covid-19.

Método

las actividades prácticas de una disciplina, que aborda la gestión del Sistema Único de Salud, fueron suspendidas durante la pandemia. Ante este hecho, se formó un grupo para discutir la práctica profesional, asegurando la integración entre enseñanza y servicio. A partir de los diálogos y textos producidos, se elaboró esta reflexión, teniendo como marco teórico el Análisis Institucional.

Resultados

algunos analizadores revelaron desafíos como la influencia y el difícil acceso a las tecnologías digitales en la enseñanza y en el proceso de trabajo, además del miedo y la inseguridad vivenciados por las autoras. El grupo analizó sus implicaciones, compartiendo sentimientos y ansiedades, sin perder de vista los cambios necesarios en los procesos de trabajo.

Conclusión e implicaciones para la práctica

El Análisis Institucional contribuyó a realizar este estudio “en caliente”, en este contexto de pandemia, planteando interrogantes y contradicciones vividas en los servicios de salud y en la universidad, fortaleciendo la integración enseñanza -servicio. Pero, a través del recorte de tiempo, prácticas y escenarios, este estudio trae limitaciones en cuanto a los impactos para la enseñanza y la asistencia brindada, permitiendo la realización de otras investigaciones.

Palabras clave:
Enfermería; Curso de Enfermería; Servicios de salud; Coronavirus; Servicios de Integración Docente Asistencial

INTRODUCTION

The National Curricular Guidelines (NCG) for Undergraduate Nursing Courses, approved by Resolution CNE/CNS No. 03 of November 7, 2001, make explicit the commitment to the principles and guidelines of the Unified Health System (UHS) and the training of critical and reflective professionals, based on ethical precepts, inserted in a historical and social context and able to intervene in the health needs of the population.¹

From the movement of curriculum change to meet the NCGs and the relevant legislation, the teachers of the undergraduate nursing course at a public university in the state of Minas Gerais, developed a discipline with the objective of knowing the organization and functioning of the health system, with regard to the management of the Health Care Network (HCN) in UHS. This course is taught to 3rd period students and has a total workload of 75 hours, 45 hours of theory and 30 hours of practical activities.

To develop the programmatic content of this discipline, a teaching methodology based on the dialogical conception of learning is used, centered on the critical analysis of the student who problematizes the main issues of the reality of health services, seeking to know the management of UHS and the user's path in the HCN. Until the second semester of 2019, theoretical classes were interspersed with practical observation activities, in the health services that make up the Sanitary Districts of the Municipal Health Secretariat.

Thus, at each practical activity the student experienced the reality of a particular health service: Basic Health Unit (BHU) and the Family Health Strategy; Specialty Outpatient Clinics; Emergency Care Unit (ECU) and Hospital. In these practice fields, the students were accompanied by teachers of the discipline and managers of each health service, with an average of seven students per teacher and a total of four visits of four hours each.

As of the first half of 2020, these technical visits could not take place due to the spread of the disease called Covid-19, caused by the SARS-CoV-2 coronavirus. On March 11th of that same year, this pathology was declared a pandemic by the World Health Organization (WHO)² and is affecting various sectors and services such as: health, education, commerce, among others, interfering greatly in the political, economic, social and cultural aspects.

This has led to the implementation of measures to protect and control the disease in various countries, in order to reduce the risk of infection and proliferation of the new coronavirus, such as temporary suspension of classes at universities, since teachers and students can be potential disseminators of this infectious agent.³

In universities, emergency remote education (ERE) has presented itself as a possibility to ensure the continuity of the teaching-learning process during the pandemic until a vaccine is available as a Covid-19 prevention measure.⁴ However, this immediate change is significantly impacting the educational system all over the world, which makes teachers, students and governments rethink their training, pedagogical processes, working conditions, school infrastructure, students' socioeconomic conditions, among other factors.

With regard to university education, it can be said that distance learning (DL) was already part of this academic universe, through the offer of undergraduate and graduate courses, courses, refresher courses, among other teaching activities. However, for health courses, such as nursing, it is not possible to offer them entirely in this teaching modality or remotely, due to the internships and practical activities that are fundamental to the training of nurses, professionals who provide assistance and manage care in health services.

Regarding the subject mentioned above, the theoretical content has been adapted to the RES modality and is being taught through virtual platforms with synchronous and asynchronous activities. However, the practical workload is still suspended and is not expected to be developed. This fact instigated us to think about how the relationship and integration between teaching and service would be in face of this discontinuity and uncertainty.

It is assumed that the “teaching-service integration can provide critical, creative and reflective thinking, since it is a deep interaction between its protagonists and the reality of health services”. This integration can be constituted as a pedagogical health workshop and, to be effective, it is necessary that a welcoming relationship occurs between both (teaching and service) and a dialogical relationship that provides analysis of the reality experienced by its protagonists (teachers, students, health professionals, managers, community, among others), stimulating the debate and reflection on the problems of the practice, besides providing mutual growth.⁵

In order to maintain, to some extent, the integration between teaching and care in the teaching-service relationship, the discipline coordinator and the monitors invited managers and nurses of the health care units where the students' technical visits take place, to form a kind of “pedagogical workshop on health in times of pandemic”. This workshop aims to discuss and reflect on aspects of professional nursing practice in the context of the pandemic, from an interlocution between concepts of the Institutional Analysis (IA) theoretical framework and the professional and academic experiences of the authors.

IA is a theoretical referential that aims to understand a given social and organizational reality and is centered on the concept of institution. This theoretical framework was born in France in the 1960s and, since the 1970s, has influenced several movements in Brazil, both in psychology and collective health.^6,7

One of its precursors, René Lourau, defined institution as a universal norm, e.g. marriage, education, wage labor, but also as the act of founding something, e.g. a family, an association or the creation of a company. Institutions, too, are represented by visible social forms, endowed with a legal and/or material organization, such as factories or hospitals.⁸

The concept of institution is complex and consists of three dynamic and dialectical moments.⁹ The first is universality, consisting of ideology, formal aspects, the system of norms and values, representing the established. The second is that of particularity, understood as the set of facts and situations that occur in institutions, they are social processes that deny and are in constant conflict with universality, characterizing the instituting. And the third is the singularity, being the dialectical movement between the instituted and the instituting, that is, it is the concrete moment of the institution, called institutionalization.⁸

Another important concept in the IA theoretical framework is that of an analyzer understood as a situation, a fact or element that provokes revelations.¹⁰ About this concept it can be said that:

in general, the effect of the analyzer is always to reveal something that remained hidden, to disorganize what was in some way organized, to give a different meaning to already known facts. This is true both for the analyses of broader social phenomena and for the analyses constructed from intervention processes with smaller groups.^11:82

In this reflection, it was assumed that the Covid-19 pandemic is a natural analyzer. But despite the revelations it brought to the various sectors of society, it is still difficult to predict the impacts in the areas of health and education, especially for the work and training of nursing professionals.

These uncertainties contributed to the motivation to form the discussion group, based on the theoretical framework of Institutional Analysis, in order to conduct this study “in the heat of the moment”, bringing to light, at this time of the pandemic, questions and contradictions experienced in health services and universities. In these organizations, professional practices are crossed by health, education, nursing, and management institutions, among others, which need to be analyzed by professionals involved with training and providing health care to users, in order to allow a better understanding of the challenges and perspectives for health work.

Given the above, this article aims to address, critically and reflectively, challenges and perspectives of professional nursing practice, training, and teaching-service integration in the context of the Covid-19 pandemic.

METHOD

The discussion and reflection group, called “health pedagogical workshop in times of pandemics,” was composed of one faculty member, one graduate student, one manager, and three nurses. This group held six meetings of two hours each, through a virtual platform, during the months of August to November 2020, to discuss topics related to the integration of teaching and care, professional practice, and the training of nursing professionals, which were linked to some concepts of the theoretical framework of IA.

In addition, the group members had the opportunity to analyze its implications, from the dialogues and the production of reflective analytical texts. In the IA approach it is important to analyze the libidinal, organizational, and ideological implications that individuals establish with institutions,¹² since this analysis allows denaturalizing and de-individualizing everyday relations in organizations.¹³

To understand the organizational aspects of the practice scenarios where the technical visits did not take place due to the Covid-19 pandemic, a brief summary was made of the characteristics of each service analyzed, that is, a BHU, a Specialty Outpatient Clinic, an Emergency Care Unit, and an Inpatient Unit of a Teaching Hospital.

The studied BHU is a preferential entrance door to Primary Health Care (PHC), it plans and assists users based on the epidemiological, sanitary, social, economic and geographic aspects of the territory, taking into account the articulation with the other services in the health care network, interdisciplinary strategies and comprehensive care. The profile of the population served is diverse, with an emphasis on homeless people and a high number of elderly people, including institutionalized ones. In addition, it provides assistance to sex workers, immigrants, squatters, and workers from all over the city. This highlights the challenges of programming actions that contemplate all in their different needs.

The outpatient clinic is linked to a public university hospital and offers multidisciplinary care in various specialties such as orthopedics, rheumatology, cardiology, pulmonology, plastic surgery, neurology, psychiatry, urology, andrology, nephrology, transplants, among others. The clientele served are users of different socioeconomic levels and with a wide age range: infants, children, young people, adults, and the elderly, who live in the capital or in several cities in the interior of Minas Gerais and even in other states. These users have comorbidities predominantly serious and/or in advanced stages of heart, oncologic, autoimmune, neurological, and cardiovascular diseases, among others.

The ECU offers medical and surgical services for adults by spontaneous demand, and receives referrals from primary care, home care, and the Mobile Emergency Care Service (MECS). The organization of the service is done through risk classification, since the patient uses the service as a gateway to care for various reasons, from situations of little urgency such as flu symptoms, diarrhea, and cuts with minor bleeding, to more serious cases such as decompensation of diabetes and hypertension, seizures, acute coronary syndrome, and vascular accidents, among others. Currently, in this pandemic scenario of Covid-19, the unit has become a reference for the care of people with symptoms and contaminated by the new coronavirus.

The hospital under analysis has the following characteristics: public, general, university, integrated to UHS and has 507 beds. In this study, the Clinical Medicine Unit stands out, which has two wings (north and south), with a capacity of 69 beds and serves patients with prognosis of recovery, rare pathologies, and in palliative care, coming from various places in the state of Minas Gerais, from the capital to the interior and metropolitan region. Currently, the north wing is serving exclusively patients suspected or infected by the new coronavirus, and the other clinical patients are served in the east wing.

From the concerns about the teaching-learning process in the context of the pandemic and the reality experienced in these practice scenarios, dialogues and reflections were produced that put into play the teaching and health services. In addition, from the analysis of the implications of the authors of this article, some analyzers stood out, revealing several issues and situations that influence professional nursing practice, which were presented in the following topic.

DIALOGUES BETWEEN TEACHING AND HEALTH SERVICES: ANALYZING IMPLICATIONS

As previously stated, the Covid-19 pandemic is a natural analyzer, because it has made several revelations, or even, giving another meaning to facts and social phenomena already known, highlighting the social and gender inequalities, corruption, job insecurity, neglect of essential sectors such as health and education, among others. Thus, in order to understand this reality and the rapid changes that are occurring, especially in the field of work and professional training, the following institutions were analyzed: health, nursing, and education.

At the university, one of the changes imposed by the Covid-19 pandemic and that constitutes a challenge is to develop remote teaching for undergraduate nursing courses. In teaching, technology contributes to and even facilitates some work processes, but it cannot be an end in itself. This worries us and leads us to reflect about how the education will be from now on, especially for nursing professionals. This professional is trained to care for people and manage teams and, for this, he needs pedagogical practices that enable a relational base so that he can meet the demands of the service in various social, historical, and cultural contexts.¹⁴

In this pandemic context, among the difficulties encountered, we can mention the teachers' lack of preparation to handle the technologies for remote teaching, the feeling of emptiness when talking in front of a cell phone or computer through digital platforms, in addition to the apprehension and adaptation of the academics to the new teaching modality.

In this sense, at first, the pandemic of COVID-19 came to disrupt what is established in the university and health services, which generates resistance from teachers and students, as well as health professionals and users, in the face of constant difficulties and challenges. However, this resistance is not only something negative, but an analyzer that allows us to contest the established and reveal the existing powers, that is, the institutions present in the Universities and in UHS.

It is emphasized in the study that resistance when taken as an analyzer exposes movements of contradiction that are always sources for understanding institutional movements. In this sense,

Resistances can be movements of complacency or retaliation, but they can also be movements of support for good practices in precarious situations. For the resistances to break out of their paralysis and acquire movement, they must be analyzed collectively, including the institutional dimensions that permeate them.^10:131

At this moment of the pandemic, the institutional dimension that concerns the financing of the health system shows that even with the dismantling and the spending cuts made in recent years, the UHS has reinforced its importance for the Brazilian population and presents effective conditions to be increasingly prepared to serve users in the health care network.¹⁵ However, managers and health teams had to review and update actions, protocols, strategies, and tools to guide surveillance and care actions for infected patients. In short, the UHS had to prepare itself to provide care to the growing number of patients with COVID-19, but at the same time maintain attention to other acute and chronic conditions and ensure the safety of patients and health professionals.

In the health care network, the BHU referred to in this study continues to guarantee health care assistance to users in an accessible and qualified manner, but seeks to maintain social distance and, at the same time, prioritizes in its agendas health care to groups that need specific care.

In the case of the specialty outpatient clinic, the service to the population was reduced, some nursing workers had to be relocated to critical sectors of the hospital to which it is linked and some aspects related to the physical area, flows, protocols and materials had to be modified. The same happened in relation to urgencies and emergencies care, because in the ECU there was a readjustment of the physical area, with reception, triage with risk classification, medication and observation rooms separated from the other services. Moreover, in this case, the number of health professionals and beds with respirators were increased. This expansion also happened in the hospital, with emphasis on the constant changes that occurred in the work process of the Clinical Medicine Unit, where there is a specific wing that concentrates the largest number of beds for isolation of patients.

It is noteworthy that in the Unit of Clinical Medicine the additional unhealthy was also considered an analyzer in this context of the pandemic, since it was established a fixed team of workers to act in the ward intended for the care of Covid-19, entitled to the maximum additional unhealthy in their salary. However, the workers of the ward that attended the other clinical patients, in addition to receiving a lower additional payment, had to cover the absences and health leaves of the fixed team, generating conflicts and a feeling of professional devaluation.

Money is a natural analyzer that reveals hidden or unmanifest aspects in organizations. In a study carried out in a public hospital in the state of São Paulo, the effects of this analyzer brought up the discussion about the salary differences of the several professionals who directly or indirectly care for the user, besides opening a space to make public the discussion about something that is public, the Brazilian health system itself. By creating spaces to discuss the analyzers, a process of unveiling the hidden meanders through which money passes in the organizations is created.¹¹

In all these scenarios analyzed, conflicts and contradictions have confronted processes instituted in professional nursing practice due to several factors such as: rapid advancement of scientific knowledge; diverse guidelines; flows, protocols, and technical notes that arise daily; continuous training process; among others. This provides the installation of instituting processes, with significant changes in how to assist the patient and organize health care, which is a major challenge for the nursing team to face the pandemic of Covid-19.

In PHC, some tools such as tele-monitoring of patients were introduced in the work process of health professionals, mainly to monitor users with respiratory symptoms performed by the nursing team; besides implementing the offer of teleconsultation for those who have chronic disease with high cardiovascular risk, performed by a physician and a nurse.

The above strategies allow that the restriction and regulation of physical access to the BHU does not represent a total blockade of access, but can be replaced by safer and more cost-effective forms of care.¹⁵ In this perspective, the expansion of these strategies can also be considered for the specialty outpatient clinics, in order to compensate for the reduction in the number of consultations during the pandemic, but at the same time, implement an effective form of follow-up, especially for users who have comorbidities in advanced stages.

Digital technology offers greater access to health actions and services, influences the care process and even social relationships, such as the “virtual visit” implemented by the ECU under study, due to the isolation and restriction of visits to patients, but that now are having the opportunity to see their friends and family by digital means.

Despite these benefits, it is known that many patients do not have access to the technology and supplies needed to provide care. Moreover, health services, especially the public ones, still need to invest a lot in this digital area. This also happens in universities, because social inequality does not allow some students to have access to appropriate technologies to accompany remote learning, and some teachers do not have sufficient financial resources to offer this type of education in their homes, due to lack of adequate infrastructure.

In this sense, it is important that society and governments develop public policies aimed mainly at education, because this transition requires planning, continued and permanent education for teachers, accessible and appropriate technologies in quantity and quality. In this way, the entire academic community will be able to continue playing its fundamental role in society, which consists of research, extension projects, innovations, and the production of patents that drive the country's scientific and technological development.¹⁶

But the difficulties faced are still diverse, from the most objective to the subjective related to feelings and emotions. This pandemic context has brought to professionals and users of the health system moments of insecurity and uncertainty, especially for the nursing team that acts on the front line of care. From fears of becoming infected and, subsequently, being a transmission agent for family members and the general population, to the fear of not providing reliable and safe care to patients, based on these new parameters and reorganization of the work process.

People are afraid of the virus and of getting infected, but they also need to be afraid of being “contaminated” by this type of long distance relationship generated as a result of the pandemic and reinforced by digital technologies. This is because both in health services and in universities, there is a risk of emotions getting lost in the midst of virtual platforms, lives and video classes, after all, verbal and non-verbal communication are essential in the constitution of the bond necessary for the formation process and the provision of comprehensive care.

Therefore, being able to analyze the libidinal, organizational and ideological implications in the pedagogical health workshop was important for the authors of this article to be able to share their anguishes, feelings, stresses, without losing sight of the real needs for changes in their work processes and places, and to mobilize forces so as not to feel paralyzed and lose the meaning of their work.

The wager is that by making analysis of the implications and having clarity of the analyzers in professional practice, this can contribute to overcome and transpose the difficulties encountered, gradually institutionalizing new practices that can go beyond the operationalization of the work already instituted. But the hope is that despite all the influence of hard technology in the processes of work and training, teachers, students and health professionals become increasingly sensitive, develop a qualified listening and have a comprehensive look, going beyond the clinical complaint of users, in order to strengthen ties and welcome them in their uniqueness.

Thus, it is possible to understand that the perspectives for the provision of care and for professional training in health care point to a daily and collective construction of actions and strategies that must be articulated and integrated between the University and the services that make up the HCN. From definitions and guidelines that are in accordance with the health needs of the population and the protection of workers, training and empowering nursing professionals, specifically nurses, to perform care management in health services.

The reflections produced in this study brought into play the dialectical movement of institutions: health, education and nursing, because they have instituted processes, that is, they are historically and socially constituted with practices based on norms and legislation. But, mainly, in this pandemic scenario, they are being questioned and going through several modifications, which break the established and open spaces for the instituting, which means new ways of working. It is in this movement of institutionalization that institutions are renewed, from new conceptions and forms, for the professions, for the areas of health and education.

(IN) CONCLUSIONS AND CONTRIBUTIONS TO PROFESSIONAL PRACTICE

Considering that the nursing team is responsible for most of the care provided to users in the various health services, we sought to understand some analyzers and analyze the implications of the authors with the various institutions that cross their professional and academic practices.

The collective analysis of the implications was necessary to face the “chaos”, because it is necessary to disorganize in order to bring the work processes back to order, transposing the barriers of the established to deal with the adversities of a pandemic. An example of a social actor that needs to be increasingly incorporated into this debate are the nursing students, who in a way, in this context, are being prepared since their training to deal with difficult and unknown situations.

Thus, this study presents some reflections based on the need to maintain the dialogue between teaching and service during the pandemic, even with the suspension of practical activities and the performance of emergency remote teaching. Since it is circumscribed to a limited period of time, practices and scenarios, it presents limitations regarding the impacts on the care provided and for the teaching of health system management and nursing management, which reinforces the need to know and deepen the investigations on the practice and professional training by carrying out other studies and research.

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Edited by

ASSOCIATE EDITOR

Antonio José de Almeida Filho

Publication Dates

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

History

• Received
  07 Dec 2020
• Accepted
  17 Mar 2021