The teaching of sanitary surveillance in the training of nursesABSTRACT
Objective: To investigate the teaching of sanitary surveillance in undergraduate nursing courses in Brazil, seeking to know how this theme is addressed during the training of nurses.
Method: The universe of study was composed of Political-Pedagogical Projects, syllabi and curricula of nursing undergraduate courses from Brazilian public institutions. The quantitative analysis was developed through descriptive and inferential statistics, and for the qualitative part, a software was used to analyze the documents.
Results: A total of 153 public institutions’ websites were analyzed. Of these, only 98 presented a Political-Pedagogical Project, a syllabus or a curriculum for on-line consultation, and only 2.04% of these programs had a specific discipline focused on teaching sanitary surveillance.
Conclusion: The findings indicate that the contents related to the teaching of sanitary surveillance in nursing courses of public higher education institutions in Brazil, when present, are inserted, mostly, in other curricular components.
DESCRIPTORS Education; Nursing; Health Surveillance; Public Health Surveillance; Teaching; Curriculum
RESUMO
Objetivo: Investigar o ensino da vigilância sanitária nos cursos de graduação em enfermagem no Brasil, buscando-se conhecer como essa temática é abordada durante o processo de formação dos enfermeiros.
Método: Estudo com métodos mistos. O universo da pesquisa foi composto de Projetos Político-Pedagógicos, ementas ou matrizes curriculares dos cursos de graduação em enfermagem de instituições públicas brasileiras. A análise quantitativa foi desenvolvida por meio de estatística descritiva e inferencial, e, na parte qualitativa, utilizou-se de um software para analisar os documentos dos cursos.
Resultados: Foram analisados 153 sítios eletrônicos de instituições públicas, destas, apenas 98 apresentaram Projeto Político-Pedagógico, ementa ou matriz curricular para consulta online, e somente 2,04% desses programas possuíam uma disciplina específica voltada para o ensino da vigilância sanitária.
Conclusão: Os achados sinalizaram que os conteúdos relativos ao ensino da área de vigilância sanitária nas instituições públicas de ensino superior em enfermagem no país, quando presentes, encontram-se majoritariamente inseridos em outros componentes curriculares.
DESCRITORES Educação em Enfermagem; Vigilância Sanitária; Vigilância em Saúde Pública; Ensino; Currículo
RESUMEN
Objetivo: Investigar la enseñanza de la vigilancia sanitaria en las carreras de enfermería en Brasil, tratando de conocer cómo se aborda esa temática durante el proceso de formación de los enfermeros.
Método: Estudio con métodos mixtos. El universo de la investigación estuvo compuesto de Proyectos Políticos Pedagógicos, enmiendas o matrices curriculares de las carreras de enfermería de centros públicos brasileños. El análisis cuantitativo fue desarrollado por medio de estadística descriptiva e inferencial y, en la parte cualitativa, se utilizó un software para analizar los documentos de las carreras.
Resultados: Fueron analizados 153 sitios electrónicos de centros públicos. De estas, solo 98 presentaron Proyecto Político Pedagógico, enmienda o matriz curricular para consulta en línea y solo el 2,04% de dichos programas tenían una asignatura específica dirigida a la enseñanza de la vigilancia sanitaria.
Conclusión: Los hallazgos señalaron que los contenidos relativos a la enseñanza del área de vigilancia sanitaria en los centros públicos de enseñanza superior en enfermería en el país, cuando presentes, se hallan mayoritariamente insertados en otros componentes curriculares.
DESCRIPTORES Educación en Enfermería; Vigilancia Sanitaria; Vigilancia en Salud Pública; Enseñanza; Curriculum
INTRODUCTION
Measures in the field of sanitary surveillance emerged in Brazil at the same time as Public Health. However, it was only in 1990 that the creation of the Organic Health Law - Law no. 8080/90, September 19th, 1990 - regulated health actions and services in the national territory and regularized these measures as one of the fields of action of the Unified Health System (SUS - Sistema Único de Saúde)(1-2). Currently, Sanitary Surveillance (SS) is part of a larger group called Health Surveillance (HS), which has the objective of assessing and monitoring the health of the population, in a partnership with health systems and aiming to establish pertinent actions and activities to promote health and prevent diseases. According to Ordinance GM/MS no. 1,378, from July 9th 2013, along with SS, epidemiological surveillance, environmental surveillance and workers’ health are part of HS, as well as other practices and work processes(3).
In turn, sanitary surveillance can be defined as a set of actions capable of eliminating, reducing or preventing health risks, and of intervening in health problems caused by the environment, the production and circulation of goods and the provision of services related to health(2). This concept allowed SS to reformulate its role, adding new measures to its old surveillance practices, expanding its area of action from prevention to health protection, and demanding from professionals a broader sanitary knowledge based on risk assessment, quality and safety®. In this sense, the competences related to SS are comprehensive and include: regulation and sanitary control of production, circulation, custody, transportation and commercialization of substances and products of interest for health and regulation and sanitary control of medical technologies, ports, airports, borders and services directly or indirectly related to health and to the environment, including workers’ health(4). Due to its diversity of objects and practices, sanitary surveillance is currently considered the most complex area of public health in our country, since its field of action is an articulation between economic, legal-political and medical-sanitary areas, and it includes interdisciplinary, multi-professional and inter-institutional activities(1).
Thus, SS actions are developed by professionals of several areas of training, in the three spheres of power: Federal, State and Municipal. Nurses are part of the multi-professional team and compose a model of collective organization aimed at effective health protection as a social law and state duty(5).
Resolution CNE/CES No. 3, of November 7th, 2001, which establishes the national guidelines of the nursing undergraduate course, states that the training of nurses should meet health-related social needs, with emphasis on the SUS, and ensure comprehensiveness, quality and humanization of care, so that the professional can act in the different scenarios of the practice, which include health surveillance services. For this, the professional should know the assumptions of the clinical and epidemiological models and identify the individual and collective health needs of the population and their conditioning and determining factors. However, the approval of these guidelines does not ensure that they will be incorporated into educational institutions, since in practice, this implementation will depend on the Political-Pedagogical Project of each institution(6-7).
On this topic, many authors have highlighted that teaching centers still present limitations in the education process of health professionals, with difficulties to provide learners with training to act in all spheres of the SUS in a satisfactory manner. This is because the training still uses the Flexner's model of education, which prioritizes disease to the detriment of prevention and health promotion. This culminates in a fragmented education, disarticulated from the reality of the health system, and with incompatibility between theory and practice and no experience of interdisciplinarity. In this sense, institutions are being challenged to break standards regarding professional training, facing the need to develop actions that will reorient this process, integrating teaching and health services to train professionals with critical thinking and who are able to act in the perspective proposed by the SUS(6,8-9).
In order for nurses to develop actions and effectively contribute to the area of sanitary surveillance, they need to further explore the issue. However, when comparing SS with other areas of Public Health in nursing, such as epidemiological surveillance and worker's health, it is possible to perceive that it is still little studied, and academic studies on the subject are still scarce, either due to its complexity or because of other priorities(5). Thus, one way of taking a more effective approach to this theme is understanding how health surveillance is addressed during the nurses’ training process, since this is the period during which the knowledge necessary for the future practice of the worker is acquired(9-10).
Given the above, this study aimed to investigate the teaching of sanitary surveillance in undergraduate nursing courses in Brazil, seeking to know how this theme is addressed during the training of nurses.
METHOD
Type of study
This is an exploratory study with mixed methods. This type of design allows the collection and analysis of data both quantitatively and qualitatively, in a persuasive and rigorous way. This means that both approaches are combined in a simultaneous manner and one constructs the other or is incorporated into the other(11).
Scenario
The universe of study was composed of Political-Pedagogical Projects (PPP), syllabi and curricula of nursing courses of Brazilian public institutions. The eligibility criteria were: being a higher education institution duly registered on the website of the National Ministry of Education (e-MEC); being a baccalaureate, licentiate (teaching training degree) or obstetrical nursing course; having the Political-Pedagogical Project (PPP), syllabi or curriculum available digitally. Courses from private and/or philanthropic institutions were excluded. Based on the criteria, the final sample was composed of 98 PPPs.
Data collection
Data was collected between March and May, 2017, by two specialists in sanitary surveillance, one epidemiologist and three nurses, through a semi-structured instrument, which addressed issues related to the type of course, the region and the teaching of sanitary surveillance.
Data analysis and treatment
The quantitative data was analyzed by descriptive and inferential statistics. In this case, the Mann-Whitney and Kruskal-Wallis tests were applied, considering the non-parametric nature of the variables, to compare the recurrence of the terms surveillance and sanitary surveillance. Data were processed by the public access software Epi Info, version 7.2.0.1 for Windows® (CDC, Atlanta, USA), considering a 95% confidence interval and significance level of 0.05.
In the qualitative analysis, the Political-Pedagogical Projects were thoroughly read with emphasis in the organization of the curriculum and the syllabi. Due to the volume of qualitative data, the open software IRAMUTEQ (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires), version 0.7 alpha 2014, was chosen(11). The purpose of this program is to provide different types of text analysis, from simple ones such as basic lexicography (word frequency calculation) to multivariate analysis (descending hierarchical classification, similarity analysis)(12).
In this manuscript, the aforementioned software was applied for the descriptive analysis of text, using the Reinert Method for the elaboration of the dendrogram of content related to the topic “sanitary surveillance” present in the curricular documents of nursing courses in Brazil(13). It is worth mentioning that the software used “is a data processing tool which performs a lexicographic analysis of the textual content, demonstrating distributions and classes that reveal the categories of analysis evidenced in the text corpus”(14). In order to preserve the identity of the Higher Education Institutions (HEIs) analyzed, the excerpts from their Political-Pedagogical Projects (PPP) were identified by the acronym PPP HEI, followed by a number in sequential order (PPP HEI_1, PPP HEI_2, successively until PPP HEI_98).
RESULTS
The search on the Ministry of Education website (e-MEC) revealed a total of 153 Brazilian public higher education institutions (HEIs) that offer the Nursing undergraduate course. The institutions were consulted, generating the following data: the HEIs with undergraduate course in Nursing are mostly Federal (54.25%), are more prevalent in the Northeast region (42.48%), and the predominant type of education is baccalaureate (87.58%). Out of the 153 HEIs, only 98 presented a Political-Pedagogical Project (PPP), curriculum of the courses or the syllabi for on-line consultation (Table 1). These institutional documents were fully analyzed to meet the objectives of the present study.
Characteristics of Higher Education Institutions participating in the research - Brazil, 2017.
The analysis showed that, of the 98 HEIs with curricular documents available online for consultation, only two (2.04%) presented a specific discipline focused directly on the teaching of sanitary surveillance, and both of them were optional disciplines. However, despite the fact of not having an exclusive curricular component, SS was inserted 24 times (24.24%) in other disciplines, totaling 26 (26.26%) HEIs that presented content related to SS. However, 72 HEIs did not directly address contents about the area in their curriculum, since they did not mention the term health surveillance.
Among the components with content related to SS, the following stand out: Nursing and health surveillance (11, 54.57%), Epidemiology (03, 13.65%), Environmental Health (03, 13.65%), Psychosocial basis of Nursing practice (01, 4.55%), Parasitology, Biosafety and Infection Control and Hospital Sanitary Risks (01, 4.55%) and Nursing Practice and Comprehensive Health Care (01, 4.55%). This finding shows the variability of contexts in which SS is addressed.
When analyzing the recurrence of the term surveillance in the HEIs documents, it was observed that it appears on average 5.9 times in each institutional document, with a maximum recurrence of 77 times, while the term sanitary surveillance appears on average 0.9 times and with maximum recurrence of eight times (Table 2).
Recurrence of terms related to health surveillance and surveillance in the institutional documents of public HEI's nursing courses - Brazil, 2017.
Table 3 addresses the comparison of the occurrence of the term sanitary surveillance according to the characteristics of the HEIs surveyed. Regarding the sphere of power, the Federal sphere is predominant. It was verified that the Southeast region presented a mean recurrence of the term surveillance superior to the other regions of Brazil. As for the type of professional training, the baccalaureate has a greater recurrence of this term when compared to the other types. Even when health surveillance has its own discipline, there is no significant difference in the recurrence of the term. When considering SS inserted in other disciplines, the term sanitary surveillance demonstrates statistically superior recurrence (p=0.000).
Comparação da recorrência do termo vigilância em relação à esfera, ao tipo de formação profissional, à existência de disciplina própria e à inserção em outra disciplina - Brasil, 2017.
Classes of the study and their descriptions
Using the software IRAMUTEQ to analyze the HEIs’ documents, it was possible to recognize 39 elementary text units, from 111 text segments. There were 3,660 occurrences, using 76.58% of the total corpus, a number considered satisfactory for the analysis under discussion.
Through the Descending Hierarchical Classification, according to the method described by Reinert, it was possible to identify and analyze the textual domains, as well as the interpretation of meanings, giving them names and respective meanings in classes (Figure 1).
This classification allows understanding the expressions and each of the words presented, analyzing them based on their places and social insertions(12-13). This way, this corpus gave rise to five classes. For each class, a list of words generated from the chi-square test (X2) was computed.
Class 1: Nurses’ training versus their performance in health services
This class made up 18.82% of the analyzed corpus. The main words that emerged here were: function, nurse, immunization, basic and health services. Thus, this class pointed out the basic functions developed by nurses in health services, such as Immunization, Epidemiological Surveillance, Worker's Health and Health Education, that is, it is related to a more general aspect of the role played by this professional, encompassing their generalist training described in the PPPs analyzed.
To train a critical and reflexive nurse with technical, scientific, ethical, political, social and human competence to exercise, coordinate and give technical and social direction to nursing work processes: assisting/intervening, teaching/learning, managing and investigating, at all levels of complexity of the health services network and in training and permanent education in health/ nursing (PPP HIE_37).
Class 2: The Political-Pedagogical Project and the concern with community problems
The lexicographic analysis of this class, which represented 18.82% of the analyzed data, indicates that there is a tendency on the part of the institutions to work considering the problems identified in the community. The most frequent words of the text segments selected by their frequency and X2 values were: identify, need, problem and community.
Profile of the graduated student (…) Able to identify the social needs of the population and their determinants (…) Able to respond to regional health specificities through strategically planned interventions (PPP HIE_38).
Class 3: Health surveillance system and the nurse's training process
The vocabulary of this class made up 14.12% of the content analyzed. The prevailing terms here demonstrate that there is a concern on the part of the HEIs to include disciplines that address sanitary surveillance in their curricula. The teaching of this topic in universities covers epidemiological, environmental and sanitary surveillance. However, the appearance of words such as notification, investigation and information with higher values in the test shows that epidemiological surveillance has a greater space in the academy than the other areas.
Syllabus of the discipline Nursing Practice/Comprehensive Health Care III (…) Areas of Health Surveillance: Epidemiological Surveillance: notification of diseases and aggravations, information systems. Environmental Surveillance: environmental management, environmental pollution. Sanitary Surveillance: waste management, water and sewage management (PPP HIE_50).
Syllabus of the discipline Nursing and Health Surveillance: (…) Concepts, objectives, functions and planning. Sanitary Surveillance; Epidemiological Surveillance; Workers Health. Basic Health Indicators in Brazil (PPP HIE_81).
Class 4: Hidden health surveillance curriculum
Through the lexical vocabulary of this class, which made up 23.53% of the textual data analyzed, it was possible to perceive that, due to the fact that sanitary surveillance does not present its own discipline in most of the HEIs studied, its contents are diluted in other disciplines, in most cases, throughout the training process of future nurses. Issues such as food quality, hospital infection and control, environmental control, sanitation, and SUS that emerged in this class indicate that these issues are discussed in the classroom.
Discipline environmental and sanitary education (…) Addresses the relationship between the environment and sanitary practices and their influence on the human health-disease process, and the methodologies of health surveillance (epidemiological surveillance and sanitary surveillance) (PPP HEI_27).
Class 5: Epidemiological surveillance
This class represented 24.71% of the total corpus, and its contents expressed that epidemiological surveillance has a prominent role within the nursing curriculum in Brazil. In addition to addressing the specific contents of this discipline, this class also encompasses, in many institutions, the teaching of other surveillances, such as environmental and sanitary, giving once again an aspect of greater importance to that area in relation to the others.
Discipline of Epidemiology (…) National health information systems. Health surveillance: epidemiological, sanitary and environmental surveillance (PPP HEI_04).
Discipline Nursing in Collective Health I (…) Meanings of the disease process. Epidemiological surveillance. Sanitary Surveillance (PPP HEI_15).
DISCUSSION
This work was originated based on reflections on the need for a nursing education linked to the future practice of the professionals, considering that one of the nurses’ activities is to work in the area of sanitary surveillance.
The reduced number of curricular documents available online was also found in another study, which observed that some institutions do not have the PPPs of their courses, or they are outdated or even under construction for long periods of time(15).
The Political-Pedagogical Project is the theoretical-methodological object that carries the way of thinking and planning of each course and defines guidelines and predilection in the formation of the citizen. The political principle of the PPP is notorious, since it defines paths and objectives for the formative course of the student, that is, it displays its non-neutral educational practice(16). Thus, the nurse's training should be based on reality and construction of knowledge, according to the National Curricular Guidelines for the Nursing Course (DCN/ENF)(6-7). The DCN/ENF orients the institutions on the aspects of nursing professional training. These guidelines point to the relevance of the articulation between theory and practice, in a critical and reflexive manner, aimed at meeting the health needs of the population and forming professionals with the expected profile to be engaged in the Unified Health System (SUS), where sanitary surveillance is inserted(6).
A study that assessed the situation of SS services in Brazil in 2001 in all States, Capitals and Cities with more than 200,000 inhabitants identified that the most numerous professional categories in this area were pharmacists, nurses, veterinarians, dental surgeons and physicians(17). The results of this study are in agreement with the data found in another research, in which the category of pharmacists was more frequent in the area of sanitary surveillance, followed by nurses, veterinarians and dentists(17), revealing the importance of a nurse's training focused on the performance in this area.
Regarding the low recurrence of sanitary surveillance as a curricular component, it is important to highlight that the need for disciplines that address this subject in nursing undergraduate courses is justified not only because it is one of the areas of nursing work, but also because this subject provides information about the health system, such as structuring, grounding, models of care, concepts of epidemiology and sanitary surveillance itself(1) Since this knowledge is not commonly approached through a specific discipline, as observed in this study, the lack of emphasis on contents related to sanitary surveillance in the country's higher education institutions leads the professional who works in this area to seek specialization - there are lato sensu graduate courses in sanitary surveillance all over the country - since their actions are complex and require specialized and up-to-date knowledge, especially about sanitary legislation(18-19).
There were no indications of practices associated with the sanitary surveillance approach. Nursing courses should now seek to train professionals capable of actively participating in the paradigm shift process in education and health care, in line with SUS principles. To this end, tools such as theoretical and practical classes in undergraduate courses, visits to the various fields of work, and encouragement for students to participate in research and extension projects should be used(8-9).
Aiming at improving the training of human resources for the SUS and associating teaching and practice, some inter-ministerial actions have supported the implementation of new experiences, such as the Health Work Education Program - Health Surveillance (PET/VS). This is an instrument to enable work initiation programs, internships and experiences, aimed at students, according to the SUS needs. Its central axis is the integration between teaching and practice, aiming to insert students in the real scenario of SUS’ practices since the beginning of their formation(6). Thus, the PET/VS is an important strategy for the training of nurses capable of developing health surveillance actions.
In contrast to the limited space given directly to sanitary surveillance within the analyzed PPPs, there is a high presence of the term epidemiological surveillance, which characterizes a greater representation of the teaching of this topic in nursing institutions in relation to the former. This fact can be explained by the trajectory of the epidemiological services in our country, which were historically structured with a view to the formation of human resources, in an incessant search for the integration between educational institutions and health services. Hospital epidemiology services now constitute important poles for training and qualification in epidemiological surveillance and function as nursing internships(20).
Based on this study, it is possible to affirm that, despite the growing demand for nursing professionals trained to work in all spheres of the SUS and to meet the population's health needs in relation to health surveillance, the documents analyzed show a tendency for the dispersion of content in different curricular components. This points out the need for a broad discussion about the undergraduate curricula regarding the training for acting at SS. Institutional documents of the National Agency of Sanitary Surveillance (ANVISA —Agência Nacional de Vigilância Sanitária) found a low qualification of professionals working in this area, demonstrating the urgency to solve this problem through a greater offer of training courses for professionals already active in the area, with partnerships with public health schools and universities, and also with the tool of distance education(17).
Regarding the term surveillance in relation to sanitary surveillance, there is a greater number of recurrences in the institutions analyzed, possibly because it encompasses the other components of the health surveillance system. It is inferred that, although the institutions do not have a discipline called sanitary surveillance, the concept of surveillance, even if it is linked to other areas, was discussed in the classroom. Such preliminary notions can arouse in the nursing students the interest in the subject in question, providing the student with a first contact that can be deepened with optional disciplines in the undergraduate course and postgraduate courses in the area.
Analyzing the corpus of the study as a whole, it was possible to verify that it contained elements that indicated that the contents related to the area of health surveillance (class 3) guide the nurses’ training process. However, when the subject is specifically directed to sanitary surveillance (class 4), it is evident that the knowledge necessary to understand SS is indirectly contemplated, through several components that address the contents related to this subject. The hidden curriculum corresponds to rules and norms that are not explicit, but that guide the relations that are established in practice. Thus, contents such as hospital infection and food quality, present in the PPPs analyzed, contribute to the performance of the future nurse in the area of SS, even though this relationship is not directly described in the formal curriculum of the course(21).
This is because the knowledge and practices of sanitary surveillance are located in a field of convergence of several disciplines and areas of human knowledge, such as pharmacology, epidemiology, health education, biosafety and bioethics. However, for an effective understanding of SS, its approach should not be limited to these contents. It is true that sanitary surveillance feeds and benefits from these disciplines, but in order to be more effective, it also needs a space of its own, to discuss from its definition and contextualization in our health system until the extent health legislation, providing students with the necessary tools to effectively recognize the role of nurses in SS services(1).
It is well known that the different surveillances that are part HS are intertwined. However, each of them preserves its specificities, including compliance with current legislation, and, therefore, its approach must be based on the recognition of these particularities. In view of the above, it should be emphasized that the study of these surveillances as a group should be something done with caution, with the risk of compromising the greatest strength in each one of them: their specificities(1,6,8).
Nursing students should obtain knowledge that can improve their performance in several areas, including sanitary surveillance. The systematic implementation of curriculum content directly addressing the issue of SS is associated with the development of skills that the graduated student will need to work in this area.
Finally, the following research limitations are presented: (i) only PPPs available online were consulted; and (ii) only public higher education institutions were considered. Thus, it is suggested that future research expands the scope to all institutions, including private institutions and institutions that do not have their PPP available for consultation on the Internet. Future studies should also include an investigation with nursing students, to apprehend their perceptions about their training in the area of SS.
CONCLUSION
The results of this research indicate that the contents related to the teaching of sanitary surveillance in higher education public institutions in our country, when present, are mostly inserted in several curricular components, which may point to a weaker training in this area.
It is hoped that, with this study, Brazilian higher education institutions will be able to analyze whether their curricula contemplate the teaching of health surveillance in a systematic way, also analyzing whether they are able to train professionals to act in this area, in accordance with the principles and guidelines of the SUS and with the National Guidelines of the Nursing Course.
In this sense, we propose a reflection on the subject of sanitary surveillance as a possible curricular component in the curriculum of nursing undergraduate courses, even if as an optional discipline. In order to do this, this proposal must be contextualized in the Political-Pedagogical Project (PPP) of the universities.
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20 Escosteguy CC, Pereira AGL, Medronho RA. Três décadas de epidemiología hospitalar e o desafio da integração da Vigilância em Saúde: reflexões a partir de um caso. Ciênc Saúde Coletiva [Internet]. 2017 [citado 2018 mar. 10]; 22(10):3365-79. Disponível em: www.scielo.br/pdf/csc/v22n10/1413-8123-csc-22-10-3365.pdf
» www.scielo.br/pdf/csc/v22n10/1413-8123-csc-22-10-3365.pdf - 21 Moreira AFB, coordenador. Currículo: questões atuais. Campinas: Papirus; 2015.
Publication Dates
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Publication in this collection
13 Dec 2018 -
Date of issue
2018
History
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Received
21 Sept 2017 -
Accepted
04 June 2018
Source: Open software IRAMUTEQ version 0.7 alpha 2014.